Date of Award

January 2024

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Jonathan N. Grauer


Understanding the cost of healthcare is an increasingly prevalent and important topic in medicine. Healthcare costs are an increasing burden on the United States economy, in which orthopaedics plays a significant role. Variability in cost/expenditures highlights areas for potential streamlining and optimization. Lumbar laminotomy, total shoulder arthroplasty (TSA), total knee arthroplasty (TKA), and anterior cruciate ligament reconstruction (ACLr) are examples of such procedures. The current thesis aimed to examine the variability in the overall 90-day postoperative reimbursement associated with these four common orthopaedic procedures and to assess the factors associated with increased cost.

The current thesis used data from PearlDiver, which is a large, national, multi-insurance, administrative claims database to identify patients who underwent each of the procedures evaluated. For each of these procedures, the 90-day total reimbursements were determined. Additional variables defined included: patient age, sex, Elixhauser Comorbidity Index, insurance plan (commercial, Medicare, Medicaid), surgical setting (in-patient vs. outpatient), perioperative events (adverse event, emergency department [ED] visit, returning to the hospital /readmission), and in some cases geographic region of the country (West, South, Midwest, Northeast). For each of these, overall 90-day reimbursement was defined/assessed with the mean ± standard deviation (SD) and median (interquartile range [IQR]). To examine the independent incremental impact of each variable a multivariable linear regression was performed.

Large variability was identified for each of the procedures examined. For lumbar laminotomy: A total of 28,621 laminotomy/discectomies were identified. Ninety-day postoperative reimbursements had an average ± standard deviation of $9,453.83 ± 19,343.99 and, with a non-normal distribution, the median (inner quartile range) was $3,314 ($5,460). For TSA: A total of 112,188 TSA patients (aTSA: 36,164 [32.2%]; rTSA: 76,024 [67.8%]) were identified. The average ± standard deviation 90-day overall postoperative reimbursement for aTSA was $6,714.26 ± 9,587.46 and rTSA was $6,246.45 ± 9,506.59. The total reimbursement for aTSA was $242,814,515 and for rTSA was $474,836,301. For TKA: A total of 1,066,327 TKA patients were identified. Ninety-day postoperative reimbursements had an average ± standard deviation of $11,212.99 ± $15,000.62, a median (interquartile range) of $4,472.00 ($13,101.00), and a total of $11,946,962,912. For ACLr: A total of 249,484 patients who underwent ACLr were identified. For the overall 90-day reimbursement, the average ± standard deviation was $4,281.91 ± $4,982.61, the median (interquartile range) was $3,032 ($3,461), and the total reimbursement for the patient cohort was $1,049,250,747.For each of these procedures, defined variables were associated with changes in reimbursement.

Overall, each of the procedures studied revealed a large variability of cost to the healthcare system. Generally, the largest cost increases were associated with an in-patient index procedure or a hospital readmission. These results highlight the need to balance performing outpatient surgeries in appropriate patients versus the risk of readmissions and other defined areas for cost containment strategies.


This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.