Operative vs Nonoperative Management of Achilles Tendon Rupture: A Cost Analysis

Abstract

Background:

Achilles tendon rupture (ATR) is a common injury with a growing incidence rate. Treatment is either operative or nonoperative. However, evidence is lacking on the cost comparison between these modalities. The objective of this study is to investigate the cost differences between operative and nonoperative treatment of ATR using a large national database.

Methods:

Patients who received treatment for an ATR were abstracted from the large national commercial insurance claims database, Marketscan Commercial Claims and Encounters Database (n = 100 825) and divided into nonoperative (n = 75 731) and operative (n = 25 094) cohorts. Demographics, location, and health care charges were compared using multivariable regression analysis. Subanalysis of costs for medical services including clinic visits, imaging studies, opioid usage, and physical therapy were conducted. Patients who underwent secondary repair were excluded.

Results:

Operative treatment was associated with increased net and total payments, coinsurance, copayment, deductible, coordination of benefits (COB) / savings, greater number of clinic visits, radiographs, magnetic resonance imaging (MRI) scans, and physical therapy (PT) sessions, and with higher net costs due to clinic visits, radiographs, MRIs, and PT (P < .001). Operative repair at an ambulatory surgical center was associated with a lower net and total payment, and a significantly higher deductible compared to in-hospital settings (P < .001). Both cohorts received similar numbers of opioid prescriptions during the study period. Yet, operative patients had a significantly shorter duration of opioid use. After controlling for confounders, operative repair was also independently associated with lower net costs due to opioid prescriptions.

Conclusion:

Compared with nonoperatively managed ATR, surgical repair is associated with greater costs partially because of greater utilization of clinic visits, imaging, and physical therapy sessions. However, surgical costs may be reduced when procedures are performed in ambulatory surgery centers vs hospital facilities. Nonoperative treatment is associated with higher prescription costs secondary to longer duration of opioid use.

Level of Evidence:

Level III, retrospective cohort study.

Introduction

Achilles tendon rupture (ATR) is a common orthopaedic injury that can cause significant functional limitation.^4,8,9,21 The annual incidence of ATR is estimated to be between 13 and 55 per 100 000 and has increased significantly over the last generation, with one study finding a 10-fold increase between 1979 and 2011.⁹ This increasing incidence of ATR, as well as surgical procedures to manage this injury, becomes more important as the cost of delivering orthopaedic care increases and the US health care system shifts toward a value-based care model. As such, there has been renewed interest in the cost-effectiveness of a variety of orthopaedic interventions, including ATR surgery.^12,18

Operative and nonoperative approaches to management of ATR are both practical and evidence based.^4,5,8,14,21 Although operative management has traditionally been the favored approach, more recent analyses have shown that nonoperative management with functional rehabilitation produces similar functional outcomes without the added morbidity of potential surgical complications, such as infection or nerve damage.⁸ Overall, the literature shows that these options are equivalent with respect to return of strength and range of motion, rerupture rate, and return to previous level of activity.^8,13,20,22

As cost considerations become increasingly prominent in the average orthopaedic surgeon’s day-to-day medical decision making, it is important to understand the cost effectiveness of different management strategies for common orthopaedic problems, such as ATR. To date, there is no consensus in the literature regarding the cost-effectiveness of operative management compared to nonoperative management of ATR, and of the cost incurred by the medical services that accompany these surgical techniques. The objective of this study is to understand the cost differential and influence on outcome between nonoperative and operative management of ATR in the US population. We hypothesize that operative management will be more costly and have more ancillary services associated compared to nonoperative management.

Methods

Data Source and Selection

This was a retrospective analysis of the IBM Marketscan Commercial Claims and Encounters Database, which includes more than 215 million deidentified, individual-level private health insurance claims by beneficiaries, their spouses, or dependents enrolled by a participating employer, health plan, or government organization in the United States. This database includes diagnosis codes, procedure codes, and associated costs, as well as demographic and other health-related data, and has been used extensively in the field of orthopaedics in analyses of costs and spending.^{15 -17}

Patients who experienced an ATR between 2010 and 2020 were identified in the Marketscan database using International Classification of Diseases (ICD)-9 and ICD-10 codes (ICD-9 727.667 and ICD-10 S860X). This study excluded patients who had a secondary repair during the study period and surgical patients who required inpatient admission.

Patient Characteristics

Between 2010 and 2020, a total of 100 825 patients submitted claims for an ATR. Of these, 75 731 (75.1%) were managed nonoperatively and 25 094 (24.9%) underwent primary operative repair without revision. Patient characteristics are displayed in Table 1.

Table 1.

Patient Characteristics: Nonoperative vs Operative Achilles Tendon Rupture Cohorts.

Variables	Total (N = 100 825)	Nonoperative (n = 75 731)	Operative (n = 25 094)	P
Age, y, mean ± SD	43.1 ± 13.9	43.3 ± 14.5	42.3 ± 11.9	<.001
Female, n (%)	39 610 (39.3)	33 190 (43.8)	6420 (25.6)	<.001
Geographic region, n (%)
Northeast	21 306 (21.1)	16 512 (21.8)	4794 (19.1)	<.001
North Central	21 308 (21.1)	15 849 (20.9)	5459 (21.8)
South	38 415 (38.1)	28 372 (37.5)	10 043 (40.0)
West	18 613 (18.5)	14 081 (18.6)	4532 (18.1)
Unknown	1183 (1.2)	917 (1.2)	266 (1.1)
Employment status, n (%)
Full-time	59 324 (58.8)	44 952 (59.4)	14 372 (57.3)	<.001
Part-time	1091 (1.1)	830 (1.1)	261 (1.0)
Retiree	4723 (4.7)	3854 (5.1)	869 (3.5)
Disability	287 (0.28)	209 (0.28)	78 (0.31)
Dependent	117 (0.12)	99 (0.13)	18 (0.07)
Other/unknown	35 283 (35.0)	25 787 (34.1)	9496 (37.8)
Plan type, n (%)
Basic	2 (0.002)	2 (0.003)	0 (0.0)	<.001
Comprehensive	2010 (2.0)	1560 (2.1)	450 (1.8)
EPO	1602 (1.6)	1166 (1.5)	436 (1.7)
HMO	11 211 (11.1)	8540 (11.3)	2671 (10.6)
POS	8135 (8.1)	6244 (8.2)	1891 (7.5)
PPO	57 142 (56.7)	43 006 (56.8)	14 155 (56.4)
CDHP	8667 (8.6)	6367 (8.4)	2300 (9.2)
HDHP	7731 (7.7)	5510 (7.3)	2221 (8.9)
In-network services, n (%)	91 963 (91.2)	68 973 (91.1)	22 990 (91.6)	.63
Encounters, n, mean ± SD	15.0 ± 28.0	10.4 ± 23.1	28.9 ± 35.8	<.001

Abbreviations: CDHP, consumer-driven health plan; EPO, exclusive provider organization; HDHP, high-deductible health plan; HMO, health maintenance organization; POS, point-of-service; PPO, preferred provider organization.

Variables and Outcome Measures

Preoperative patient demographics and characteristics assessed included age, gender, geographic region, and employment status, as well as information about their health insurance and care, including plan type, in-network service, and number of encounters. Patients were designated as having received nonoperative vs operative management of ATR, with operative repair defined by Current Procedural Terminology (CPT) codes 27650 and 27652. Utilization of the following medical services was recorded: clinic visits, ankle radiographs, lower extremity magnetic resonance imaging (MRI), and physical therapy (PT). Duration of opioid use and surgery setting (hospital vs ambulatory surgery center [ASC]) were also collected. The primary outcome measures were net payment, total payment, coinsurance, copayment, deductible, and coordination of benefits per savings (COB/savings) amounts.

Statistical Analyses

To compare operatively and nonoperatively managed ATR, Student t test was utilized for continuous variables and chi-squared test for dichotomous variables. Poisson multivariable regression was then conducted to determine whether surgical intervention was independently associated with cost outcomes, adjusting for the identified confounders. Subanalysis was also performed to assess cost contributions of medical services, opioid use, and surgery setting.

Results

Cost for Nonoperative vs Operative Achilles Rupture Management

Because of the limitations of using a large database, the results of the study may not reflect a true cost comparison. Multivariable regression analysis demonstrated that surgical management of ATR was independently associated with increased net payment (IRR 6.99, 95% CI 6.98-6.99), total payment (IRR 6.40, 95% CI 6.39-6.40), coinsurance (IRR 8.39, 95% CI 8.39-8.40), copayment (IRR 1.60, 95% CI 1.60-1.61), deductible (IRR 3.84, 95% CI 3.84-3.85), and COB/savings (IRR 7.19, 95% CI 7.17-7.21) compared with nonoperative management (P < .001). Contributing modifiers to ATR treatment costs are listed in Table 2.

Table 2.

Cost for Nonoperative vs Operative Achilles Tendon Rupture Management.

Variables	Total (N = 100 825)	Nonoperative (n = 75 731)	Operative				P
			Total (n = 25 094)	No Graft (n = 22 638)	Graft (n = 2456)	P
Net paymenta, $	2027.55 ± 4250.85	754.86 ± 2285.64	5864.94 ± 6098.61	5689.27 ± 5830.16	7483.58 ± 7988.76	<.001	<.001
Total payment, $	2586.48 ± 4866.08	1019.37 ± 2523.08	7316.42 ± 6793.34	7138.04 ± 6534.27	8960.09 ± 8660.20	<.001	<.001
Coinsurance, $	214.94 ± 561.38	68.14 ± 256.87	657.98 ± 897.68	650.07 ± 885.78	730.91 ± 997.97	<.001	<.001
Copayment, $	69.31 ± 183.55	57.58 ± 162.63	104.73 ± 232.11	104.61 ± 233.32	105.79 ± 220.72	.81	<.001
Deductible payment, $	238.01 ± 625.46	125.07 ± 341.38	578.96 ± 1032.27	588.67 ± 1038.82	489.41 ± 965.41	<.001	<.001
COB/savings, $	24.27 ± 494.01	10.38 ± 200.85	66.29 ± 926.14	63.44 ± 874.03	92.54 ± 1311.91	.14	<.001

^aNet payment = total payment – coinsurance – copayment – deductible – coordination of benefits (COB).

Cost Comparison for Primary ATR Repair by Outpatient Surgery Setting

Compared with outpatient hospital surgery, operative repair at an ASC was associated with a significantly lower net payment (IRR 0.72, 95% CI 0.71-0.72), total payment (IRR 0.77, 0.77-0.78), and coinsurance (IRR 0.90, 0.90-0.90). Outpatient surgery at an ASC was also associated with significantly higher deductible (IRR 1.21, 1.21-1.21) (P < .001). Copayment and COB/savings were comparable between hospital and ASC settings (Table 3).

Table 3.

Cost for Primary Operative Achilles Tendon Rupture Management by Outpatient Surgery Setting.

Variables	Hospital (n = 16 430)	ASC (n = 8664)	P
Net paymenta, $	6539.78 ± 6597.94	4585.52 ± 4761.97	<.001
Total payment, $	7960.00 ± 7295.20	6096.26 ± 5520.41	<.001
Coinsurance, $	676.89 ± 900.55	622.13 ± 891.16	<.001
Copayment, $	103.28 ± 232.59	107.47 ± 231.18	.17
Deductible payment, $	530.12 ± 993.61	671.60 ± 1095.99	<.001
COB/savings, $	72.53 ± 978.25	54.43 ± 817.99	.14

Abbreviations: ASC, ambulatory surgery center.

^aNet employer payment = total payment – coinsurance – copayment – deductible – coordination of benefits (COB).

Utilization of and Cost Contributions by Ancillary Medical Services

Operative management of ATR was independently associated with greater number of clinic visits (IRR 1.25, 95% CI 1.23-1.26), radiographs (IRR 1.95, 95% CI 1.89-2.01), MRIs (IRR 1.41, 95% CI 1.36-1.47), and PT sessions (IRR 1.81, 95% CI 1.80-1.82) (P < .001). Operative repair was also associated with higher net costs due to clinic visits (IRR 1.45, 95% CI 1.45-1.45), radiographs (IRR 2.37, 95% CI 2.35-2.38), MRIs (IRR 1.45, 95% CI 1.45-1.45), and PT (IRR 1.97, 95% CI 1.96-1.97) (P < .001). Detailed values are shown in Table 4.

Table 4.

Medical Service Costs for Nonoperative vs Operative Achilles Tendon Rupture Management.

Medical Service	Total (N = 100 825)	Nonoperative (n = 75 731)	Operative				P
			Total (n = 25 094)	No Graft (n = 22 638)	Graft (n = 2456)	P
Clinic visits
Mean no.	1.1 ± 1.5	0.99 ± 1.5	1.4 ± 1.6	1.4 ± 1.6	1.4 ± 1.8	.04	<.001
Net payment, $	66.31 ± 151.16	57.25 ± 137.67	93.65 ± 183.33	94.33 ± 187.66	87.43 ± 137.10	.08	<.001
Radiographs
Mean no.	0.18 ± 0.47	0.14 ± 0.40	0.30 ± 0.61	0.30 ± 0.61	0.26 ± 0.56	<.001	<.001
Net payment, $	8.07 ± 50.55	5.65 ± 43.33	15.37 ± 67.31	15.61 ± 67.97	13.18 ± 60.83	.09	<.001
MRI
Mean no.	0.15 ± 0.43	0.13 ± 0.41	0.19 ± 0.50	0.19 ± 0.49	0.24 ± 0.56	<.001	<.001
Net payment, $	62.38 ± 277.46	56.45 ± 268.57	80.27 ± 302.03	76.67 ± 292.30	113.48 ± 378.64	<.001	<.001
PT sessions
Mean no.	8.9 ± 25.1	7.2 ± 21.9	14.2 ± 32.4	14.2 ± 32.7	14.0 ± 30.0	.69	<.001
PT duration, mo	2.3 ± 4.0	2.0 ± 3.6	2.7 ± 4.7	2.8 ± 4.7	2.6 ± 4.5	.30	<.001
Net payment, $	276.05 ± 931.42	206.65 ± 778.45	485.47 ± 1264.29	487.07 ± 1268.08	470.68 ± 1228.88	.54	<.001
Opioid prescriptions
Mean no.	1.2 ± 5.8	1.2 ± 1.4	1.2 ± 10.0	1.2 ± 10.5	1.2 ± 0.56	.83	.39
Use duration, d	27.0 ± 172.1	28.6 ± 182.5	22.3 ± 135.8	21.2 ± 130.6	32.0 ± 176.5	<.001	<.001
Net payment, $	72.97 ± 1529.47	81.45 ± 1571.12	47.38 ± 1395.93	45.39 ± 1445.16	65.74 ± 812.70	.49	.002

Abbreviations: MRI, magnetic resonance imaging; PT, physical therapy.

Utilization of and Cost Contributions by Opioid Prescriptions

Patients undergoing nonoperative and operative management of ATR received similar numbers of opioid prescriptions during the study period (1.2 ± 1.4 vs 1.2 ± 10.0, P = .39). Yet, operative patients had a significantly shorter duration of opioid use (22.3 ± 135.8 vs 28.6 ± 182.5 days). After controlling for confounders, operative repair was also independently associated with lower net costs due to opioid prescriptions (IRR 0.77, 95% CI 0.77-0.77) (Table 4).

Discussion

ATR is an increasingly common orthopaedic injury that may be treated either operatively or nonoperatively with similar functional outcomes.^4,8,9,21 Amid the societal shift to value-based care, understanding the cost differential between treatment options is critical to the judicious use of health care resources. Using the commercially available Marketscan database, this study shows that 100 825 patients experienced ATR between 2010 and 2020. Of these, 24.9% were managed operatively. Nonoperative treatment of ATR was more cost-effective, with operative treatment associated with increased net and total payment, coinsurance, copayment, deductible, and COB/savings. Operative patients also incurred greater costs due to ancillary medical services yet had shorter opioid use duration and lower associated costs compared to nonoperative care. For patients undergoing operative repair, costs were lower when the surgery was performed at an ASC vs hospital setting.

This study is the largest of its kind to investigate cost comparisons between operative and nonoperative treatment of ATR. The study also elucidates the demographic characteristics of patients undergoing either operative or nonoperative ATR. Most patients in this study were middle-aged men who were treated nonoperatively. Su et al¹⁵ showed that younger patients were more likely to be treated operatively. This may be related to activity level, which could influence the cost-effectiveness of a treatment. As operative treatment has been shown to provide earlier return to work and sports, along with stronger plantar flexion strength,^8,15 operative management could contribute to a reduction in societal costs resulting from underperformance or loss of workdays.¹⁵ In addition to their young age, the majority of our study population were full-time workers. This demographic may seek a faster return to work or do not have time to complete functional rehabilitation leading to pursuits in operative treatment, whereas nonoperative treatment may be more suitable for individuals who are not as active.

Our results are consistent with the current literature regarding the cost of operative vs nonoperative management of ATR, showing that operative management is associated with higher costs compared to nonoperative treatment.^{3,15 -17} We found that patients undergoing operative repair used more clinic visits, radiographs, MRIs, and PT sessions as well as incurred greater costs associated with these services. Additional contributors to the cost differential beyond these findings may include increased facility, equipment, and professional fees for operative management.¹⁷ Among operative patients, our subanalysis is also the first to reveal lower costs for ASC vs hospital ATR repair, which aligns with existing studies assessing costs for outpatient orthopaedic procedures.^2,6,7 Notably, patient out-of-pocket expenses in the form of copayments were similar regardless of surgery setting.

Interestingly, our analysis revealed that nonoperative patients used opioids for a significantly longer duration and garnered higher prescription costs when compared with operative counterparts. Prior studies have demonstrated that patients have higher pain scores at up to an 18-month follow-up with ATR that is nonoperatively managed, a contributing factor to higher quality of life for surgical patients.^10,11 Thus, orthopaedic surgeons must be wary of the potential for prolonged opioid use in nonoperative ATR and consider alternative multimodal regimens to adequately control pain and limit prescription costs.

Although the cost differential for operative vs nonoperative ATR repair is known anecdotally, there have been few previous studies investigating these cost differences. A retrospective cost-minimization analysis by Truntzer et al¹⁷ also demonstrated that that the cost of nonoperative management was significantly lower than that of operative management. However, the cited study utilized the PearlDiver claims database, which is limited to pre-2015 data, and included a study population of only 5044 patients. An economic decision model by Su et al¹⁵ and randomized controlled trial by Westin et al¹⁹ further highlight the relative cost-effectiveness of the 2 approaches to ATR, with conflicting results but consistent demonstration of the higher costs of operative repair. The present study uses the largest cohort to date and is the first to assess medical service and opioid prescription contributions to overall costs.

The findings of this study should be considered in the context of its limitations, particularly those inherent to retrospective studies leveraging large national claims databases. Such databases are vulnerable to variability in data coding, which can compromise data accuracy and integrity and result in errors or biases in the database. The data are also entered fundamentally for financial considerations and not for research or epidemiology reasons, and therefore may not include information on clinically relevant data, such as prior activity to surgery, injury mechanism/severity, and functional or pain scores. Similarly, our data were limited in patient demographic and clinical details, which can substantially influence procedural decisions. Moreover, there is annual variation in the population of patients based on insurance coverage, employment, and other factors that may affect a patient’s presence or absence from the database.¹ Finally, a major limitation of this study is an inability to account for overall societal costs, including costs secondary to time off work due to ATR, which would provide valuable information to enhance our findings. Despite these limitations, to date, this is the largest study to investigate the cost differential between operative and nonoperative management of ATR, as well as the main drivers of these costs.

Conclusion

Both operative and nonoperative management strategies for ATR place a financial burden on the US health care economy. Compared with nonoperatively managed ATR, surgical repair is associated with greater costs that are in part due to greater utilization of clinic visits, imaging, and physical therapy sessions. However, surgical costs may be reduced when procedures are performed in ASCs vs hospital facilities. Additionally, nonoperative treatment is associated with higher prescription costs secondary to longer duration of opioid use. Altogether, these findings can help inform surgical decision making and aid surgeons in providing cost-effective care.