Date of Award

January 2017

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Gary E. Friedlaender

Second Advisor

Kevin J. Bozic


Value in healthcare is defined as outcomes divided by the cost to achieve them. In a healthcare system under increasing scrutiny to serve more patients at lower costs, pursuing value-driven strategies aligns the incentives of healthcare’s various stakeholders to provide better outcomes for patients at lower costs.

New models for data sharing can help clinicians and patients decide which interventions will best drive improved outcomes if they allow the exploration of the totality of available evidence. The controversy surrounding the safety of recombinant human bone morphogenetic protein-2 (rhBMP-2) provides a case example of putting the Yale Open Data Access (YODA) Project into practice. A review of the existing literature showed complications including heterotopic ossification, postoperative radiculitis, and endplate osteolysis associated with the use of rhBMP-2 in posterior spinal fusion techniques.

Given that two expert groups were provided with the same data and general aims, it was hypothesized that approaches and results of two independent systematic reviews and meta-analyses would be highly similar. An analysis of these reviews showed that they used different methodological approaches, with one center choosing to stratify by surgical approach and the other group combining data from all approaches. Results were broadly similar though there were some important differences. One center found a statistically significant, but small, benefit whereas the other center reported no advantage in comparing rhBMP-2 and control groups. In the analysis of harms, neither showed an increased cancer risk at 48 months, although one center reported a significant increase at 24 months. Conclusions reflected these differences in summary estimates of benefit balanced with small but potentially important risk of harm. Replication of systematic reviews are valuable as even expert groups looking at the same data may come to different conclusions.

Though efforts like data sharing can help clinicians better understand healthcare outcomes, measuring costs is a critical step in understanding and managing resource usage to improve value in healthcare. Time Driven Activity based Costing (TDABC) is a financial accounting methodology which can more accurately measure costs in orthopaedic surgery than commonly used hospital accounting methodologies. This methodology was put into practice in an academic medical center for primary total knee and hip arthroplasty patients of three surgeons. This accounting method requires the creation of process maps which detail the various steps of delivering total joint arthroplasty before combining them with financial data to derive an episode cost. This process itself can identify areas for process improvement. This process identified actionable areas of process improvement in weekend discharge, blood transfusion rates, anesthesia impacts on length of stay, patient waiting times, operating room turnover delays due to peripheral nerve block placement, and an opportunity for patient clinical and administrative optimization before surgery.

The implementation of TDABC methodology not only can lead to more accurate cost accounting in total joint replacement but uncover opportunities for operational improvement.


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