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The Economic Implications of a Multimodal Analgesic Regimen for Patients Undergoing Major Orthopedic Surgery: A Comparative Study of Direct Costs
  1. Christopher M. Duncan, MD*,
  2. Kirsten Hall Long, PhD,
  3. David O. Warner, MD* and
  4. James R. Hebl, MD*
  1. From the Departments of *Anesthesiology and
  2. Healthcare Policy and Research, Mayo Clinic College of Medicine, Rochester, MN.
  1. Address correspondence to: James R. Hebl, MD, 200 First St SW, Rochester, MN 55905 (e-mail: hebl.james{at}


Background and Objectives: Total knee and total hip arthoplasty (THA) are 2 of the most common surgical procedures performed in the United States and represent the greatest single Medicare procedural expenditure. This study was designed to evaluate the economic impact of implementing a multimodal analgesic regimen (Total Joint Regional Anesthesia [TJRA] Clinical Pathway) on the estimated direct medical costs of patients undergoing lower extremity joint replacement surgery.

Methods: An economic cost comparison was performed on Mayo Clinic patients (n = 100) undergoing traditional total knee or total hip arthroplasty using the TJRA Clinical Pathway. Study patients were matched 1:1 with historical controls undergoing similar procedures using traditional anesthetic (non-TJRA) techniques. Matching criteria included age, sex, surgeon, type of procedure, and American Society of Anesthesiologists (ASA) physical status (PS) classification. Hospital-based direct costs were collected for each patient and analyzed in standardized inflation-adjusted constant dollars using cost-to-charge ratios, wage indexes, and physician services valued using Medicare reimbursement rates. The estimated mean direct hospital costs were compared between groups, and a subgroup analysis was performed based on ASA PS classification.

Results: The estimated mean direct hospital costs were significantly reduced among TJRA patients when compared with controls (cost difference, $1999; 95% confidence interval, $584-$3231; P = 0.0004). A significant reduction in hospital-based (Medicare Part A) costs accounted for the majority of the total cost savings.

Conclusions: Use of a comprehensive, multimodal analgesic regimen (TJRA Clinical Pathway) in patients undergoing lower extremity joint replacement surgery provides a significant reduction in the estimated total direct medical costs. The reduction in mean cost is primarily associated with lower hospital-based (Medicare Part A) costs, with the greatest overall cost difference appearing among patients with significant comorbidities (ASA PS III-IV patients).

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  • This study was supported by the Mayo Clinic Department of Anesthesiology and Mayo Clinic Department of Healthcare Policy and Research.