Measurement of Resource Utilization for Total and Reverse Shoulder Arthroplasty

5 Points on 5 Points on Measurement of Resource Utilization for Total and Reverse Shoulder rthroplasty Richard S. Tannenbaum, S, Ronald Navarro, MD, Nazeem Virani, MD, MPH, rent Stephens, MD, Jordan King, S, dam Lorenzetti, MD, Peter Simon, PhD, Rachel lark,, Geoffrey P. Stone, MD, Mark Fischer, JD, MHS, ndrew Green, MD, and Mark. Frankle, MD s total health care costs reach almost $3 trillion per year capturing more than 17% of the total US gross domestic product payers are searching for more effective ways to limit health care spending. 1,2 One increasingly discussed plan is payment bundling. 3 This one-lump-sum payment model arose as a result of rapid year-on-year increases in total reimbursements under the current, fee-for-service model. The enters for Medicare & Medicaid Services hypothesized that a single all-inclusive payment for a procedure or set of services would incentivize improvements in patient-centered care and disincentivize cost-shifting behaviors. 4 undled reimbursement is becoming increasingly common in orthopedic practice. With the recent introduction of the undled Payment for are Improvement Initiative, several orthopedic practices around the United States are already actively engaged in creating models Home Health & Therapy 5.69% Room & oard 6.88% Surgical Supplies & Instruments 7.82% Surgeon & Surgical ssist 9.69% Implants 37.77% OR rea Usage 12.27% for bundled payment for common elective procedures and for associated services provided up to 9 days after surgery. 3,5 undled payment increases the burden on the provider to understand the cost of care provided during a care cycle. However, not only has the current system blinded physicians to the cost of care, but current antitrust legislation has made discussions of pricing with colleagues (so-called price collusion) illegal and subject to fines of up to $1 million per person and $ million per organization, 6 therefore limiting orthopedic physician involvement. Given these legal constraints, instead of measuring direct costs of goods, we developed a grocery list approach in which direct comparisons are made of resources (goods and services) used and delivered during the entire 9-day cycle of care for patients who undergo anatomical total shoulder Figure 1. Top 1 cost items for () total shoulder arthroplasty and () reverse shoulder arthroplasty. bbreviation: OR, operating room. Preoperative linical are 2.2% Other 6.89% Preoperative linical are 1.56% Other 5.22% Follow-up linical are 2.44% Follow-up linical are 1.78% Pharmacy 4.9% Pharmacy 2.85% nesthesia 4.27% nesthesia 3.4% Home Health & Therapy 4.5% Room & oard 5.46% Surgical Supplies & Instruments 6.14% Surgeon & Surgical ssist 6.9% Implants 53.88% OR rea Usage 9.1% uthors Disclosure Statement: Mr. Tannenbaum reports he works for a company that receives research grants from DJO Surgical, a designer and manufacturer of products related to the subject of this work. Ms. lark also works for a company that receives research grants from DJO Surgical. Dr. Green reports he is a paid consultant for DJO Surgical, Tornier, rthrex, and Smith & Nephew, designers and manufacturers of products related to the subject of this work, and receives research support from rthrex and Smith & Nephew, royalties and consulting fees from Tornier, and speaker honoraria from DJO Surgical. Dr. Frankle reports he is a paid consultant and speakers bureau member for DJO Surgical. The other authors report no actual or potential conflict of interest in relation to this article. 446 The merican Journal of Orthopedics October 215 www.amjorthopedics.com

5 45 4 35 25 15 5 verage holding time 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 28 26 24 22 18 16 14 12 8 6 4 2 verage OR time 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 4 36 32 28 24 16 12 8 4 verage holding time 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 28 26 24 22 18 16 14 12 8 6 4 2 verage OR time 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 Holding time, RS Holding time, TS 5 15 25 Figure 2. Holding time (minutes): () before total shoulder arthroplasty (TS; 25 patients), () before reverse shoulder arthroplasty (RS; 25 patients), and () and compared. OR time, RS OR time, TS 5 15 25 Figure 3. Operating room (OR) time (minutes): () for total shoulder arthroplasty (TS; 25 patients), () for reverse shoulder arthroplasty (RS; 25 patients), and () and compared. DO NOT OPY 32 28 26 verage anesthesia time 24 28 22 26 18 24 verage PU time 16 22 14 12 18 8 6 16 4 14 2 12 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 8 6 4 2 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 28 26 24 verage anesthesia time 22 18 16 14 12 8 6 4 2 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 nesthesia time, RS nesthesia time, TS 15 16 17 18 19 21 32 28 26 24 22 18 16 14 12 8 6 4 2 verage PU time 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 Figure 4. nesthesia time (minutes): () for total shoulder arthroplasty (TS; 25 patients), () for reverse shoulder arthroplasty (RS; 25 patients), and () and compared. Figure 5. Postanesthesia care unit (PU) time (minutes) for () total shoulder arthroplasty (25 patients) and () reverse shoulder arthroplasty (25 patients). www.amjorthopedics.com October 215 The merican Journal of Orthopedics 447

5 Points on Measurement of Resource Utilization for Total and Reverse Shoulder rthroplasty PU time 41% Holding time 18% Operating room time 41% 9 8 7 6 5 4 3 2 1 1 Lidocaine 2 Ondansetron 3 Propofol 4 Sevoflurane 5 efazolin 6 LR 7 Midazolam 8 Rocuronium 9.9% NS 1 Ephedrine 11 Fentanyl 12 Glycopyrrolate 13 Neostigmine 14 Phenylephrine 15 Rantidine 16 Succinylcholine 17 Remifentanil 18 lbumin 19 Esmolol 2 Ropivacaine 21 cetaminophen 22 lindamycin 23 Dexamethasone 24 Hydrocortisone 25 Hydromorphone 26 Isoflurane 27 Metoclopramide 28 Metoprolol 29 Morphine 3 Scopolamine nesthesia Medications 31 Vecuronium PU time 44% Holding time 11% Figure 6. verage distribution of patient time for () total shoulder arthroplasty and () reverse shoulder arthroplasty. bbreviation: PU, postanesthesia care unit. Operating room time 45% nesthesia Medications Figure 8. nesthesia medications used and percentages of patients receiving them during () total shoulder arthroplasty and () reverse shoulder arthroplasty. bbreviations: LR, lactated ringers; NS, normal saline. 7. arthroplasty (TS) or reverse shoulder arthroplasty (RS). We 6. used one surgeon s practice experience as a model for measuring other orthopedic surgeons resource utilization, based 5. verage Number of Days 4. 3. on their electronic medical records (EMR) system data. y 2. capturing the costs of the components of resource utilization 1.. rather than just the final cost of care, we can assess, compare, 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 understand, endorse, and address these driving factors. Time (days) 9 8 7 6 5 4 3 2 1 1 Lidocaine 2 Rocuronium 3 Sevoflurane 4 Fentanyl 5 LR 6 Ondansetron 7 Propofol 8 Midazolam 9 Succinylcholine 1.9% NS 11 Glycopyrrolate 12 Neostigmine 13 Phenylephrine 14 Remifentanil 15 efazolin 16 Esmolol 17 lindamycin 18 Ephedrine 19 Hydroxyethyl Styrene 2 lbumin 21 Diltiazem 22 Etomidate 23 Metoprolol Time (days) 8. 7. 6. 5. 4. 3. 2. 1.. verage Number of Days 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 Hours spent as inpatient, RS Hours spent as inpatient, TS.5 1. 1.5 2. 2.5 3. Time (days) Figure 7. Inpatient time (days) for () total shoulder arthroplasty (TS; 25 patients) and () reverse shoulder arthroplasty (RS; 25 patients). () Inpatient time (hours) for and compared. 1 The significance of resource utilization To maximize the efficiency of their practices, highvolume shoulder surgeons have introduced standardization to health care delivery. 7 Identifying specific efficiencies makes uniform acceptance of beneficial practice patterns possible. To facilitate comparison of goods and services used during an episode of surgical care, Virani and colleagues 8,9 studied the costs of TS and RS and calculated the top 1 driving cost factors for these procedures (Figure 1). Their systematic analysis provided a framework for a common method of communication, allowing an orthopedic surgeon to gain a more complete understanding of the resources used during a particular operative procedure in his or her practice, and allowing several physicians to compare and contrast the resources collectively used for a single procedure, facilitating an understanding of different practice patterns within a local 448 The merican Journal of Orthopedics October 215 www.amjorthopedics.com

R. S. Tannenbaum et al 2 4 6 8 2 4 6 8 1 hydromorphone 1 senna-docusate 8.6-5 mg per tablet 2 famotidine tablet 2 mupirocin 2% ointment 3 mupirocin 2% ointment 3 dextrose 5% and.45% Nal with Kl 2 meq infusion 4 senna-docusate 8.6-5 mg 4 famotidine (PF) injection 2 mg 5 dextrose 5% w/kl 2 meq infusion 5 heparin, porcine (PF) 1 unit/ml injection 6 hydrocodone-acetaminophen 6 ropivacaine (PF).5% in sodium chloride.9% ml infusion 7 cefazolin IVP 1 g 7 cefazolin IVP 1 g 8 ropivacaine (PF).5% ml infusion 8 famotidine tablet 2 mg 9 heparin, porcine (PF) 1 unit/ml injection 9 hydrocodone-acetaminophen 5-325 mg per tablet 1 Kl S R tablet 1 ondansetron Hl (PF) 4 mg/2 ml injection Soln 4 mg 11 fentanyl citrate, ropivacaine (PF) 11 potassium chloride S R tablet 4 meq 12 midazolam injection 12 clindamycin 6 mg/5 ml IVP 6 mg 13 morphine 2 mg/ml injection 2-4 mg 13 hydrocodone-acetaminophen 7.5-325 mg per tablet 14 ondansetron Hl (PF) 4 mg/2 ml injection 14 hydromorphone (PF) 2 mg/ml injection 1 mg 15 sodium chloride.9% 1, ml bolus 15 lactated ringers infusion 16 chlorhexidine gluconate 2% towelette 16 hydromorphone injection 1 mg 17 heparin flush unit/ml injection 17 pantoprazole E tablet 4 mg 18 lisinopril tablet 18.9% Nal infusion 19 acetaminophen tablet 65 mg 19 calcium carbonate chewable tablet 6 mg 2 acetylsalicylic acid E tablet 2 chlorhexidine gluconate 2% towelette 21 iron polysaccharides capsule 15 mg 21 insulin aspart InPn 2-1 Units 22 pantoprazole E tablet 22 potassium chloride S R tablet 2 meq 23 vitamin tablet 5 mg 23 zolpidem tablet 5 mg 24 clindamycin 24 clopidogrel tablet 75 mg 25 diphenhydramine capsule 25 mg 25 folic acid tablet 1 mg 26 duloxetine DR capsule 6 mg 26 heparin, porcine (PF) 1 unit/ml injection 5 units 27 insulin aspart InPn 27 polyethylene glycol packet 17 g 28 levothyroxine tablet 28 sodium chloride.9% flush 2-1 ml 29 metoclopramide Hl IVP 29 acetaminophen tablet 65 mg 3 metoprolol succinate tablet 3 calcium carbonate chewable tablet 4 mg 31 multivitamin tablet (1 tablet) 31 fentanyl 2 mcg/ml, ropivacaine (PF).5% in Nal.9% ml nerve block 32 polyethylene glycol packet 17 g 32 fentanyl injection 5 mcg 33 pravastatin tablet 4 mg 33 gabapentin capsule mg 34 pregabalin 34 hydrocortisone sod succ (PF) mg/2 ml injection mg 35 rosuvastatin tablet 35 magnesium oxide tablet 4 mg 36 valsartan 36 meperidine (PF) 5 mg/ml injection 5 mg 37 zolpidem tablet 5 mg 37 midazolam injection 2 mg 38.9% Nal infusion 38 multivitamin tablet (1 tablet) 39 allopurinol tablet mg 39 oxycodone-acetaminophen 5-325 mg per tablet (1 tablet) 4 amlodipine tablet 4 oxycodone-acetaminophen 5-325 mg per tablet (1-2 tablets) 41 atenolol tablet 25 mg 41 pantoprazole E tablet 2 mg DO 42 atorvastatin tablet NOT OPY 42 pantoprazole injection 4 mg 43 enalaprilat injection 43 sinvastatin tablet 2 mg 44 fenofibrate tablet 44 tamsulosin 24 hr capsule.4 mg 45 finasteride tablet 5 mg 45 vitamin tablet 5 mg 46 furosemide tablet 46 albumin human 5% bottle 12.5 g 47 ketorolac injection 3 mg 47 albuterol nebulizer solution 2.5 mg 48 lactated ringers infusion 48 amiodarone tablet mg 49 magnesium oxide tablet 4 mg 49 amlodipine tablet 1 mg 5 oxycodone 5 atorvastatin tablet 1 mg Medication Name Medication Name Figure 9. Medications used and percentages of patients receiving them after () total shoulder arthroplasty and () reverse shoulder arthroplasty. bbreviations: bbreviations: R, controlled release; DR, delayed release; E, enteric coated; InPn, indium phosphide nitride; IVP, intravenous piggyback; PF, perfusion fluid; S, sustained action; soln, solution. community. t a societal level, these data can be collected to help guide overall recommendations. 2 How we defined utilization To define the resources used, we had to decide which procedure components cost the most. Virani and colleagues 8,9 found that the top 1 cost drivers accounted for 93.11% and 94.77% of the total cost of the TS and RS care cycles, respectively (Figure 1). For each cost driver, information on resources used (goods, services, overhead) was collected on 2 forms, the Hospital Utilization Form (7 hospital-based items) and the linical Utilization Form (3 non-hospital-based items). To make hospital data easy to compile, we piloted use of a smart form in the Epicare EMR system to isolate and auto-populate specific data fields. 3 EMR data collection With EMR becoming mandatory for all public and private health care providers starting in 214, utilization data are now included in a single unified system. Working with our in-house information technology department, we developed an algorithm to populate this information in a separate, easy-to-follow hospital utilization form. This form can be adopted by other institutions. lthough Epicare EMR is used by 52% of hospitals and at our institution, the data points required to make the same measurements are generalizable and exist in other EMRs. Smartlinks, a tool in this EMR, allows utilization data to be quickly retrieved from different locations in a medical record and allows a form to be electronically completed in seconds. Data can be retrieved for any patient in the EMR system, www.amjorthopedics.com October 215 The merican Journal of Orthopedics 449

5 Points on Measurement of Resource Utilization for Total and Reverse Shoulder rthroplasty 2 4 6 8 2 4 6 8 1 Standard Total Shoulder DS Pack bdominal Pad 2 Quick Site lean Up Kit Foley Tray atheter Latex 16FR (french size) 3 hloraprep Orange Tint 26mL raided omposite Suture #2 4 Dressing order Postoperative 4X12 lade Saw XL Thick 1.24mm 5 Suture 2/, violet, 3,4.21 Standard Total Shoulder DS Pack 6 Solution Irrigation Nal.9% ml hloraprep Orange Tint 26mL 7 High Speed Round ur 5.mm Suture 2- GS11 UD 3in 8 bsorbable Suture 5X3in violet Postoperative Silicone Foam Dressing (4"x12") 9 Patient Positioning Kit Quick Site lean Up Kit 1 lade Saw XL Thick 1.24mm Irrigation Solution Nal.9% ml 11 Sutures 3- (USP) P- 14 Dyed 18 Head Foam Support 12 bdominal Pad and Roll, 16 x 12 Nonadherent Dressing Pads 3x8 13 Support Head Foam Surgical gown, fabric reinforced XXL 14 Suture Ticron 1, lue, 6X18,Pre-cut Suture, lue, 5,3",-2/HOS-14 15 lade Saw ntimicrobial Incise Drapes 16 Incision Drapes Skin losure Strips, H1547, 1/2 in x 4 in 17 Gown Fabric Reinforced XXL Saw lade 18 Foley Tray atheter Latex 16FR (french size) dhesive Towel Drapes 19 raided omposite Suture #2 High Speed Round ur 5.mm 2 Suture, lue, 5,3,-2/Hos-14 Sleeve ompression alf 43cm 21 Solution Irrigation H2 15mL Suture, 1,lue, 6X18" 22 Skin losure Strips, H1547, 1/2 in x 4 in bsorbable Suture HS11 UD 3in 23 Nonadherent Dressing Pads 3 X 8 Dressing Sponge 4X4 24 Suction Tube, Frazier, 3 DG, 12FR Non-Latex Gloves sz 8.5 25 Syringe 6mL ath Tip Mayo catgut non-sterile 1/2 circle taper point 26 Sterile Drape Solution Irrigation H2 Sterile 15mL 27 Needle, Mayo atgut, 1/2 ircle Taper, sz4 Disposable arbon Steel Surgical lades #1 28 ompressive alf Sleeve Medium 43cm Positioning Patient are Kit 29 Tubing, Suction, onnecting, 3/16 X 2 Stocking ompression Thigh High Nylon ntiembolism 3 Pack Mini asin Set Surgical Underglove with Indicator Size 8.5 31 Tongue lade, 6 Immobilizer Shoulder Universal 32 Transparent plastic U-drape Suture 3- USP P-12 Dye 18 33 Disposable Steel Surgical lades #1 4 Port Manifold Systems 34 Non Latex Gloves Size 8.5 Suture 3- USP P-14 Dye 18 35 Puncture Indicating Underglove Size 8.5 Suture 5 USP V 3S 36 Dressing Sponge 4 X 4 Universal atheter and Tubing Securement 37 atheter & Tubing Securement bdomen Pad 8" X 7.5" 38 Suture Tape With Needle 3mm 6mL atheter Tip Syringe 39 Transparent Film Dressing Frame 4X1 Transparent Film Dressing Frame 4X1 4 Stocking ompression Thigh High Nylon Puncture Indicator Surgical Underglove sz 7.5 41 one ement Mixing and Delivery System Non-Latex Glove sz 8. DO 42 Transparent Film Dressing Frame 4X4.75 NOT Puncture OPY Indicator Surgical Underglove sz 8. 43 Synthetic bsorbable Sutures GS24 dye 36in Non Latex Glove sz 7.5 44 Thigh Length ntiembolism Stockings Vacuum Mixing owl and 18 Gram ement artridge 45 Transosseous Suture Passer Suture Tape With Needle 1mm 46 Glove with Puncture Indicator Size 7.5 ement Mixer with Vacuum ttachment 47 Liquid film-forming dressing 4mL Evacuator Kit, 1/8 In PV With Trocar 48 Puncture Indicating Surgical Underglove sz 8. Dressing Tegaderm 4X4.75 49 bdomen Pad 8X7.5 in Round arbide ur 5.mm 5 Non-latex Gloves Size 7.5 Tubing Pneumatic Hand Pack Surgical Supply Name Surgical Supply Name Figure 1. Surgical supplies used and percentages of patients receiving them after () total shoulder arthroplasty and () reverse shoulder arthroplasty. regardless of when that patient s hospital stay occurred. We populated data from surgeries performed 2 years before the start of this project. 4 What we can learn from these data Data from a pilot study of 25 patients who underwent primary anatomical TS for osteoarthritis and 25 patients who underwent primary RS for massive rotator cuff tear allowed us to generate graphical representations of a single surgeon s practice patterns that most affected the cost of care. Time in holding, time in the operating room, time in the postanesthesia care unit, and percentage of patients receiving different medications were recorded for each procedure (Figures 2 11). The study did not capture the wide variances in practice patterns in shoulder arthroplasty, and therefore other surgeons resource utilization may differ Number of Visits 5 4.5 4 3.5 3 2.5 2 1.5 1.5 RS TS 2.6 2.3 verage Number of Skilled Nursing Visits Figure 11. verage number of skilled nursing visits and average number of physical therapy visits after total shoulder arthroplasty (TS) and reverse shoulder arthroplasty (RS). 4.6 3.6 verage Number of Physical Therapy Visits 45 The merican Journal of Orthopedics October 215 www.amjorthopedics.com

R. S. Tannenbaum et al from ours. However, replicating this methodology at other institutions will produce a more robust data set from which conclusions about resource utilization and, indirectly, cost of care can be made. 5 Future possibilities y using existing EMR tools to better understand resource utilization, orthopedic surgeons can play a constructive role in the dialogue on health care costs and new reimbursement models. The data presented here are not meant to be interpreted as hard and fast numbers on global resource utilization, but instead we intend to establish a model for collecting data on resource utilization. Resource utilization begins the dialogue that allows orthopedic surgeons and specialty societies to speak a common language without discussing actual cost numbers, which is discouraged under antitrust regulation. The data presented will allow comparisons to be made between surgeons in all practice settings to highlight areas of inconsistency in order to further improve patient care. lthough this work involved only 5 patients undergoing only 2 types of surgeries, the resource-capturing methodology can be expanded to include more procedures and orthopedic practices. s all hospitals are now required to have EMRs, the metrics tracked in this work can be found on any patient medical record and auto-populated using our open-source utilization forms. Starting this data collection at your hospital may require no more than a conversation with the informatics department, as the metrics can for the most part be populated into a database on surgeon request. s orthopedic surgeons return to the economic health care discussion, this information could prove essential in helping the individual surgeon and the orthopedic community justify the cost of care as well as fully understand the cost drivers for musculoskeletal care. Mr. Tannenbaum is Research Fellow, Foundation for Orthopaedic Research and Education, Phillip Spiegel Orthopaedic Research Laboratory, Tampa, Florida. Dr. Navarro is Regional oordinating hief of Orthopaedic Surgery, Department of Orthopaedics, Kaiser Permanente, Harbor ity, alifornia. Dr. Virani is Research Fellow, Foundation for Orthopaedic Research and Education, Phillip Spiegel Orthopaedic Research Laboratory, Tampa, Florida. Dr. Stephens is Upper Extremity Fellow, Shoulder Service, Florida Orthopaedic Institute, Tampa, Florida. Ms. King is Healthcare nalyst, chieve Home are, Tampa, Florida. Dr. Lorenzetti is Orthopaedic Fellow, and Dr. Simon is Staff Scientist, Foundation for Orthopaedic Research and Education, Phillip Spiegel Orthopaedic Research Laboratory, Tampa, Florida. Ms. lark is Upper Extremity linical Research Manager, and Dr. Stone is Fellow, Shoulder Service, Florida Orthopaedic Institute, Tampa, Florida. Mr. Fischer is Department dministrator/perioperative nalyst, Department of Orthopaedics, Kaiser Permanente, Harbor ity, alifornia. Dr. Green is ssociate Professor, Warren lpert Medical School, rown University, Providence, Rhode Island. Dr. Frankle is Director, Shoulder Service, Florida Orthopaedic Institute, Tampa, Florida. ddress correspondence to: Mark. Frankle, MD, Shoulder Service, Florida Orthopaedic Institute, 132 N Telecom Pkwy, Tampa, FL 33637 (tel, 813-978-97; email, mfrankle@floridaortho.com). m J Orthop. 215;44(1):446-452. opyright Frontline Medical ommunications Inc. 215. ll rights reserved. References 1. National health expenditures 213 highlights. enters for Medicare & Medicaid Services website. http://www.cms.gov/research-statistics-dataand-systems/statistics-trends-and-reports/nationalhealthexpenddata/ downloads/highlights.pdf. ccessed September 14, 215. 2. Wilson K. Health care costs 11: slow growth persists. alifornia Health- are Foundation website. http://www.chcf.org/publications/214/7/ health-care-costs-11. Published July 214. ccessed ugust 24, 215. 3. Froimson MI, Rana, White RE Jr, et al. undled Payments for are Improvement Initiative: the next evolution of payment formulations: HKS undled Payment Task Force. J rthroplasty. 213;28(8 suppl):157-165. 4. Morley M, ogasky S, Gage, Flood S, Ingber MJ. Medicare post-acute care episodes and payment bundling. Medicare Medicaid Res Rev. 214;4(1). 5. Teusink MJ, Virani N, Polikandriotis J, Frankle M. ost analysis in shoulder arthroplasty surgery. dv Orthop. 212;212:692869. 6. Fassbender E, Pandya S. Legislation focuses on OS priorities. merican cademy of Orthopaedic Surgeons website. http://www.aaos.org/news/ aaosnow/may14/advocacy2.asp. OS Now. Published May 214. ccessed ugust 24, 215. 7. Porter ME, Teisberg EO. Redefining Health are: reating Value-ased ompetition on Results. oston, M: Harvard usiness School Press; 6. 8. Virani N, Williams D, lark R, Polikandriotis J, Downes KL, Frankle M. Preparing for the bundled-payment initiative: the cost and clinical outcomes of reverse shoulder arthroplasty for the surgical treatment of advanced rotator cuff deficiency at an average 4-year follow-up. J Shoulder Elbow Surg. 213;22(12):1612-1622. 9. Virani N, Williams D, lark R, Polikandriotis J, Downes KL, Frankle M. Preparing for the bundled-payment initiative: the cost and clinical outcomes of total shoulder arthroplasty for the surgical treatment of glenohumeral arthritis at an average 4-year follow-up. J Shoulder Elbow Surg. 213;22(12):161-1611. ommentary Peter D. Mcann, MD, Editor-in-hief In this month s issue of The merican Journal of Orthopedics, Tannenbaum and colleagues present a 5 Points article on Measurement of Resource Utilization for Total and Reverse Shoulder rthroplasty. This is an excellent article that summarizes the authors methodology of determining not only the overall cost of hospital care for shoulder replacement but a detailed analysis of many components contributing to that cost. The steps are fairly straightforward: identify the various components of the cost, gather the data contributing to those costs, and then analyze what are the major expenditures that contribute to the overall cost. Sounds simple, but, in practice, it is anything but! s health care expenditures in the United States continue to increase and approach 2% of the gross domestic ontinued on page 452 www.amjorthopedics.com October 215 The merican Journal of Orthopedics 451

5 Points on Measurement of Resource Utilization for Total and Reverse Shoulder rthroplasty ontinued from page 451 product, every sector of the health care industry is searching for ways to curtail and eventually decrease the cost of health care. However, one cannot control costs without accurate data that defines those costs. In this article, Tannenbaum and colleagues have provided a methodology to help both hospital administrators and surgeons determine the overall cost of shoulder arthroplasty, but their principles of analysis can be applied to all aspects of hospital care. Such efforts are gaining the attention of many leaders of the health care industry. For example, in the September 8, 215, edition of The New York Times, I was very interested to read the article What are a Hospital s osts? Utah System Is Trying to Learn. 1 The article reviewed the efforts of Dr. Vivian Lee, chief executive at University of Utah Health are, to determine the actual cost of all care provided by the university hospital, the same goal as the present 5 Points article on shoulder arthroplasty but on a vastly greater scale. nalyzing those costs guided Dr. Lee and her colleagues to alter clinical programs, which led to a decrease of 3% in hospital expenditures and fewer complications. 1 We are all indebted to Mr. Tannenbaum and his coauthors for providing the journal s readers with a clear map that we can use to both understand and navigate the current maze of hospital costs. Using such a guide, we will be able to gather information that not only saves money, but will improve care by directing resources to services that actually benefit our patients. uthor s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this commentary. Reference 1. Kolata G. What are a hospital s costs? Utah system is trying to learn. New York Times. September 8, 215:1. http://www.nytimes.com/215/9/8/ health/what-are-a-hospitals-costs-utah-system-is-trying-to-learn.html. ccessed September 17, 215. 215 Resident Writer s ward The 215 Resident Writer s ward competition is sponsored by DePuy Synthes Institute. Orthopedic residents are invited to submit original studies, review papers, or case reports for publication. Papers published in 215 will be judged by The merican Journal of Orthopedics Editorial oard. Honoraria will be presented to the winners at the 216 OS annual meeting. $1,5 for the First-Place ward $1, for the Second-Place ward $5 for the Third-Place ward To qualify for consideration, papers must have the resident as the first-listed author and must be accepted through the journal s standard blinded-review process. Papers submitted in 215 but not published until 216 will automatically qualify for the 216 competition. Manuscripts should be prepared according to our Information for uthors and submitted via our online submission system, Editorial Manager, at www.editorialmanager.com/mjorthop. Supported by