Cost of staff and personnel, as we know in any business is a big cost.
Is it cost effective? And if it is more expensive, who bears that cost burden? The hospital? The payor? The patient?
At Indiana University Health, where I work, we pulled some of the data to look at this cost question. We looked at mean operative time. Posterior approach was 80 minutes. Direct anterior approach was 89 minutes. Not that much difference.
In-room time was about 30 minutes greater for the direct anterior approach. Set-up of the table. And our anesthesiologist uses 3x the dosages of spinal bupivacaine in those patients—because we all share the same anesthesiologists as a large group-due to the long set-up time. When you look at the mean variable direct cost, no dramatic difference.
When you tease out the 2 high volume surgeons, because I think high volume surgeons can streamline their processes, you see operative time pretty similar. Both about 68 minutes. Both of them did over 100 cases during the 6-month period where the data was collected so not surprising.
The mean in room time is where you start to see some difference. It’s that set-up time we talked about. Almost 30 minutes.
The mean variable direct cost difference, which we now look at all the time, with implants excluded, the direct anterior approach costs $1,000 more per case than the posterior approach.
There have been claims of decreased cost, and I will tell you the one publication that’s in the Journal of Medical Economics, was based on length of stay, which we know is not really related to approach. And the percentage of discharge to home, which is much more related to social issues (Kamath, et al., J Med Econ, 2018).
There were multiple fatal flaws in that publication despite propensity of matching.
The trend to outpatient…that’s something to consider…there’s no doubt that’s not going away and by 2026 they expect over half of our hip replacements to be done in the outpatient setting.
Is the direct anterior approach the optimal approach for an ambulatory surgery center (ASC)? I would say, “Is a freestanding ambulatory surgery center a place for a learning curve?”
What complications are more stressful for a smaller staff, anesthesia and the surgeons? Is it intra-operative proximal femoral or trochanteric fracture? Or excessive intra-operative blood loss?
ASCs typically have more limited staff, resources and square footage to run the table, store the table and run the fluoroscopy machines. And you don’t need any of those with the posterior approach.
The direct anterior approach is not better, it’s just different. The direct anterior approach is not more efficient. It’s not less costly. It consumes greater resources.
Every day in my office I get asked the question: “You don’t use the direct anterior approach?” And when I tell them no, they start to get angry because they’ve been on the internet and they say, “How can you not do that? That is the best approach. Don’t you read?”
I would say to the posterior approach surgeons, don’t be ashamed. You’re not a bad surgeon because you don’t do the direct anterior approach.
When all of our data is compared, I want to stand at the top—and I’m pretty competitive—and I’d like to be the cheapest, highest quality surgeon that exists.
Dr. Meneghini seems to have made his reputation by reporting the bad results of the anterior approach. He touts his use of the posterior approach but does not report his results regarding alignment, leg length and dislocation. He does not mention use of an alternative approach for cases of spasticity(cerebral palsy etc.)where a posterior approach is contra-indicated. He seems to have a prejudice for the posterior approach rather than an objective view in my opinion.