A study that attempted to quantify the cost of retained surgical items (RSIs) during primary total joint arthroplasty likely underestimates the true hit that hospitals take when these events occur, both the authors and another expert said.
The poster of the study, presented at the 2015 annual meeting of the International Society for Pharmacoeconomics and Outcomes Research (abstract PM58), used data from the 2009-2012 National (Nationwide) Inpatient Sample (NIS) to arrive at a cost of $6,412 per foreign object left behind. The authors also calculated that the rate of RSIs was one per 6,878 primary total hip arthroplasties and one per 11,961 primary total knee arthroplasties. The overall rate was one per 11,948 procedures.
These incidents are among the ‘never events’ deemed by the Centers for Medicare & Medicaid Services to be too serious to ever have a legitimate reason to occur, and therefore are not reimbursed by the agency. This may lead to the underreporting of RSIs, the authors said.
“Medicare doesn’t reimburse for costs associated with RSIs, and many private insurers have followed suit. That creates a disincentive for reporting them,” said Bryce Van Doren, MPA, MPH, the lead author of the poster and a graduate research assistant at the OrthoCarolina Research Institute, Charlotte, N.C., as well as a doctoral student at the College of Health and Human Services–University of North Carolina at Charlotte.
Robert Cima, MD, professor of surgery and chair of the Surgical Quality and Safety Committee at Mayo Clinic in Rochester, Minn., who was not involved in the study, said although RSI cost estimates are “particularly difficult to determine,” the numbers reported in the poster are much lower than in his experience handling this issue over the last decade and in published reports.
“In many situations, the bills are written off by the institution, charges are adjusted and any payouts are usually associated with a confidentiality agreement, so the true costs of these events are unknown,” Dr. Cima said. “Additionally, other costs—lost productivity from meetings/root cause analysis/sentinel events, legal fees, practice redesign—are all hidden costs rarely captured. But still, there are ways of capturing the data, and the poster’s numbers seem rather low.”
Dr. Cima added that while he does not minimize the seriousness of these events, most orthopedic RSIs are not entire instruments but, instead, the tip of a drill or broken portion of a rod, plate or screw. In the vast majority of the cases, although the patients were told about the RSI and it was documented, trying to retrieve these small objects puts patients at greater risk for complications than leaving them in place.
Mr. Van Doren, along with Susan Odum, PhD, a senior research scientist at the OrthoCarolina Research Institute, and another colleague, identified patients in the NIS who underwent total joint arthroplasty using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes (998.4 and 998.7), including code E871.0, the code for a foreign object left in the body during a surgical procedure. The investigators could only identify cases of RSI during the perioperative period.
The team estimated costs using the NIS charge-to-cost ratio for each hospital with patients in the database.
Overall, 761,214 patients in the database had a total joint arthroplasty, and approximately 0.01% (77/761,214) had an RSI. Thirty-five (45%) of these were among patients with total hip arthroplasty, and the rest were in those with total knee arthroplasty. The investigators extrapolated these numbers to the whole country and estimated that every year, 43 total hip replacement patients and 52 total knee replacement patients will have an RSI.
“It was surprising that the rate was higher in the knee than in the hip—there’s not a lot of places for items to get out of sight in a knee,” said Dr. Odum, who is also an adjunct faculty member at the University of North Carolina at Charlotte.
The patients experiencing RSIs underwent an average of one additional procedure than those without an RSI. The researchers calculated that the average additional cost of each RSI—based on the difference between costs associated with patients with and without an RSI—was $6,412. The researchers did not adjust for differences between the two groups, although they hope to do so in a future large-scale study.