Abstract
Aims: To estimate the cost to hospitals of materials (i.e. medications, equipment, and supplies) required to administer common interventions for post-surgical analgesia after total knee arthroplasty (TKA), including single-injection peripheral nerve block (sPNB), continuous peripheral nerve block (cPNB), periarticular infiltration of multi-drug cocktails, continuous epidural analgesia, intravenous patient-controlled analgesia (IV PCA), and local infiltration of bupivacaine liposome injectable suspension (BLIS).
Materials and methods: This analysis was conducted using a mixed methods approach combining published literature, publicly available data sources, and administrative data, to first identify the materials required to administer these interventions, and then estimate the cost to the hospital of those materials. Medication costs were estimated primarily using the Wholesale Acquisition Costs (WAC), the cost of reusable equipment was obtained from published sources, and costs for disposable supplies were obtained from the US Government Services Administration (GSA) database. Where uncertainty existed about the technique used when administering these interventions, costs were calculated for multiple scenarios reflecting different assumptions.
Results: The total cost of materials (i.e. medications, equipment, and supplies) required to provide post-surgical analgesia was $41.88 for sPNB with bupivacaine; $756.57 for cFNB with ropivacaine; $16.38 for periarticular infiltration with bupivacaine, morphine, methylprednisolone, and cefuroxime; $453.84 for continuous epidural analgesia with fentanyl and ropivacaine; $178.94 for IV PCA with morphine; and $319.00 for BLIS.
Limitations: This analysis did not consider the cost of healthcare providers required to administer these interventions. In addition, this analysis focused on the cost of materials and, therefore, did not consider aspects of relative efficacy or safety, or how the choice of intervention for post-surgical analgesia might impact outcomes such as length of stay, re-admissions, discharge status, adverse events, or total hospitalization costs.
Conclusions: This study provided an estimate of the costs to hospitals for materials required to administer commonly used interventions for post-surgical analgesia after TKA.
Introduction
Inadequate post-surgical analgesia in patients undergoing total knee arthroplasty (TKA) can lead to delays in ambulation, prolonged hospital stay, re-admission, and, by extension, healthcare costsCitation1–3. Historically, opioids have been the mainstay of post-surgical pain control, often administered using intravenous patient-controlled analgesia (IV PCA) devices. However, the use of opioids to manage post-surgical pain is associated with frequent, harmful, and costly opioid-related adverse events (ORAEs), and even short-term exposure to opioids can lead to chronic use and long-term sequelaeCitation4,Citation5.
A better understanding of the risks and benefits of relying on opioids for post-surgical analgesia has prompted the development of opioid-sparing approaches that combine interventions with different analgesic mechanisms of action (i.e. multimodal analgesia)Citation6,Citation7. Interventions providing extended local or regional analgesia at the surgical site are often the foundation for multimodal analgesia, and may include single-injection peripheral nerve block (sPNB), continuous peripheral nerve block (cPNB), periarticular infiltration of multi-drug cocktails, continuous epidural analgesia, and local infiltration with a long-acting local analgesic such as bupivacaine liposome injectable suspension (BLIS). These interventions are often combined with systemic analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, or other non-opioid, adjunctive analgesicsCitation7,Citation8.
The efficacy and safety of these multimodal interventions are well-studied, and their use is supported by recommendations in evidence-based clinical practice guidelinesCitation7. However, the relative cost of these interventions to hospitals is not as well understood, and cost has been cited as a potential barrier to providing optimal post-surgical analgesiaCitation9. Because Medicare reimburses hospitals for joint arthroplasties using pre-determined rates based on diagnosis-related groups (DRGs), and not based on the amount of resources actually used, hospitals are motivated to evaluate resource use and identify opportunities for cost containment. Estimating the total costs of these interventions from a hospital perspective can be challenging, as their components may span budgets across multiple hospital departments. For example, cPNB may require local anesthetics from the pharmacy budget, equipment from the materials management budget, supplies from the operating room budget, and nursing time from the orthopedic service line budget, to name but a few related components. When such costs are fragmented, individuals managing hospital budgets in isolation may have an incomplete perspective on the relative costs of different interventions for post-surgical analgesia.
Previous studies have attempted to estimate the cost of various interventions for post-surgical analgesia, but only did so for some surgeriesCitation10, as part of a bundled clinical pathwayCitation11, or did not estimate the cost of specific materials (e.g. medications, equipment and supplies)Citation12–14. Having this information would likely inform stakeholders, including healthcare providers, hospital administrators, and third-party payers, who are interested in comparing the costs of interventions used for post-surgical analgesia. The primary objective of this study was, therefore, to estimate the cost to hospitals of materials (i.e. medications, equipment, and supplies) for interventions commonly used in combination, and recommended in clinical practice guidelinesCitation7, for post-surgical analgesia after TKA, including sPNB, cPNB, periarticular infiltration of multi-drug cocktails, continuous epidural analgesia, IV PCA, and local infiltration with BLIS.
Methods
Resources required
This costing analysis was conducted using a mixed methods approach that combined published literature, publicly available sources of data, and administrative data, to first identify the resources required to administer these interventions, and then estimate the cost to the hospital of providing those resources. This analysis was primarily interested in resources that could have a material impact on the overall cost of these interventions for post-surgical analgesia, including medications, equipment, and supplies.
This analysis did not consider resources related to hospital personnel (e.g. physicians, nurses, pharmacists), for several reasons. First, accurately estimating the amount of time spent by these providers to deliver each intervention would require time-based, activity-driven costing. Such an approach has been taken to estimate nursing, pharmacy, central supply, and engineering staff time required for IV PCACitation15, but has not been conducted in the US for the other interventions of interest. For example, physician and nursing time and other associated costs have been estimated for various interventions for post-surgical analgesia in Italy, but that analysis did not include pharmacist timeCitation16. Second, it is unclear what the cost to the hospital (i.e. the perspective chosen for this analysis) should be for provider time if it was considered, since staffing levels are dictated by provider to patient ratios and other metrics, rather than the number of specific interventions performed.
This analysis also excluded resources required primarily for TKA surgery (e.g. time in operating room), or anesthesia (e.g. time in post-anesthesia care unit), or resources that were common to all post-surgical analgesia interventions (e.g. monitoring of vital signs). In addition, the cost of complications such as hospital re-admission or emergency department visits for uncontrolled pain or other complications was not included, since this information is not readily available for the interventions compared.
The materials (i.e. medications, equipment, and supplies) required to administer sPNB, cPNB, periarticular infiltration of multi-drug cocktail, continuous epidural, IV PCA, and BLIS were first identified using instructional materials from the New York School of Regional Anesthesia (NYSORA) (www.nysora.com). This preliminary list was reviewed and refined by one of the authors, a practicing anesthesiologist experienced with a variety of approaches to post-surgical analgesia; informal feedback on this list was also sought from colleagues to determine if critical resources were omitted.
Costing
Once the materials (i.e. medications, equipment, and supplies) required to administer these interventions were identified, various approaches were taken to estimate their costs from the hospital’s perspective. Because the interventions chosen are intended to provide post-surgical analgesia throughout the period of most intense post-surgical pain, and consistent with a previous costing analysis of IV PCA for TKACitation17, costs were estimated over a 48-h period (i.e. day of surgery, post-surgical day 1, and post-surgical day 2).
For most medications, the unit cost to the hospital was estimated using the Wholesale Acquisition Costs (WAC) from the Truven Health Analytics Red BookCitation18. For BLIS, which is often purchased directly from the manufacturer, the price from the manufacturer was used rather than the WAC, which assumes a markup from a wholesaler. The quantity of medications required (i.e. total dose) was obtained from published literature and product labeling, as summarized below. The cost of per use of reusable equipment (e.g. IV PCA pump) was obtained from published sourcesCitation17,Citation19,Citation20 updated to 2016 costs using the Medical Care component of the Consumer Price Index. The cost of supplies (e.g. needles, syringes, elastomeric pump) required for these interventions was obtained from the Government Services Administration (GSA) databaseCitation21, which was used as a publicly available proxy for the purchase prices of equipment supplies that may be available to larger hospitals. Where uncertainty existed about the specific technique used when administering these interventions, we calculated costs for multiple scenarios reflecting different medication and dosing assumptions.
Results
A summary of hospital costs for materials for each of these interventions, both individually by cost type (i.e. medications, equipment, and supplies), as well as overall by intervention, is shown in . A detailed listing of the materials required for each of these interventions and their unit costs to the hospital are shown in .
Figure 1. Summary of equipment, supply, and medication costs of post-surgical analgesic interventions.
Table 1. Materials cost of post-surgical analgesic interventions.
sPNB
Randomized controlled trials (RCTs) examining sPNB for TKA (e.g. single shot femoral nerve block, adductor canal block, sciatic nerve block) have used either bupivacaine or ropivacaine as the local anesthetic, at concentrations of 0.25–0.50% and volumes of 10–40 mLCitation22. In our analysis, we assumed that sPNB was administered using 20 mL of bupivacaine 0.25% provided in 10 mL vials. We assumed that sPNB was administered under ultrasound guidance requiring a diagnostic ultrasound machine with a linear transducerCitation22. Required supplies included a sterile ultrasound probe sleeve, a standard nerve block tray (i.e. needles, syringes, prep solution, sponge sticks), an additional 20 mL syringe, and an additional 22-gauge, 50–100 mm, short bevel, insulated needle.
The total cost to the hospital for the materials required for sPNB over 48 h was, therefore, estimated at $41.88, including $3.22 (8%) for medications, $8.46 (20%) for equipment, and $30.20 (72%) for supplies. Using bupivacaine 0.5% rather than 0.25% increased costs 3% to $43.18, while doubling the volume of bupivacaine 0.25% to 40 mL increased costs 8% to $45.10.
cPNB
RCTs examining cPNB for TKA (i.e. continuous femoral nerve block) have used either bupivacaine or ropivacaine as the local anesthetic, at concentrations of 0.125–0.20%, infused at volumes of 6–14 mL/hCitation22. In our analysis, we assumed that cFNB used ropivacaine 0.2% infused at 10 mL/h for 48 h (total 480 mL), provided in 100 mL vials. We assumed that cPNB was administered under ultrasound guidance requiring a diagnostic ultrasound machine with a linear transducerCitation22. Continuous local anesthetic delivery can be accomplished using a reusable electronic pump, or with a disposable elastomeric pump. Both types have been shown to be equally effective in managing post-operative pain, but elastomeric pumps are associated with fewer technical issues and greater patient satisfactionCitation23, and, thus, are included in our calculation. In addition to the elastomeric pump kit (i.e. On-Q, 400 mL, with Select-A-Flow and SilverSoaker catheter), required supplies included a sterile ultrasound probe sleeve, a standard continuous nerve block tray (i.e. needles, syringes, prep solution, sponge sticks), an additional 20 mL syringe, an additional 22-gauge, 50–100 mm, short bevel, insulated needle, and a neoprene knee immobilizer (as recommended for fall prevention in patients undergoing TKACitation24).
The total cost to the hospital for the materials required for cPNB over 48 h was, therefore, estimated at $756.57, including $193.15 (26%) for medications, $8.46 (1%) for equipment, and $554.96 (73%) for supplies. Lowering the infusion rate to 6 mL/h decreased costs 10% to $679.31, since only three 100 mL vials of ropivacaine would be required, while raising the infusion rate to 14 mL/h increased costs 10% to $833.93 since seven vials would be required.
Periarticular infiltration of multi-drug cocktail
Periarticular infiltration of multi-drug cocktails may combine numerous medications, including NSAIDs, local anesthetics, epinephrine, opioids, antibiotics, and corticosteroidsCitation25–27. The Ranawat Orthopedic Center protocol for periarticular infiltration of multi-drug cocktails has been widely published, and consists of an initial, deep periarticular injection prior to bone cementation, followed by a second, superficial injection prior to wound closingCitation28–31. The first injection consists of a cocktail of bupivacaine 0.5% with epinephrine (24–30 mL), normal saline (20–22 mL), morphine sulfate (8–10 mg), and methylprednisolone 40 mg; the second injection consists of 40 mL of bupivacaine 0.25%. For costing purposes, these doses were rounded to the nearest available vial size, and it was assumed that each injection was made using a 60 mL syringe and a 22-gauge, 1.5-inch needleCitation27.
The total cost to the hospital for the materials required for periarticular infiltration of multi-drug cocktail over 48 h was, therefore, estimated at $16.38, including $13.04 for the first injection ($12.59 in medications and $0.45 in supplies) and $3.34 for the second injection ($2.89 in medications and $0.45 in supplies).
Continuous epidural
Continuous epidural analgesia for TKA may be administered using different local anesthetics (e.g. bupivacaine, lidocaine, ropivacaine) with or without opioids (e.g. morphine, fentanyl) at various concentrations, infusion rates, and durationsCitation7,Citation32. The two largest RCTs identified for continuous epidural for TKA administered ropivacaine 0.2% with morphine 0.08 mg/mL at a volume of 4 mL/h for 24 hCitation33 or ropivacaine 0.4% with fentanyl 4 mcg/mL at volumes of 6–10 mL/h until the morning of post-surgical day 3Citation34. In our analysis, we assumed that continuous epidural was administered using a commercially available combination of ropivacaine 0.2% with fentanyl 4 mcg/mL at 8 mL/h for 48 h (total 384 mL). We assumed that a PCA pump was used for the continuous infusion, and that a capnography monitor was used to monitor respiratory function. Required supplies included a standard epidural tray (i.e. epidural needles, Luer lock syringes, catheters, prep solution), a PCA extension set, and a disposable capnography cannula.
The total cost to the hospital for the materials required for continuous epidural over 48 h was, therefore, estimated at $453.84, including $249.36 (55%) for medications, $153.33 (34%) for equipment, and $51.15 (11%) for supplies. Lowering the infusion rate to 4 mL/h decreased costs 27% to $329.16, since only two 100 mL bags would be required, while raising the infusion rate to 10 mL/h increased costs 14% to $516.18, since five 100 mL bags of ropivacaine with fentanyl would be required. If the infusion were administered for only 24 h at 8 mL/h, costs would decrease to $275.52, with only two 100 mL bags and only 1 day of PCA pump use required.
IV PCA
Protocols for IV PCA also vary widely in terms of the medications used, doses given, device settings, and duration of use. A previous economic analysis of IV PCA for TKA that was conducted using hospital chargemaster data from a large group purchasing organization reported that the most commonly used medications were hydromorphone 0.2 mg/mL (57% of patients) and morphine 1 mg/mL (43% of patients)Citation17. In our analysis, we assumed that IV PCA was administered using morphine provided in 30 mL cartridges (containing 30 mg of morphine), and that two cartridges were usedCitation17. We assumed that a PCA pump was used, and that a capnography monitor was used to monitor respiratory function. Required supplies included a PCA extension set and a disposable capnography cannula.
The total cost to the hospital for the materials required for IV PCA over 48 h was, therefore, estimated at $179.74, including $15.96 (9%) for medications, $153.33 (85%) for equipment, and $10.45 (6%) for supplies. Using hydromorphone rather than morphine increased costs 37% to $246.86, due to the higher unit cost of hydromorphone cartridges ($20.77 each) and the higher number of cartridges required (four, based on a previous economic analysis)Citation17.
BLIS
Various techniques have been reported for administering local infiltration of BLIS for TKA, with or without varying amounts of traditional bupivacaine 0.25–0.50%, and also by varying the amount of normal saline with which the BLIS can be expanded, consistent with its labelingCitation35. In our analysis, we assumed that a 20 mL vial of BLIS (containing 266 mg of liposomal bupivacaine) was combined with a 30 mL vial of bupivacaine 0.25% and a 70 mL vial of normal saline, for a total volume of 120 mL. These assumptions are based on the administration technique used in the most recent company-sponsored RCT on BLIS in TKA. We assumed that no equipment was required for BLIS, and that the required supplies included a 20 mL syringe and a 22 gauge, 1.5” needle.
The total cost to the hospital for the materials required for BLIS over 48 h was, therefore, estimated at $319.00, including $318.58 (99.9%) for medications, and $0.42 (0.1%) for supplies.
Discussion
This study provides an estimate of hospital costs for the materials (i.e. medication, equipment, and supplies) required to administer six commonly used interventions to manage post-surgical pain after TKA, including sPNB, cPNB, continuous epidural, IV PCA, and BLIS. To our knowledge, this is the first such assessment conducted in the US, and may provide the most realistic estimate of the relative costs to the hospital for the materials required for these interventions. It is important to note that, while our analysis estimated the materials required for these interventions in isolation, these interventions are commonly combined to provide multimodal analgesia (e.g. sPNB and IV PCA). The total cost to the hospital for the materials required for multimodal post-surgical analgesia should, therefore, sum the costs of the individual interventions studied. This is particularly relevant for interventions using single-dose administration of medications with short-term efficacy (e.g. sPNB, periarticular infiltration of multi-drug cocktails) that may necessitate other interventions to provide extended post-surgical analgesia for 48 h or more.
The estimated cost to the hospital for the materials (i.e. medications, equipment, and supplies) required to administer the six interventions of interest ranged from $16.38 for periarticular infiltration of multi-drug cocktails to $756.57 for cPNB. The cost of medications required ranged from $3.22 for sPNB with bupivacaine to $318.58 for BLIS, while the cost of equipment required ranged from $0 for BLIS to $153.33 for continuous epidural and IV PCA, and the cost of supplies required ranged from $0.42 for BLIS to $554.96 for cPNB.
These costs are based on the assumptions outlined above regarding technique, drug selection, and dosing. It is important to note that these techniques are not standardized, and new techniques are frequently introduced into clinical practice. For example, there is a growing body of evidence supporting the use of additive medications aimed at improving the efficacy and prolonging the duration of peripheral nerve blockCitation36,Citation37, the cost of which depends on the selected additive and dosing. A number of studies have evaluated the addition of dexmedetomidine at doses up to 1.5 mcg/kg to a single-injection femoral nerve block with bupivacaine or ropivacaineCitation38–40, which would increase costs by $42.00.
The large differences noted in the costs of medications, equipment, and supplies required for each of these interventions suggests that opinions on the relative costs of these interventions may differ widely among different stakeholders within a hospital, depending on the specific costs for which they are financially responsible. For example, sPNB and IV PCA may seem relatively inexpensive for someone managing the hospital medication budget, since most of their costs are incurred in the equipment and supplies budgets. Similarly, cPNB may seem relatively inexpensive to someone managing the equipment budget, but has substantial costs for both the medication and supplies budgets. Also, since virtually all costs for BLIS are in the medication budget, it may be perceived as the costliest option from a hospital pharmacy perspective. While the estimated costs of materials for both continuous epidural and cPNB were higher than BLIS, they were distributed across different budgets (i.e. medication, equipment, and supplies), which may change how their relative costs are perceived by pharmacy administrators. This suggests that hospital costs should be viewed from an integrated perspective (e.g. chief financial officer) to make more informed decisions about the relative costs of these interventions.
It is also important to interpret the cost to the hospital of these materials (i.e. medication, equipment, and supplies) within the context of the total cost to the hospital of TKA, including hospitalization costs of $12,165–$22,550, depending on the hospital, payer type, and region, as well as additional costs for post-acute care (e.g. rehabilitation, skilled nursing facility admission) and re-admissionsCitation41–44. The largest components of hospitalization costs for TKA are the knee implant (which may be up to half the total), with room and board and operating room costs comprising the majority of the remainderCitation43,Citation45. In comparison, the cost to the hospitals for the materials (i.e. medication, equipment, and supplies) required for post-surgical analgesia represent less than 5% of the cost of TKA.
Our estimate of the costs to the hospital for materials (i.e. medication, equipment, and supplies) required for cPNB is similar to previous estimates reported in the literature, including an analysis of line item charges for cPNB medications and suppliesCitation46. A 2011 analysis based on the cost of items used for cPNB was $573 per patient, adjusted to $663 to represent 2016 costsCitation47. Although no comparable estimates were found on hospital costs of continuous epidural in the US, a study conducted in France reported that the costs for equipment and supplies were more than twice as high for continuous epidural analgesia as IV PCACitation48, which was confirmed in this study.
Limitations
There are several important limitations to this analysis. We estimated the cost of medications and supplies using publicly available wholesale prices from the Truven Red Book and the GSA rather than using real-world costs, because the latter are often confidential, and supplier agreements can prevent sharing this information publicly. We also did not attempt to estimate costs from administrative databases of hospital charges (e.g. Premier Perspectives database) and publicly available hospital charge to cost ratios (e.g. from the Centers for Medicare and Medicaid Services). Those ratios are mainly intended to estimate the mean aggregate costs of an entire hospitalization rather than the true cost of specific items such as medications and supplies. Moreover, costs of reusable equipment were obtained from published literature and, thus, are subject to the limitations of the studies in which they were estimated.
An additional limitation is that our analysis did not consider the cost of the healthcare providers (e.g. physician, nurse, and pharmacist) required to administer these interventions, as explained above. Since several of the interventions examined involve catheters (e.g. cPNB, continuous epidural, IV PCA), programmable equipment (e.g. PCA pump and capnography monitor for continuous epidural and IV PCA), and adjustable supplies (e.g. elastomeric pump for cPNB), the personnel costs associated with monitoring, adjusting, programming, and troubleshooting these components could be substantial. For example, a study that examined the different tasks associated with providing IV PCA for post-surgical analgesia in a hospital setting found that it required 67.4 min of nursing time, 7.9 min of pharmacist time, and 9.8 min of pharmacy technician time per patientCitation15; similar estimates were not identified in the literature for cPNB and continuous epidural analgesia.
Another limitation is that this costing analysis was focused solely on estimating hospital costs for materials (i.e. medication, equipment, and supplies) for each of these interventions, independent of their relative efficacy (e.g. impact on pain, physical function, activities of daily living, supplemental opioid use), safety (e.g. incidence of ORAEs, other complications such as falls, catheter-related infection, and phlebitis), patient preference (e.g. satisfaction with post-surgical analgesia, minimizing exposure to opioids), and healthcare resource use (e.g. re-admissions, follow-up visits). Ultimately, decisions about the optimal intervention for post-surgical analgesia for TKA should incorporate these aspects.
Furthermore, this analysis did not consider potential economic outcomes that may be associated with these interventions. For example, differences in hospital length of stay, discharges to skilled nursing facilities, incidence of ORAEs, and re-admissions have been reported when comparing different interventions for post-surgical analgesia following TKACitation49. The costs to hospitals of these outcomes under a 90-day bundled payment program such as the CMS Comprehensive Care for Joint Replacement (CJR) for TKA could dwarf the costs of materials (i.e. medication, equipment, and supplies), and further change perspectives about the relative costs of these interventions. Concerns have also been raised about the potential long-term harms (e.g. chronic use, diversion, misuse, abuse) of short-term opioids prescribed for post-surgical analgesia, since 6–7% of opioid-naïve patients who received opioids after surgery were still using them 90 days laterCitation5. If specific interventions for post-surgical analgesia after TKA can reduce (or eliminate) the need for post-surgical opioids, this could further alter the relative societal costs of the interventions examined.
Lastly, this study did not include all potential medication regimens and techniques that can be used in the management of post-surgical pain in patients undergoing TKA. Specifically, we were unable to evaluate the cost of cFNB using reusable electronic pumps, because, while the cost of the pump itself can be identified, the approximate number of uses per pump could not be estimated and would be needed to determine the cost per use.
Conclusions
This study identified the materials (i.e. medications, equipment, and supplies) required to administer six commonly used interventions for post-surgical analgesia following TKA, and estimated the cost of those materials to the hospital over a 48 h period using publicly available data sources. Large differences were found in the cost of materials (i.e. medication, equipment, and supplies) for these interventions, as well as the proportion of costs related to medications, equipment, and supplies for each intervention. The results of this study may help inform stakeholders about differences in perspectives that may exist within a hospital about the relative cost of these interventions based on the specific materials used and the budgets involved.
Transparency
Declaration of funding
This study was sponsored by Pacira Pharmaceuticals, Inc.
Declaration of financial/other relationships
SC is an employee of Pharmerit International, which provided consulting services to Pacira Pharmaceuticals on this project. NS provided consulting services to Pharmerit International on this project. SD is an employee of Pacira Pharmaceuticals. JME peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
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