Assessing the Work Relative Value Unit System in Orthopaedic Oncology: A Matched Cohort Analysis

Benign and malignant bone and soft-tissue tumors have a broad range of clinical presentations. Operative management ranges from limited excision to complex resection and reconstruction. The work relative value unit (wRVU) is designed to quantify physician time, technical skill, and effort, but it is unclear whether current assignments adequately reflect the overall procedural demands of musculoskeletal orthopaedic oncology. The aim of this study was to compare wRVU generation between orthopaedic oncology procedures and matched nononcologic orthopaedic procedures after controlling for measures of physician time and intensity.

A retrospective observational study was conducted using the American College of Surgeons' National Surgical Quality Improvement Program. Musculoskeletal orthopaedic oncology cases were stratified by Current Procedural Terminology (CPT) code according to tumor type. Mahalanobis distance matching was used to match orthopaedic oncology cases with nononcology orthopaedic controls. Total case wRVU generation was compared between groups.

Among 2,138,294 orthopaedic cases, 6,700 were musculoskeletal orthopaedic oncology cases (mean age 48 years, 45% female, 61% White, 9.6% Black, 5.0% Asian, 1.4% Other, and 23% unknown/not reported). After matching, oncology cases had 19.0% lower average wRVU (16.2 vs. 20.0) than matched controls despite similar operative times and case characteristics. The mean total case wRVUs were lower for benign soft-tissue tumors (9.7 vs. 15.8, -38.6%), benign bone tumors (11.0 vs. 15.8, -30.6%), and malignant soft-tissue tumors (18.1 vs. 26.3, -31.1%) compared with matched orthopaedic controls. By contrast, malignant bone tumors generated higher mean total case wRVUs than matched controls (43.9 vs. 37.0, +18.9%). Using a standardized workload of 675 operative hours per year, orthopaedic oncology procedures were estimated to generate 6,883 annual wRVUs vs. 8,570 for matched controls, corresponding to $56,167 lower annualized Medicare-based procedural value.

Musculoskeletal orthopaedic oncology procedures generated fewer wRVUs than matched nononcologic orthopaedic procedures. We advocate for hospital and department leaders to consider this discrepancy within the wRVU model and account for it when designing compensation models for orthopaedic oncologists.

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.