I'd like to thank the committee for having me here today. I'm currently a fellow at Brown University and performed this study in conjunction with Dr. Brett Owens, and will be proceeding to Sports Fellowship at Duke next year. Today I'd like to chat with you a little bit about case volume as a predictor of graft selection and cost for anterior cruciate ligament reconstruction. I have no disclosures relevant to this discussion. Anterior cruciate ligament reconstruction is one of the most commonly performed procedures in the United States, and as such, there is a high amount of cost associated with the procedure. We know from past studies that low case volume surgeons and centers are associated with risk factors like reoperation and re-injury following ACL reconstruction. We also know that based on the MOON work group that allograft futilization is associated with higher failure rates, and this is particularly true in younger patients. Here we see in patients younger than 20 a steep increase in failure rates with allograft futilization. Currently much more is known in the literature about which perioperative risk factors and patient risk factors increase the cost of ACL reconstruction. Here you'll see that general anesthesia increases the cost by $2,000. Greater than one medical condition increases the cost by $1,800, and one minute of OR time increases the cost of ACL reconstruction by about $100. So specifically we decided to look at whether or not surgeon or surgeon center case volume has an impact on the usage of allograft and the overall cost of ACL reconstruction. With regards to our study design, we utilize the HCUP ambulatory surgery database for the state of Florida. Specifically we use Florida because they provide unique physician and facility identifiers which allow us to track specific surgeons and surgery centers over time and place. We looked at the cost for every instance of CPT-2988, and we perform multivariate regression to calculate which factors have the largest impact on cost of an ACL reconstruction. Here's the results of the multivariate regression. I'll hit on some of the high points here. As you might expect, hospital admission was overall devastating for the total cost of care, adding about $20,000 to the episode of care. High physician volume saved overall $5,000 over on the entire period of care. Meniscus repair added approximately $7,500. Allograft usage added $10,000 to the episode of care. And finally, high facility volumes took away approximately $1,800 from the episode of care. When you specifically look at high volume surgeons and stratify by that, we see that higher volume surgeons above perform meniscus repair 5% more of the time compared to lower volume surgeons. We see that higher throughput facilities perform meniscal repair approximately 7% more often than low throughput facilities. If you stratify and specifically look at low volume surgeons, we found that these surgeons were 3.5 times more likely to use allograft in a patient less than 18 years old. So with regard to the limitations of this study, first of all, this was a claims-based database, and as such, we used CHARGE as a proxy for costs, although that being said, we have done this in previous papers. And then given the granularity of the HCU database, we were unable to specifically look at the type of graft used. So in conclusion, allograft usage represents a major factor on the cost of ACL reconstruction to the tune of about $10,000. This is extremely important because this variable is completely within the surgeon control. Lower volume surgeons were 3.5 times more likely to use allografts in the young patient population, specifically less than 18 years old. And higher volume surgeons and centers were significantly more cost-effective despite being more likely to perform concomitant meniscal repair. These are my references, and thank you for your attention.

case volume

graft selection

cost

ACL reconstruction

allograft usage