Abstract
Background
Demand for platelet-rich plasma (PRP) injections for osteoarthritis has dramatically increased in recent years despite conflicting evidence regarding its efficacy and highly variable pricing in the top orthopaedic centers in the United States, because PRP is typically not covered by insurance. A previous study investigating the mean price of PRP injections obtained information only from centers advertising online the availability of PRP injections. Thus, there is a need for further clarification of the overall availability and variability in cost of PRP injections in the orthopaedic community as well as an analysis of relevant regional demographic and hospital characteristics that could be associated with PRP pricing.
Questions/purposes
Our study purposes were to (1) report the availability and price variation of knee PRP injections at top-ranked United States orthopaedic centers, (2) characterize the availability of pricing information for a PRP injection over the telephone, (3) determine whether hospital characteristics (Orthopaedic Score [U.S. News & World Report measure of hospital orthopaedic department performance], size, teaching status, and rural-urban status) were associated with PRP injection availability and pricing, and (4) characterize the price variation, if it exists, of PRP injections in three metropolitan areas and individual institutions.
Methods
In this prospective study, a scripted telephone call to publicly listed clinic telephone numbers was used to determine the availability and price estimate (amount to be paid by the patient) of a PRP injection for knee osteoarthritis from the top 25 hospitals from each United States Census region selected from the U.S. News & World Report ranking of best hospitals for orthopaedics. Univariable analyses examined factors associated with PRP injection availability and willingness to disclose pricing, differences across regions, and the association between hospital characteristics (Orthopaedic Score, size, teaching status, and rural-urban status) and pricing. The Orthopaedic Score is a score assigned to each hospital by U.S. News & World Report as a measure of hospital performance based partly on patient outcomes, with higher scores indicating better outcomes.
Results
Overall, 87% (87 of 100) of respondents stated they offered PRP injections. Pricing ranged from USD 350 to USD 2815 (median USD 800) per injection, with the highest prices in the Northeast. The largest price range was in the Midwest, where more than two-thirds of PRP injections given at hospitals that disclosed pricing cost USD 500 to USD 1000. Of the hospitals that offered PRP injections, 68% (59 of 87) were willing to disclose price information over the telephone. PRP injection pricing was inversely correlated with hospital Orthopaedic Score (-3% price change [95% CI -5% to -1%]; p = 0.01) and not associated with any of the other hospital characteristics that were studied, such as patient population median income and total hospital expenses. An intracity analysis revealed wide variations in PRP pricing in all metropolitan areas that were analyzed, ranging from a minimum of USD 300 within 10 miles of metropolitan area B to a maximum of USD 1269 within 20 miles of metropolitan area C.
Conclusion
We found that although PRP injections are widely available, pricing continues to be a substantial financial burden on patients, with large price variability among institutions. We also found that if patients are willing to shop around in a metropolitan area, there is potential to save a meaningful amount of money.
Clinical Relevance
As public interest in biologics in orthopaedic surgery increases, knowledge of its pricing should be clarified to consumers. The debated efficacy of PRP injections, combined with our findings that it is an expensive out-of-pocket procedure, suggests that PRP has limited cost-effectiveness, with variable, discrete pricing. As such, the price of PRP injections should be clearly disclosed to patients so they can make informed healthcare decisions.
Introduction
Public interest in and use of platelet-rich plasma (PRP) injections has greatly increased over the past decade [5]. Although PRP injections have been FDA-approved and are deemed safe, their clinical efficacy for the treatment of osteoarthritis (OA) is unclear [4, 7, 15, 19, 24, 26, 29]. Recent guidelines, including those from the American Academy of Orthopaedic Surgeons, indicate that only limited evidence suggests that PRP injections reduce pain or improve function in patients with symptomatic knee OA [1, 14]. Current OA guidelines from the American College of Rheumatology [12] and Osteoarthritis Research Society International [3] do not recommend PRP for knee OA because of a lack of high-quality evidence and emphasize the need for more rigorous studies. A meta-analysis of 34 randomized controlled trials comparing PRP ad control groups found that PRP did not outperform steroid injections by a clinically important amount, and that conclusions about PRP’s efficacy are only supported by low-quality evidence [9]. Rajan et al. [23] suggest that PRP may have value for patients at high risk for perioperative and postoperative complications or who are at high risk for undergoing revision arthroplasty. However, the authors also noted that in their Markov model to evaluate the use of PRP injections for knee OA, PRP injections are not cost-effective, and these patients have lower quality-adjusted life year scores than patients undergoing TKA [23].
Because of the lack of evidence supporting the use of PRP injections, they are typically not covered by insurance [21]. Patients seeking PRP despite unsubstantiated claims of efficacy may pay out of pocket, but there are limited data on hospital charges for PRP injections at top academic centers in the United States. However, patient interest in PRP has grown over time, and an increasing number of providers are using PRP in their practices. Thus, such data may be useful for patients and providers alike because consumer prices for common procedures can vary widely across regions, and it is unclear what factors drive this variation in consumer prices owing to a lack of transparency about factors associated with this variation [25]. A 2019 study focusing on only centers that advertised PRP online found a mean price of USD 714 ± USD 144 [21]. However, to obtain a comprehensive estimate of price variation, a greater number and wider range of centers must be queried. Moreover, it is unclear to what extent hospital characteristics such as hospital region or patient volume may be associated with PRP pricing.
As such, we aimed to (1) report the availability and price variation of knee PRP injections at top-ranked United States orthopaedic centers, (2) characterize the availability of pricing information for a PRP injection over the telephone, (3) determine whether hospital characteristics (Orthopaedic Score [U.S. News & World Report measure of hospital orthopaedic department performance], size, teaching status, and rural-urban status) were associated with PRP injection availability and pricing, and (4) characterize the price variation, if it exists, of PRP injections in three metropolitan areas and individual institutions.
Patients and Methods
Hospital Data Collection
This prospective, observational study evaluated a sample of the top 100 orthopaedic hospitals (top 25 from each United States census region [Northeast, Midwest, West, and South]) ranked by the 2021 U.S. News & World Report list of best hospitals for orthopaedics; this methodology has been previously applied [22, 25]. From the ranking list, the Orthopaedic Score was also collected, which is a score (of 100 possible points) assigned to each hospital based on an analysis of clinical outcomes, patient volume, patient experience, nursing staff, and clinical technologies, with higher scores indicating better outcomes [31]. This methodology was chosen because top academic orthopaedic hospitals may have better brand-name reputation with patients; thus, patients seeking PRP injections might start to educate themselves about pricing by contacting these centers. Furthermore, this methodology has been used to obtain consumer prices for orthopaedic procedures [22, 25].
A scripted telephone call simulating a 55-year-old patient with a history of unilateral knee OA whose physician recommended a PRP injection was used to approximate a standardized patient requesting an over-the-telephone quote (hospital charge) for a single PRP injection. A description of the procedure, knee PRP injection, and if necessary, the Current Procedural Terminology code 0232T was provided by researchers. Calls were made during business hours (9 AM to 5 PM for each time zone) from Monday through Friday (excluding holidays), and each center was given a minimum of three opportunities (calls) to confirm whether they provided PRP injections and to provide researchers with a quote for a single PRP injection. For each call, researchers contacted the orthopaedic sports medicine department at each institution via the publicly listed numbers on their respective websites. If an orthopaedic sports medicine telephone number was not listed, the general orthopaedics number was called. If it was necessary to transfer the call to another department, such as accounts receivable, researchers would remain on the call for as many transfers as was necessary to obtain the required information, including transfers to the billing department. If a price was obtained during the first telephone call, we did not call the same hospital twice. All hospitals in the sample responded to telephone calls. We conducted a pilot trial of 11 hospitals approximately 4 weeks before contacting all 100 hospitals. Prices obtained during the pilot trial matched prices obtained during the study.
PRP Availability and Willingness to Disclose PRP Pricing Over the Telephone
For PRP availability, a “no” was indicated when an employee advised researchers that they either definitively do not offer PRP injections or could not locate information on procedure availability given the Current Procedural Terminology code or description. For PRP pricing, a “no” was indicated when researchers were directly informed that the hospital could not provide pricing over the telephone or required a physician’s visit at that hospital before providing pricing. For both availability and pricing, if the employee advised researchers they would call back with information, one follow-up call was made within 48 hours of the initial call to remind the employee to provide the information; if the information was not provided within 48 hours after the follow-up call, a “no” was indicated. Data about the availability and pricing of PRP injections were collected between March 21, 2022, and April 18, 2022. Data were collected by team members (JT, MH, RR, AMR, and RC).
Hospital Characteristics and Patient Demographic Information
Hospital characteristics used for analysis included the Orthopaedic Score from the U.S. News & World Report as well as the number of staffed beds, annual outpatient visits, annual total expenses, annual payroll expenses, personnel, teaching status, and hospital address extracted from the American Hospital Association Hospital Statistics database [2]. We used the hospital address for intracity analysis and to obtain hospital patient population demographic information including the hospital ZIP Code–specific median income from the United States Census Bureau and urban-rural classification from the United States Department of Agriculture [6]. Rural-urban classification was divided into metropolitan areas with fewer than 250,000 inhabitants, 250,000 to 1 million inhabitants, and 1 million or more inhabitants. Upon completion of data collection and analyses, the information was deidentified.
Primary and Secondary Study Goals
Our primary goal was to report the availability of PRP injections and willingness to disclose PRP pricing over the telephone at top-ranked orthopaedic centers. To achieve this goal, we obtained a list of the top 100 ranked orthopaedic hospitals in the United States. Then, we called each orthopaedic institution and indicated a “yes” or “no” about whether the institution was willing and able to provide a price for the injection over the telephone.
Our secondary study goals were to determine whether hospital characteristics were associated with PRP availability and pricing. We also aimed to characterize the price variation of PRP injections in metropolitan areas and individual institutions. To determine the association between hospital characteristics and PRP availability, we used a univariable chi-square analysis. Then, we used a multivariable generalized linear model with a gamma distribution to examine the relationship between continuous and categorical hospital characteristics, patient demographic information, and the reported price of PRP injections. To characterize price variation of PRP injections in metropolitan areas, we conducted an “intracity analysis” and “institutional analysis,” detailed below.
Intracity Analysis
To assess PRP injection price variations in metropolitan areas, we examined the three most populous cities and their surrounding regions, according to 2020 to 2021 United States Census Bureau survey data [30]. Our institutional review board exemption required us to not disclose the exact metropolitan areas that we analyzed. Hospitals in the full 100-hospital cohort in each of the three cities were identified; the hospital with the highest PRP price was then established. Subsequently, hospitals included in the study that were within a 10-mile, 20-mile, or 35-mile radius of the hospital with the highest PRP price were examined to determine the potential maximum savings between the highest-priced hospital and lowest-priced hospital in the respective radius and the maximum dollars (USD) saved per mile traveled in that radius. The maximum dollars saved per mile was calculated by first determining the cost difference between the hospital with the highest PRP price and another hospital’s PRP price in the same city or region. Then, the cost difference was divided by the driving distance (miles) between the two hospitals, as determined by Google Maps. The resultant value was then used for our dollars (USD) saved per mile analysis. These two steps were repeated for each hospital that fell within the 10-mile, 20-mile, or 35-mile radius in the highest-priced hospital in that city.
Institutional Analysis
To assess institutional variations in PRP pricing, we selected a sample of the top 10 institutions from the Northeast region of the United States because this region has the highest density of top academic orthopaedic centers, and we contacted the offices of different orthopaedists practicing at each institution if there were multiple orthopaedists listed. We compared pricing for orthopaedists at the same institution to determine whether there was a uniform pricing structure across the institution or whether individual orthopaedists set different prices.
Ethical Approval
This study was exempted from review by our institutional review board because the collected data do not involve human subjects, and the study does not require informed consent or involve an analysis of identifiable data.
Statistical Analysis
Analyses were performed for the full 100-hospital cohort and stratified by United States Census region. Descriptive statistics were calculated for hospital characteristics, hospital patient population characteristics, and PRP pricing, including the proportion of hospitals offering PRP, the proportion willing to disclose pricing, the median price of PRP, price quartiles, interquartile range, and absolute range. Kruskal-Wallis H-tests were applied to detect significant differences in hospital characteristics, patient demographic information, and PRP pricing across United States Census regions. We used a univariable chi-square analysis to detect significant differences in PRP availability and pricing disclosure based on hospital characteristics and patient demographic information. Continuous variables were categorized into four quartiles for the analysis. A multivariable generalized linear model with a gamma distribution examined the relationship between continuous and categorical hospital characteristics, patient demographic information, and the reported price of PRP, adjusted for hospital and hospital patient demographic characteristics. Effect estimates are reported in % change (compared with the reference) and 95% confidence intervals. Analyses were performed using SAS statistical software, version 9.4 (SAS Institute Inc).
Results
Availability and Price Variation of Knee PRP Injections
Availability of PRP Injections
A total of 96% of hospitals (24 of 25) in the Northeast region offered PRP injections, 68% (17 of 25) in the Midwest offered PRP, 88% (22 of 25) in the South offered PRP, and 96% (24 of 25) in the West offered PRP (Table 1). Overall, 87% (87 of 100) of respondents at these top-ranked orthopaedic institutions stated they offered PRP injections.
Table 1.
Regional breakdown of hospital characteristics, hospitals offering PRP injection, and hospitals willing to disclose PRP pricing
| Northeast (n = 25) | Midwest (n = 25) | South (n = 25) | West (n = 25) | p value | |
| Hospitals offering PRP injections | 96% (24) | 68% (17) | 88% (22) | 96% (24) | 0.002 |
| Hospitals that disclosed pricing | 71% (17) | 76% (13) | 59% (13) | 67% (16) | 0.07 |
| Staffed beds | 787 (2541) | 715 (1285) | 652 (2693) | 415 (819) | 0.04 |
| Annual outpatient visits | 729,473 (3,471,869) | 526,396 (7,262,864) | 35,5547 (1,889,996) | 370,343 (1,312,590) | 0.31 |
| Annual total expenses in USDa | 1940 (7116) | 1173 (6029) | 1028 (3773) | 1099 (4588) | 0.11 |
| Annual payroll expenses in USDa | 618 (3367) | 440 (3064) | 312 (1221) | 419 (1520) | 0.04 |
| Personnel numbera | 6937 (24,378) | 5597 (32,637) | 4158 (18,709) | 3911 (13,360) | 0.07 |
| Proportion that are teaching hospitals | 100% (25) | 96% 24) | 96% (24) | 76% (19) | 0.02 |
| Rural-urban continuum | 0.93 | ||||
| Counties in metropolitan areas with population of 1 million or more | 21 | 20 | 20 | 18 | |
| Counties in metropolitan areas with population of 250,000 to 1 million | 4 | 1 | 3 | 3 | |
| Counties in metropolitan areas with population less than 250,000 | 0 | 3 | 2 | 0 | |
| ZIP Code–specific patient income in USD | 97,317 (173,724) | 72,190 (150,598) | 66,569 (102,420) | 78,720 (115,859) | 0.42 |
| Orthopedic Scoreb | 55 (50) | 51 (33) | 51 (16) | 54 (30) | 0.04 |
Data presented as % (n) or median (range). Range was calculated as maximum – minimum.
In millions of USD.
Orthopedic Score is a score (of 100 possible points) assigned by U.S. News & World Report to each hospital based on an analysis of clinical outcomes, patient volume, patient experience, nursing staff, and clinical technologies, with higher scores indicating better outcomes.
National Variation in PRP Pricing
The median price for PRP injections was USD 800 (range USD 350 to USD 2815) (Fig. 1). The Midwest had the largest absolute range (USD 350 to USD 2815), and the Northeast had the smallest absolute range (USD 400 to USD 1200). The Northeast had the highest median price (USD 1000 [range USD 400 to USD 1200]), followed by the West (USD 788 [range USD 450 to USD 1467]), the Midwest (USD 750 [range USD 350 to USD 2815]), and the South (USD 700 [range USD 350 to USD 1942]). After controlling for potential confounding variables such as hospital annual total expenses and hospital ZIP Code–specific median income, we found that the South had lower PRP pricing (-33% price change [95% CI -54% to -2%]; p = 0.04) than the West, and there were no differences in pricing between other regions and the West (Supplemental Table 1; http://links.lww.com/CORR/B237).
Fig. 1.
This figure shows the distribution of institutions offering PRP injections at various price points.
Availability of Pricing Information for a PRP Injection Over the Telephone
Of the hospitals with PRP injection prices available, 68% (59 of 87) were willing to disclose PRP pricing information over the telephone; this ranged from 59% (13 of 22) in the South to 77% (13 of 17) in the Midwest (p = 0.07). The proportions of hospitals in the West and Northeast that were willing to disclose this information were 67% (16 of 24) and 71% (17 of 24), respectively (Table 1).
Hospital Characteristics Associated With PRP Injection Availability and Pricing
The orthopaedic institutions we contacted were overwhelmingly teaching hospitals (92%), mostly in metropolitan areas with at least 1 million inhabitants. There was no difference between regions in terms of the hospital patient population’s median ZIP Code–specific income. However, the Northeast (55) had the highest median hospital Orthopaedic Score, followed by the West (54), Midwest (51), and the South (51) (p = 0.04) (Table 1). We found differences in the availability of PRP injections across regions (Northeast 96%, Midwest 68%, South 88%, West 96%; p = 0.002) but not teaching status. We also found differences in hospitals’ willingness to disclose the price of PRP injections based on their Orthopaedic Score (first quartile: 50%, second quartile: 74%, third quartile: 58%, and fourth quartile: 91%; p = 0.02), total expenses (first quartile: 65%, second quartile: 42%, third quartile: 67%, and fourth quartile: 86%; p = 0.04), and hospital payroll expense (first quartile: 70%, second quartile: 28%, third quartile: 79%, and fourth quartile: 81%; p = 0.003) (Supplemental Table 2; http://links.lww.com/CORR/B238). In terms of factors associated with PRP pricing, we found that the Orthopaedic Score was inversely associated with PRP pricing (-3% price change per unit increase in Orthopaedic Score [95% CI -5% to -1%]; p = 0.01), indicating that higher-ranked centers had lower prices for PRP injections.
Price Variation of PRP Injections Within Metropolitan Areas and Individual Institutions
Intracity Variation in PRP Pricing
Wide variations in PRP pricing were found in all three metropolitan areas we analyzed. For all three metropolitan areas, an increase in travel distance resulted in an increase in the maximum dollar amount saved, ranging from USD 300 within a 10-mile radius in metropolitan area B to USD 1269 within a 35-mile radius in metropolitan area C. However, the amount saved (USD) per mile traveled decreased with a longer travel distance. Nevertheless, by researching the costs of PRP injections at different hospitals, we found that patients who wish to have PRP injections may receive PRP injections for a lower price if they are willing to travel to nearby providers (Table 2).
Table 2.
Intracity price variations for PRP injections
| Maximum amount saved within a given 1-mile radius of metropolitan area | Maximum amount saved per 1 mile traveled within a given 1-mile radius of metropolitan area | |||||
| 10 miles | 20 miles | 35 miles | 10 miles | 20 miles | 35 miles | |
| Metropolitan area A | 550 | 600 | 600 | 57 | 39 | 33 |
| Metropolitan area B | 300 | 341 | 550 | 39 | 15 | 14 |
| Metropolitan area C | 1250 | 1269 | 1269 | 78 | 65 | 50 |
Prices are in USD.
Institutional Variation in PRP Pricing
Nine of 10 hospitals included in this analysis established center-wide uniform pricing for PRP injections, and one institution allowed their orthopaedic surgeons to set individual prices, ranging from USD 750 to USD 1000 per injection according to telephone call responses from three separate orthopaedic surgeon offices associated with a single hospital.
Discussion
This study is particularly relevant in the current landscape because there has been increasing interest in PRP injections for orthopaedic applications, both in orthopaedic research and among the general public over the past few years [5, 20]. There is limited information on the pricing of PRP at top academic centers; because of these centers’ name-brand recognition, they may be where patients start their search for PRP injection pricing. We found that although PRP injections are widely available at these surveyed hospitals, price transparency is relatively limited. We found substantial price variability for PRP injections across the United States and even found variability between providers in the same city. After controlling for potentially confounding factors, we found no association between PRP injection pricing and patient demographic information such as median income. Providers and patients should be aware of the pricing variation that exists. Evidence-based or not, the demand for PRP injections is there, and this study allows patients who choose to be treated by academic surgeons to become better-educated consumers when electing to receive a PRP injection, although patients should be informed there is limited evidence behind PRP before receiving the injection. With better-educated consumers, providers are challenged to justify their pricing, especially if they are charging a higher price.
Limitations
Although we contacted the top 100 orthopaedic hospitals to assess trends in the academic orthopaedic community, the information from these hospitals may not represent broader pricing patterns, which include private practice groups and nonorthopaedic specialists who might offer PRP injections. However, given the name-brand recognition that many top academic centers hold, it would be reasonable to assume that a proportion of patients seeking information on PRP pricing would contact these centers first before contacting less-well-known orthopaedic practices. Furthermore, the availability of PRP injections does not vary between private and academic practices [18]. Furthermore, several institutions asked study team members to make an appointment for an evaluation by one of their surgeons before providing a price. Thus, patients at these institutions may be able to obtain a price by overcoming some of these initial barriers but would still not be able to obtain pricing information over the telephone. Qualitatively, study team members reported being asked for detailed patient identifiers, such as name, date of birth, address, and telephone number before being provided with pricing information. Thus, if office staff were unable to identify the patient from our standardized patient script, we were unable to obtain PRP pricing over the telephone from some institutions. However, these barriers further characterize issues of price transparency for PRP injection procedures, especially for new patients (new to that specific practice) shopping around for PRP injections, emphasizing our study objectives of recognizing price variations and transparency. Additionally, we were unable to collect possible additional “hidden” costs associated with PRP injections. Quotes provided by some facilities may be incomplete. For example, consultation fees, facilities fees, and equipment fees may not be included in the whole PRP price. Therefore, future studies could investigate other aspects of costs associated with out-of-pocket orthobiologic therapies to provide a more comprehensive estimate of PRP pricing. Lastly, although we obtained the out-of-pocket price for a single PRP injection, we did not ask for the number of injections in each institution’s standard treatment protocol, and thus a single PRP injection may not be the total out-of-pocket price for patients at institutions where the standard treatment protocol involves more than one PRP injection.
Availability and Price Variation of Knee PRP Injections
We found that 87% (87 of 100) of top-ranked hospitals offered PRP injections. A study surveying American Orthopaedic Society for Sports Medicine members in 2019 found that 76% of members used PRP in their practice [20]. However, another study in 2019 using telephone calls to sports medicine orthopaedic practices in an American Orthopaedic Society for Sports Medicine database found that only 61% of sports medicine practices offer PRP injections [18]. Despite the use of different sampling methods, this suggests that either PRP is growing in popularity with further expansion of its use in the orthopaedic community in the past 3 years or that top-ranked academic centers may be more likely to offer PRP injections. Although the best-available evidence suggests that PRP is ineffective, the pricing information we uncovered can improve our understanding of out-of-pocket cost variations for orthobiologic treatments for patients who wish to pursue this treatment despite the lack of evidence supporting its use. We found a median price of USD 800 for PRP, which is higher than the price of USD 685 found by a study in 2017 [21]. Even after adjusting for inflation, this is lower than the median price of USD 800 found in our study. This suggests that PRP pricing may have increased at a higher rate than the rate of inflation, because USD 685 in 2017 is equivalent to USD 757 in 2021. This difference could have been a function of differences in study methodology. Piuzzi et al. [21] characterized the prices of PRP injections at PRP centers that were found using online search engines, whereas the current study used a sample consisting of the top-ranked orthopaedic hospitals nationwide, which we believe allows for better insight into trends in the academic orthopaedic community. This is important because top academic centers have brand-name reputation, so patients may start their search at these institutions should they want to become an educated consumer on the pricing of a PRP injection. Although the best-available evidence suggests that PRP is ineffective, studies have shown an increase in interest by patients and providers [5, 20]. Cohen et al. [5] found an increase in the number of Google queries related to PRP injections for the hip and knee, and a study surveying American Orthopaedic Society for Sports Medicine members found that most sports medicine physicians use PRP and that PRP is increasing in use [20]. Thus, the information found in this study is important, because top academic centers may be where patients start their search for pricing on PRP injections. An educated consumer will also challenge providers to better justify the need and price for a PRP injection, especially if their price is higher. Although the median price in our study was USD 800, the absolute range and IQR we found showed high variability in the pricing of PRP. At the national level, we found an absolute range of USD 2465 (minimum USD 350 to maximum USD 2815) and an IQR of USD 400 (25th percentile: USD 600 to 75th percentile: USD 1000). This is almost double the absolute range of USD 1010 (minimum USD 380 to maximum USD 1390) found by Piuzzi et al. [21] for knee OA, and higher than the range in a study on PRP injections for rotator cuff repairs (minimum USD 1000 to maximum USD 1500) [27]. However, another study on PRP found an even higher absolute range than this study did (USD 4798) [18]. Considering our findings and those in other studies, there is substantial variability in the price of PRP injections.
Availability of Pricing Information for a PRP Injection Over the Telephone
We found that only 68% (59 of 87) of the hospitals that offer PRP were willing to disclose their price for a PRP injection, which is lower than the 85% proportion found by Piuzzi et al. [21] in a highly selective sample. However, this may have been because of the aforementioned differences in methodology. The proportion of centers willing to disclose pricing was lower than we expected; there have been greater efforts to increase price transparency in healthcare, with the Centers for Medicare and Medicaid Services passing legislation in 2019 and 2021 requiring hospitals to list their standard charges (chargemasters) publicly and list this information in a consumer-friendly format. However, one study on 500 hospitals found that about 20% of hospitals had chargemasters that were either inaccessible or did not meet mandated requirements [16]. That same study found that for 15 common chargemaster items, each item was listed under an average of 275 different names. A study examining price transparency in orthopaedic surgery examined the availability of price information for THA from 122 hospitals (two hospitals from each state plus Washington, DC, and the 20 top-ranked orthopaedic hospitals according to U.S. News and World Report rankings) [25]. They found that 60% of top-ranked hospitals and 63% of non-top-ranked hospitals were able to provide a complete price estimate including both the physician and hospital fee. This is similar to our finding of 68% (59 of 87); however, billing and pricing for THA is far more complex than for a PRP injection, and thus we expected a greater availability of PRP pricing information. Despite our expectation of a higher proportion of hospitals offering PRP pricing information, this is an improvement from a 2007 study that mailed letters to 353 California hospitals requesting price estimates for one of three elective procedures (laparoscopic cholecystectomy, hysterectomy for fibroids, and routine screening colonoscopy) [8]. In that study, only 3% of contacted hospitals provided a complete price estimate. Nonetheless, our findings suggest there is still a long way to go in integrating price transparency in orthopaedic surgery.
Hospital Characteristics Associated With PRP Injection Availability and Pricing
We found that teaching hospitals were not more likely to offer PRP injections than nonteaching hospitals. This is contrary to a study in which teaching hospitals had more availability of patient services than nonteaching hospitals [28], but this was likely because our sample was skewed heavily toward teaching hospitals. However, for factors influencing PRP pricing, we found that only the hospital Orthopaedic Score had a small negative correlation with PRP pricing. Most hospital characteristics were not associated with PRP pricing, suggesting there are likely extraneous factors associated with the decision to provide PRP injections as a service. The small correlation with the Orthopaedic Score may be partially explained by the fact that institutions with higher Orthopaedic Scores may be administering a higher volume of novel therapeutics such as PRP injections, resulting in lower costs for preparation kits owing to bulk discounts. However, additional research is needed to identify factors associated with the decision to provide this service.
Price Variation of PRP Injections Within Metropolitan Areas and Individual Institutions
In our intracity analysis, we found that patients could obtain sizable cost savings if they were willing to travel within a 10-mile radius and could save even more if they traveled further. Patients could find cost savings even within an institution. In the three cities analyzed, within a 10-mile radius, patients could obtain cost savings up to USD 1250. The minimum cost savings we found was USD 250 in the institutional analysis, which is still substantial for a single injection, especially considering the lack of guidance on the number, frequency, and timing of injections. Clinical studies have used one to nine injections over the course of 1 year [10, 11, 17]. This would translate into direct cost savings of USD 250 to USD 11,250 (USD 1250 for nine injections) for the patient. The high variability in pricing and treatment protocol further highlights the lack of evidence supporting PRP’s use and efficacy. Given this lack of evidence, PRP should not be used until or unless high-quality randomized trials are performed and replicated in order to demonstrate its efficacy.
Conclusion
This nationwide analysis of PRP pricing for knee OA provides an overview of the availability of PRP injections and the variability in its pricing in top-ranked orthopaedic institutions. We found that although PRP injections are widely available, pricing was highly variable and inversely related to the hospital Orthopaedic Score. Our intracity and institutional analyses demonstrated patients can save a meaningful amount of money on PRP injections if they are willing to shop around. However, obtaining this pricing information can be difficult, because we were only able to obtain pricing information from 68% (59 of 87) of hospitals by telephone. This highlights the need for increased price transparency of largely cash-pay procedures such as PRP injections. We believe that price transparency could benefit not only patients but also providers when counseling patients on the expected charges for a PRP injection. As public interest in biologics in orthopaedic surgery and the number of investigations into the efficacy of PRP grow, knowledge on pricing should be clarified to consumers. The debated efficacy of PRP injections, combined with our findings that it is an expensive out-of-pocket procedure, suggests PRP has limited cost-effectiveness with variable, discrete pricing. As such, the limited data on the efficacy of its use should be clearly disclosed to patients so they can make informed healthcare decisions. Patients who receive PRP should be made aware of the required number and total costs of PRP injections before undergoing therapy. Regardless, discussions between the patient and physician regarding the costs and possible benefits of different treatments are important, particularly when discussing treatments for which the best-available evidence suggests they are ineffective. Because health literacy is closely tied to improved outcomes [13], integrating a more comprehensive dialogue about PRP's costs and limited benefits to arrive at a common treatment goal can strengthen physician-patient relationships. Future studies should continue to investigate outcomes and the efficacy of PRP across a variety of patient subgroups. The current absence of evidence supporting the use of PRP also questions which factors underlie decisions to provide PRP treatment and factors associated with pricing decisions as they relate to alternatives such as corticosteroid injections.
Supplementary Material
Acknowledgment
We thank Dr. Alexis Colvin for her guidance and mentorship during the study design, data collection and analysis, and manuscript preparation phases of the project.
Footnotes
Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Ethical approval for this study was waived by the Mount Sinai Health System Institutional Review Boards (HS number: Study-21-01820).
This work was performed at the Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Contributor Information
Justin Tiao, Email: justin.tiao@icahn.mssm.edu.
Kevin Wang, Email: kevin.wang@mountsinai.org.
Michael Herrera, Email: michael.herrera@icahn.mssm.edu.
Renee Ren, Email: reneeren783@gmail.com.
Ashley M. Rosenberg, Email: ashley.rosenberg@icahn.mssm.edu.
Richawna Cassie, Email: richawna.cassie@mountsinai.org.
Jashvant Poeran, Email: jashvant.poeran@mountsinai.org.
References
- 1.Aiyer R, Noori S, Schirripa F, et al. Treatment of knee osteoarthritic pain with platelet-rich plasma: a systematic review of clinical studies. Pain Manag. 2021;11:419-431. [DOI] [PubMed] [Google Scholar]
- 2.American Hospital Association. Fast facts on U.S. hospitals, 2022. Available at: https://www.aha.org/statistics/fast-facts-us-hospitals. Accessed June 21, 2023.
- 3.Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27:1578-1589. [DOI] [PubMed] [Google Scholar]
- 4.Bennell KL, Paterson KL, Metcalf BR, et al. Effect of intra-articular platelet-rich plasma vs placebo injection on pain and medial tibial cartilage volume in patients with knee osteoarthritis: the RESTORE randomized clinical trial. JAMA. 2021;326:2021-2030. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Cohen SA, Zhuang T, Xiao M, Michad JB, Amanatullah DF, Kamal RN. Google trends analysis shows increasing public interest in platelet-rich plasma injections for hip and knee osteoarthritis. J Arthroplasty. 2021;36:3616-3622. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Cromartie J. Rural-urban continuum codes. Available at: https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx. Accessed June 21, 2023.
- 7.Dório M, Pereira RMR, Luz AGB, Deveza LA, de Oliviera RM, Fuller R. Efficacy of platelet-rich plasma and plasma for symptomatic treatment of knee osteoarthritis: a double-blinded placebo-controlled randomized clinical trial. BMC Musculoskelet Disord. 2021;22:822. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Farrell KS, Finocchio LJ, Trivedi AN, Mehrotra A. Does price transparency legislation allow the uninsured to shop for care? J Gen Intern Med. 2010;25:110-114. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Filardo G, Previtali D, Napoli F, Candrian C, Zaffagnini S, Grassi A. PRP injections for the treatment of knee osteoarthritis: a meta-analysis of randomized controlled trials. Cartilage. 2021;13:364s-375s. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Gobbi A, Lad D, Karnatzikos G. The effects of repeated intra-articular PRP injections on clinical outcomes of early osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. 2015;23:2170-2177. [DOI] [PubMed] [Google Scholar]
- 11.Hart R, Safi A, Komzák M, Jajtner P, Puskeiler M, Hartova P. Platelet-rich plasma in patients with tibiofemoral cartilage degeneration. Arch Orthop Trauma Surg. 2013;133:1295-1301. [DOI] [PubMed] [Google Scholar]
- 12.Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2020;72:149-162. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Lans A, Bales JR, Fourman MS, Borkhetaria PP, Verlaan JJ, Schwab JH. Health literacy in orthopedic surgery: a systematic review. HSS J. 2023;19:120-127. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Le ADK, Enweze L, DeBaun MR, Dragoo JL. Current clinical recommendations for use of platelet-rich plasma. Curr Rev Musculoskelet Med. 2018;11:624-634. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Li W, Pan J, Lu Z, Zhu H, Guo J, Xie D. The application of platelet-rich plasma in the treatment of knee osteoarthritis: a literature review. J Orthop Sci. 2022;27:420-428. [DOI] [PubMed] [Google Scholar]
- 16.Lu AJ, Chen EM, Vutam E, Brandt J, Sadda P. Price transparency implementation: accessibility of hospital chargemasters and variation in hospital pricing after CMS mandate. Healthc (Amst). 2020;8:100443. [DOI] [PubMed] [Google Scholar]
- 17.Metcalf KB, Mandelbaum BR, McIlwraith CW. Application of platelet-rich plasma to disorders of the knee joint. Cartilage. 2013;4:295-312. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Momaya AM, McGee AS, Dombrowsky AR, et al. The cost variability of orthobiologics. Sports Health. 2020;12:94-98. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Moton RZ, Nawaz MZ, Latif M, Akhund MA, Khan Z. Clinical and functional outcomes following platelet rich plasma in the management of knee osteoarthritis: a case series in a tertiary care hospital. J Pak Med Assoc. 2021;71:S94-S98. [PubMed] [Google Scholar]
- 20.Noback PC, Donnelley CA, Yeatts NC, et al. Utilization of orthobiologics by sports medicine physicians: a survey-based study. J Am Acad Orthop Surg Glob Res Rev. 2021;5:e20.00185. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Piuzzi NS, Ng M, Kantor A, et al. What is the price and claimed efficacy of platelet-rich plasma injections for the treatment of knee osteoarthritis in the United States? J Knee Surg. 2019;32:879-885. [DOI] [PubMed] [Google Scholar]
- 22.Racimo AR, Talathi NS, Zelenski NA, Wells L, Shah AS. How much will my child's operation cost? Availability of consumer prices from US hospitals for a common pediatric orthopaedic surgical procedure. J Pediatr Orthop. 2018;38:e411-e416. [DOI] [PubMed] [Google Scholar]
- 23.Rajan PV, Ng MK, Klika A, et al. The cost-effectiveness of platelet-rich plasma injections for knee osteoarthritis: a Markov decision analysis. J Bone Joint Surg Am. 2020;102:e104. [DOI] [PubMed] [Google Scholar]
- 24.Rodríguez-Merchán EC. Intra-articular platelet-rich plasma injections in knee osteoarthritis: a review of their current molecular mechanisms of action and their degree of efficacy. Int J Mol Sci. 2022;23:1301. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Rosenthal JA, Lu X, Cram P. Availability of consumer prices from US hospitals for a common surgical procedure. JAMA Intern Med. 2013;173:427-432. [DOI] [PubMed] [Google Scholar]
- 26.Samuelson EM, Ebel JA, Reynolds SB, Arnold RM, Brown DE. The cost-effectiveness of platelet-rich plasma compared with hyaluronic acid injections for the treatment of knee osteoarthritis. Arthroscopy. 2020;36:3072-3078. [DOI] [PubMed] [Google Scholar]
- 27.Samuelson EM, Odum SM, Fleischli JE. The cost-effectiveness of using platelet-rich plasma during rotator cuff repair: a Markov model analysis. Arthroscopy. 2016;32:1237-1244. [DOI] [PubMed] [Google Scholar]
- 28.Shahian DM, Nordberg P, Meyer GS, et al. Contemporary performance of U.S. teaching and nonteaching hospitals. Acad Med. 2012;87:701-708. [DOI] [PubMed] [Google Scholar]
- 29.Sundaram K, Vargas-Hernández JS, Sanchez TR, et al. Are subchondral intraosseous injections effective and safe for the treatment of knee osteoarthritis? A systematic review. J Knee Surg. 2019;32:1046-1057. [DOI] [PubMed] [Google Scholar]
- 30.United States Census Bureau. City and town population totals: 2020-2021. Available at: https://www.census.gov/data/tables/time-series/demo/popest/2020s-total-cities-and-towns.html. Accessed June 21, 2023.
- 31.US News Staff. FAQ: how and why we rank and rate hospitals. 2022. U.S. News & World Report L.P. Available at: https://health.usnews.com/health-care/best-hospitals/articles/faq-how-and-why-we-rank-and-rate-hospitals. Accessed June 21, 2023. [Google Scholar]