Orthopedics

Feature Article 

Treatment of Massive Irreparable Rotator Cuff Tears: A Cost-effectiveness Analysis

Jason R. Kang, MD; Aaron T. Sin, MD; Emilie V. Cheung, MD

Abstract

Massive irreparable rotator cuff tears cause significant shoulder pain and dysfunction. Physical therapy (PT), arthroscopic debridement with biceps tenotomy (AD-BT), and hemiarthroplasty (HA) are treatments shown to reduce pain and improve quality of life. Reverse total shoulder arthroplasty (RTSA) is a newer surgical treatment option that may offer improved function. A cost-effectiveness analysis of these interventions has never been performed, and no head-to-head comparative effectiveness trials currently exist. A Markov decision analytic model was used to compare RTSA, HA, AD-BT, and PT as treatments for elderly patients with massive irreparable rotator cuff tears. Probabilities for complications, perioperative death, conversion procedures, and reoperations were derived from the literature, and costs were determined by average Medicare reimbursement rates from 2011. Reverse total shoulder arthroplasty yielded the most quality-adjusted life years (QALY) with 7.69, but greater benefits came at higher costs compared with other treatments. Sensitivity analyses showed that PT was the most cost-effective intervention at a health utility of 0.75 or greater (QALY 7.35). The health utility of RTSA was 0.72 or less (QALY 7.48) or RTSA probability of no complications was 0.83 or less (QALY 7.48 at cost of $23,830). Reverse total shoulder arthroplasty yielded benefits at a cost considered good value for money compared with other treatments. Reverse total shoulder arthroplasty is the preferred and most cost-effective treatment option for elderly patients with massive irreparable rotator cuff tears. For patients seeking pain relief without functional gains, AD-BT can be considered a cost-effective and cheaper alternative. The cost-effectiveness analysis approach can help guide clinical practice as well as the policies of health care systems and insurers. [Orthopedics. 2017; 40(1):e65–e76.]

Abstract

Massive irreparable rotator cuff tears cause significant shoulder pain and dysfunction. Physical therapy (PT), arthroscopic debridement with biceps tenotomy (AD-BT), and hemiarthroplasty (HA) are treatments shown to reduce pain and improve quality of life. Reverse total shoulder arthroplasty (RTSA) is a newer surgical treatment option that may offer improved function. A cost-effectiveness analysis of these interventions has never been performed, and no head-to-head comparative effectiveness trials currently exist. A Markov decision analytic model was used to compare RTSA, HA, AD-BT, and PT as treatments for elderly patients with massive irreparable rotator cuff tears. Probabilities for complications, perioperative death, conversion procedures, and reoperations were derived from the literature, and costs were determined by average Medicare reimbursement rates from 2011. Reverse total shoulder arthroplasty yielded the most quality-adjusted life years (QALY) with 7.69, but greater benefits came at higher costs compared with other treatments. Sensitivity analyses showed that PT was the most cost-effective intervention at a health utility of 0.75 or greater (QALY 7.35). The health utility of RTSA was 0.72 or less (QALY 7.48) or RTSA probability of no complications was 0.83 or less (QALY 7.48 at cost of $23,830). Reverse total shoulder arthroplasty yielded benefits at a cost considered good value for money compared with other treatments. Reverse total shoulder arthroplasty is the preferred and most cost-effective treatment option for elderly patients with massive irreparable rotator cuff tears. For patients seeking pain relief without functional gains, AD-BT can be considered a cost-effective and cheaper alternative. The cost-effectiveness analysis approach can help guide clinical practice as well as the policies of health care systems and insurers. [Orthopedics. 2017; 40(1):e65–e76.]

Rotator cuff tears significantly impact the quality of life for patients and are one of the most common reasons for orthopedic clinic visits. Approximately 10% to 40% of all rotator cuff tears are massive (greater than 5 cm in size or complete detachment of 2 or more tendons).1–3 Massive rotator cuff tear cases account for approximately 3 million office visits per year, and a substantial proportion are determined to be irreparable on evaluation.4 As such, massive irreparable rotator cuff tears present a challenging clinical problem for both patients and orthopedic surgeons.

Interventions, such as physical therapy (PT) and arthroscopic debridement with biceps tenotomy (AD-BT), have been shown to reduce pain and improve quality of life.5,6 However, surgical treatment options, such as hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA), may offer better functionality gains.7,8 Recent studies have shown that RTSA has the potential to achieve better functional outcomes compared with other treatment strategies.9 However, RTSA has been associated with higher complication and reoperation rates as well as greater costs.8,10 Previously, cost analyses have been conducted for both rotator cuff repairs and arthroplasty for glenohumeral osteoarthritis.11,12 The cost effectiveness of interventions for massive irreparable rotator cuff tears has never been evaluated, and no head-to-head comparative effectiveness trials have been reported in the literature.

The current authors hypothesize that RTSA is a cost-effective strategy for the treatment of massive irreparable rotator cuff tears in elderly patients given a willingness-to-pay (WTP) threshold of $50,000. This threshold is a cost-effectiveness analysis standard that has gained wide acceptance for orthopedic surgery cost-utility analysis.13–16 The primary aims of this study were: (1) to determine the relative cost effectiveness of 4 treatment strategies for massive irreparable rotator cuff tears using a decision analytic model and (2) to perform sensitivity analyses of the probabilities, utilities, and costs inputs to account for model accuracy and precision.

Materials and Methods

Decision Model Overview

The decision analytic model, inputs, and supporting analysis were conducted according to recommendations by the US Panel on Cost-Effectiveness in Health and Medicine.14–16 The base case scenario was a cohort of 70-year-old female patients with shoulder pain, 90° of active forward elevation of the shoulder, and a massive irreparable rotator cuff tear on advanced imaging. Ninety degrees of active forward elevation was chosen because it is the threshold to achieve overhead motion, and less than 90° of forward elevation defines pseudoparalysis of the shoulder. The treatment strategies of PT, AD-BT, HA, and RTSA for massive irreparable rotator cuff tears were analyzed using a Markov decision analytic model (TreeAge Software, Williamstown, Massachusetts) with cycle length of 1 year. Inputs for cost were based on Centers for Medicare & Medicaid Services (CMS) reimbursement data. All other inputs were derived from the literature when available. An annual discount rate of 3% was used for both costs and utilities to reflect their present value, and the background death probability was determined from Centers for Disease Control and Prevention values.14–16

Markov Decision Analytic Model

For the Markov decision analytic model, PT, AD-BT, HA, and RTSA were used as treatment arms for massive irreparable rotator cuff tears (Figure 1). Patients enter an initial postprocedure state for 1 year in which they have experienced perioperative death, no complications, or morbidities associated with their primary procedure. For patients who have experienced morbidities, they will choose among 3 options:

  1. Not pursue any other treatment options (patients who first chose PT, AD-BT, HA, or RTSA).

  2. Undergo reoperation (patients who first chose HA or RTSA).

  3. Convert to an RTSA (patients who first chose PT, AD-BT, or HA)


Simplified schematic showing the Markov decision analytic model. Physical therapy (PT), arthroscopic debridement with biceps tenotomy (AD-BT), and reverse total shoulder arthroplasty (RTSA) also have respective subdecision trees similar to the one shown for hemiarthroplasty (HA). Each decision branch has associated transition probabilities, health state utilities, and costs, and it is assumed that all procedure-related decisions take place within 1 year. The Markov model (designated by the M) was run on an annual cycle from ages 70 through 99. Although the Markov model accounts for time-dependent decrease in health state utility toward baseline or natural death, no additional procedure costs were included.

Figure 1:

Simplified schematic showing the Markov decision analytic model. Physical therapy (PT), arthroscopic debridement with biceps tenotomy (AD-BT), and reverse total shoulder arthroplasty (RTSA) also have respective subdecision trees similar to the one shown for hemiarthroplasty (HA). Each decision branch has associated transition probabilities, health state utilities, and costs, and it is assumed that all procedure-related decisions take place within 1 year. The Markov model (designated by the M) was run on an annual cycle from ages 70 through 99. Although the Markov model accounts for time-dependent decrease in health state utility toward baseline or natural death, no additional procedure costs were included.

After this initial postprocedure state, patients enter a Markov model cycled on a yearly basis with a background probability of death from nonperioperative causes, a return to baseline clinical function, implant failure, or no clinical change. Given the baseline scenario consisting of an elderly population, patients underwent at most 2 reoperations. The approach taken with the development of this Markov decision analytic model is consistent with comparable cost-effectiveness studies in the field.11,17

Model Parameters

Probabilities and Utilities. Probabilities for complications, perioperative death, conversion procedures, and reoperations were based on a comprehensive literature review of relevant meta-analyses and primary outcome studies (Table 1). Transition probabilities between procedures and the Markov model health states, as well as health state utilities inputs expressed in QALY, were derived from the literature (Table 1). Inputs were only approximated from comparable literature values or estimated based on expert opinion (E.V.C.) when not available directly in the literature. For HA reoperations with morbidities, no direct data for massive irreparable rotator cuff tear patients were identified, so a 3 times higher complications rate relative to primary HA was assumed based on the RTSA difference noted in the literature.18,19 Patients who convert to RTSA was approximated based on PT to RTSA conversion rates.20


PT, AD-BT, HA, and RTSA Probabilities for Complications, Perioperative Death, Conversion Procedures, and Reoperations
PT, AD-BT, HA, and RTSA Probabilities for Complications, Perioperative Death, Conversion Procedures, and Reoperations

Table 1:

PT, AD-BT, HA, and RTSA Probabilities for Complications, Perioperative Death, Conversion Procedures, and Reoperations

Health state utilities are critical for cost-effectiveness analyses as they capture clinical outcomes in standardized, cross-study comparable QALY. Utilities ranged from 0 to 1, with 0 corresponding to death and 1 corresponding to complete health. Utility of patients' health states were derived by scaling shoulder scoring systems, such as the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) Society standardized shoulder assessment form, and Constant-Murley Score, to dimensions of the 36-Item Short Form Health Survey (SF-36) as described by Angst et al.21 All results were adjusted relative to a Constant-Murley baseline score of 30.

Sensitivity analysis was used to address the conflicting results on whether shoulder scores correlated with SF-36 scores.21–23 Given sparse data on the impact of complications on health state disutility, the disutility in a primary procedure was approximated to be 0.05, and in a secondary procedure, it was approximated to be 0.07. The 0.07 disutility was based on a difference between HA and reoperation HA as noted in the literature.8,24–26 Although data existed for HA and RTSA implant failure, return to baseline data were only available for RTSA; for the other 3 treatment options, rates of return to baseline were approximated based on the RTSA rates.18,27,28 Specifically, HA was estimated to have the same return to baseline rates as RTSA in years 1 to 6 and years 7+ time frames (0.02 and 0.08, respectively) to approximate similar long-term decrease in clinical effectiveness. For PT and AD-BT, a rate was estimated equivalent to an average of those 2 time frames (0.05), which approximates a gradual, steady decrease in function over time.

Costs. Costs were determined from average Medicare reimbursement rates from 2011 (Tables 23). Medicare reimbursement data reflect a national average that limits the impact of regional, health care system, and practice-specific factors on costs. Medicare serves as the largest payor in the United States for elderly patients and plays a role in the market as a “price-setting” entity. For outpatient PT and AD-BT, Current Procedural Terminology (CPT) codes were used to capture facility reimbursements and professional fees. Key primary and secondary HA and RTSA costs were captured using Medicare acute inpatient Prospective Payment System (PPS) reimbursements per Medicare Severity Diagnosis Related Group (MS-DRG) codes, and both surgeon and anesthesia professional fees per CPT codes. Additional categories were included for cost of laboratory tests and shared procedure medications. Cost of HA and RTSA implants was approximated from industry sources as no other published cost sources were available.


PT, AD-BT, HA, and RTSA Summary Costsa, With Contributing Itemized Costs
PT, AD-BT, HA, and RTSA Summary Costsa, With Contributing Itemized Costs

Table 2:

PT, AD-BT, HA, and RTSA Summary Costs, With Contributing Itemized Costs


Itemized Inpatient Costsa
Itemized Inpatient Costsa

Table 3:

Itemized Inpatient Costs

Cost-effectiveness Analysis

The Markov decision analytic model was run for the base case scenario using inputs to determine the most cost-effective treatment option. For each treatment approach, both the present value of the cost in dollars and the health state utility in QALY—accounting for the quantity and quality of life—were calculated. Cost effectiveness among the treatment options was first determined by plotting all treatments on the cost-effectiveness plane (Y-axis QALY, X-axis $US) to get a visual representation of the cost-efficiency frontier. Treatment strategies were considered strictly dominated if there was another treatment strategy that was both more effective and less costly. They were considered extended dominated if a more costly treatment option had a lower cost-effectiveness ratio or if a linear combination of 2 options on the cost-efficiency frontier strictly dominated a treatment option.

The primary quantitative result calculated, the incremental cost-effectiveness ratio (ICER), defined as (CostTreatmentA-CostTreatmentB)/(QALYTreatmentA-QALYTreatmentB), was determined between each sequential treatment option on the cost-efficiency frontier. An ICER less than the cost-effectiveness analysis standard WTP threshold of $50,000 per QALY gained (a standard accepted in the orthopedic surgery cost-utility analysis community) was considered cost effective as it provided a sufficient incremental gain in health utility at a low enough incremental cost to the health care system.13–16 The most cost-effective treatment option was the highest utility treatment approach that also had an ICER less than WTP of $50,000/QALY. If no ICER met that cutoff, then the treatment option with lowest cost and utility was the most cost-effective option.

Sensitivity Analysis

To account for input variables in the study that were not derived from the literature, sensitivity analyses were used to evaluate the relative impact of changes to the variables within reasonable ranges. For most variables, ±20% base case values was chosen as the range, although ranges were adjusted to be larger or smaller in cases where the uncertainty was greater or less, respectively. Tables 12 show the sensitivity ranges that were used for all inputs. Sensitivity analyses allowed for the impact of concurrently changing 1 or more variables to be quantified on the overall cost-effectiveness result. If the preferred, most cost-effective treatment option changed when a variable was varied across its sensitivity range, then the result was sensitive to that variable. For all probabilities, health state utilities, and costs, ICER tornado plots and 2-way sensitivity analyses were conducted.

Results

The clinical outcomes of the four interventions are different (Table 1). Higher complication rates correlated with increased invasiveness (0.0 for PT, 0.04 for HA, 0.09 for AD-BT, and 0.13 for RTSA primary procedures). The complication rates for reoperation HA increased to 0.10, and for either conversion of HA to RTSA or reoperation RTSA, the complication rate was 0.33. Perioperative death rates were 0.0 for PT and AD-BT, and 0.01 for HA and RTSA. The conversion rate to RTSA was similar for PT, AD-BT, and HA at 0.18, 0.20, and 0.18, respectively. For HA patients with complications, 0.67 decided on a reoperation HA, and the remaining 0.15 chose to stay with their primary HA procedure. For RTSA patients with complications, 0.69 chose a reoperation RTSA and 0.31 chose to stay with their primary RTSA procedure. Primary procedure health state utilities were 0.70 for PT, 0.64 for AD-BT, 0.70 for HA, and 0.75 for RTSA, with 0.05 or 0.07 disutility for complications and conversion or reoperation secondary procedures. The outcomes translated into 6.69 QALY for AD-BT, with PT increasing QALY to 7.04, HA to 7.35, and RTSA to 7.69.

The summary costs for each intervention, inclusive of inpatient facility or out-patient ambulatory surgical care fees, as well as surgeon, anesthesia, laboratory, drug, and implant fees as applicable, are shown in Table 2. Of note, complications and conversion or reoperation procedures increased cost: AD-BT, $5063 to $6397; HA, $17,380 to $30,774; and RTSA, $23,656 to $30,873. Overall, greater benefits came at higher costs: AD-BT, $5503; PT, $7180; HA, $17,414; and RTSA, $23,767.

Combining QALY and costs, PT was found to cost $4719 per QALY gained relative to AD-BT, and RTSA was found to cost $25,552 per QALY gained relative to PT (Figure 2 and Table 4). HA was extended dominated by a linear combination of PT and RTSA. At a WTP threshold of $50,000/QALY, sensitivity analyses showed that the most cost-effective intervention was PT at a health utility of approximately 0.75 or greater (QALY 7.35), AD-BT at a health utility of approximately 0.73 or greater (QALY 7.35), and HA (QALY 7.35 at the cost of $17,414) with an RTSA health utility approximately 0.72 or less (QALY 7.48) or RTSA probability of no complications 0.83 or less (QALY 7.48 at the cost of $23,830). Sensitivity of the cost-effectiveness result to the above variables was first identified using PT to RTSA and AD-BT to PT ICER tornado plots (Figures 34). Two-way sensitivity analyses demonstrate the base case relative to threshold values at which the preferred, most cost-effective intervention changes.


Cost-effectiveness analysis graph showing that reverse total shoulder arthroplasty (RTSA) is the most cost-effective treatment option and that hemiarthroplasty (HA) is extended dominated by a linear combination of physical therapy (PT) and RTSA. Of note, the incremental cost-effectiveness ratio (ICER) between arthroscopic debridement with biceps tenotomy (AD-BT) and PT of approximately 4.7K $/quality-adjusted life years (QALY), and the ICER between PT and RTSA of approximately 25.6K $/QALY are both below the standard willingness-to-pay (WTP) threshold of 50,000 $/QALY, and as such, RTSA is considered the most cost-effective treatment option. Abbreviation: K, thousand.

Figure 2:

Cost-effectiveness analysis graph showing that reverse total shoulder arthroplasty (RTSA) is the most cost-effective treatment option and that hemiarthroplasty (HA) is extended dominated by a linear combination of physical therapy (PT) and RTSA. Of note, the incremental cost-effectiveness ratio (ICER) between arthroscopic debridement with biceps tenotomy (AD-BT) and PT of approximately 4.7K $/quality-adjusted life years (QALY), and the ICER between PT and RTSA of approximately 25.6K $/QALY are both below the standard willingness-to-pay (WTP) threshold of 50,000 $/QALY, and as such, RTSA is considered the most cost-effective treatment option. Abbreviation: K, thousand.


Costa, Effectiveness, and Incremental Values for the 3 Treatment Options on the Cost-efficiency Analysis

Table 4:

Cost, Effectiveness, and Incremental Values for the 3 Treatment Options on the Cost-efficiency Analysis


Physical therapy (PT) to reverse total shoulder arthroplasty (RTSA) incremental cost-effectiveness ratio (ICER) tornado plot (A) with corresponding 2-way sensitivity analyses (B-D) for the 3 highest-impact variables: RTSA, No Complications utility (Q_RTSA_NoComp), PT utility (Q_PT), and RTSA, No Complications probability (P_RTSA_NoComp). The base case lines in the 2-way sensitivity analyses correspond to the values used for calculations in the model (RTSA, No Complications utility of 0.75, PT utility of 0.70, and RTSA, No Complications probability of 0.86). Values below $0 per quality-adjusted life years (QALY) gained correspond to dominance by 1 of the other 3 interventions. Abbreviations: AD-BT, arthroscopic debridement with biceps tenotomy; HA, hemiarthroplasty; WTP, willingness to pay.

Figure 3:

Physical therapy (PT) to reverse total shoulder arthroplasty (RTSA) incremental cost-effectiveness ratio (ICER) tornado plot (A) with corresponding 2-way sensitivity analyses (B-D) for the 3 highest-impact variables: RTSA, No Complications utility (Q_RTSA_NoComp), PT utility (Q_PT), and RTSA, No Complications probability (P_RTSA_NoComp). The base case lines in the 2-way sensitivity analyses correspond to the values used for calculations in the model (RTSA, No Complications utility of 0.75, PT utility of 0.70, and RTSA, No Complications probability of 0.86). Values below $0 per quality-adjusted life years (QALY) gained correspond to dominance by 1 of the other 3 interventions. Abbreviations: AD-BT, arthroscopic debridement with biceps tenotomy; HA, hemiarthroplasty; WTP, willingness to pay.


Arthroscopic debridement with biceps tenotomy (AD-BT) to physical therapy (PT) incremental cost-effectiveness ratio (ICER) tornado plot (A) with corresponding 2-way sensitivity analysis (B) for the 2 highest-impact variables: PT utility (Q_PT) and AD-BT, No Complications utility (Q_AD_NoComp). The base case lines in the 2-way sensitivity analysis correspond to the values used for calculations in the model (AD-BT, No Complications utility of 0.64 and PT utility of 0.70). Values below $0 per quality-adjusted life years (QALY) gained correspond to dominance by 1 of the other 3 interventions. Abbreviations: HA, hemiarthroplasty; RTSA, reverse total shoulder arthroplasty; WTP, willingness to pay.

Figure 4:

Arthroscopic debridement with biceps tenotomy (AD-BT) to physical therapy (PT) incremental cost-effectiveness ratio (ICER) tornado plot (A) with corresponding 2-way sensitivity analysis (B) for the 2 highest-impact variables: PT utility (Q_PT) and AD-BT, No Complications utility (Q_AD_NoComp). The base case lines in the 2-way sensitivity analysis correspond to the values used for calculations in the model (AD-BT, No Complications utility of 0.64 and PT utility of 0.70). Values below $0 per quality-adjusted life years (QALY) gained correspond to dominance by 1 of the other 3 interventions. Abbreviations: HA, hemiarthroplasty; RTSA, reverse total shoulder arthroplasty; WTP, willingness to pay.

Discussion

Recently, RTSA has become an increasingly popular treatment for patients with massive irreparable rotator cuff tears.29 The results of the currently described model supports this growing trend toward RTSA by establishing it as the most cost-effective treatment option from a financial perspective. Although RTSA is substantially more expensive than PT and AD-BT, the incremental cost is worth the significant clinical outcomes gains that are achieved. The extra money spent on RTSA is worth the additional cost from a societal perspective as captured by a WTP of $50,000/QALY. Clinically, this is consistent with the patient population being treated: elderly patients with painful, massive irreparable rotator cuff tears at baseline. Both HA and RTSA should be considered in patients who desire gains in functionality, whereas PT and AD-BT may be cost-efficient treatment options for elderly patients with lower functionality demands who are desiring pain relief as these interventions still offer clinical benefits at lower costs and risks associated with surgery.

Although PT and AD-BT might appear as the most cost-effective treatment option within the uncertainty ranges analyzed, those results need to be considered within their clinical context. It is unlikely that the average individual patient has the same clinical outcome and thus equivalent health utility at 0.75, whether they choose PT vs RTSA. Likewise, an increase in health utility of 0.09 from 0.64 to 0.73 for AD-BT to a level nearly as high as RTSA's base case value of 0.75 also is incongruent with clinical experience. However, the small changes in RTSA health utility (0.75 to ≤0.72) or RTSA probability of no complications (0.86 to ≤0.83) needed for a change to HA as the most cost-effective option are within the uncertainty for those model parameters.

There are several weaknesses to this cost-effectiveness study. Despite a rigorous process for identifying inputs and building the Markov decision analytic model, the study was constrained by the available literature and the limitations of the data. Few studies specifically targeted this patient population, and inputs were extracted from subsets of data or accepted for use despite partial demographic fits. Both HA and RTSA are technically demanding procedures, and provider variations, such as surgeon experience, case volume, or type of practice, could not be accounted for patient-specific factors, namely comorbidities and socioeconomic factors, which also could impact clinical outcomes. Lastly, although Medicare reimbursement data are the standard source for cost data studies, these data capture what is paid out and not the true costs to health care systems, providers, and patients. Models have inherent weaknesses, but they can be instrumental in answering clinical questions that cannot be explored through traditional clinical studies.

Conclusion

RTSA is the preferred and most cost-effective treatment option for elderly patients with massive irreparable rotator cuff tears. For patients seeking pain relief without functional gains, AD-BT can be considered as a cost-effective and less expensive alternative. The cost-effectiveness analysis approach can help guide clinical practice by individual surgeons as well as the policies of health care systems and insurers. Further study is warranted to evaluate clinical correlation between functional gains and modeling-based analyses.

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PT, AD-BT, HA, and RTSA Probabilities for Complications, Perioperative Death, Conversion Procedures, and Reoperations

Model VariableBase CaseSensitivity Analysis RangeSource/Reference(s)
Primary procedure probabilities
  AD-BT with no complications0.910.73–0.9130
  AD-BT with morbidities0.090.07–0.0930
  AD-BT perioperative death0.000.00–0.2011,31
  HA with no complications0.960.76–0.9618
  HA with morbidities0.040.03–0.0418
  HA perioperative death0.010.00–0.2111,31
  RTSA with no complications0.860.70–0.86510
  RTSA with morbidities0.130.11–0.13510
  RTSA perioperative death0.010.00–0.1911,31
Secondary procedure probabilities
  Reoperation HA with no complications0.890.71–0.89518,19
  Reoperation HA with morbidities0.100.08–0.10518,19
  Reoperation HA perioperative death0.010.00–0.2111,31
  Conversion RTSA with no complications0.670.53–0.8032,33
  Conversion RTSA with morbidities0.330.26–0.3932,33
  Conversion RTSA perioperative death0.010.00–0.01211,31
  Reoperation RTSA with no complications0.660.53–0.7910
  Reoperation RTSA with morbidities0.330.27–0.4010
  Reoperation RTSA perioperative death0.010.008–0.01211,31
Primary-secondary transition probabilities
  Conversion PT to RTSA0.180.14–0.2220
  Conversion PT to HA0.00-
  Conversion PT to AD-BT0.00-
  Staying with PT0.820.66–0.9820
  Conversion AD-BT to RTSA0.200.16–0.2420
  Conversion AD-BT to HA0.00-
  Staying with AD-BT0.800.64–0.9620
  Conversion HA to RTSA0.180.14–0.2218
  Reoperation HA0.670.53–0.8018
  Staying with HA0.150.12–0.1818
  Reoperation RTSA0.690.56–0.8310
  Staying with RTSA0.310.24–0.3710
Secondary-tertiary transition probabilities
  Conversion reoperation HA to RTSA0.180.14–0.2218
  Reoperation HA 20.670.53–0.8018
  Staying with HA 20.150.12–0.1818
  Reoperation RTSA 20.350.28–0.4210
  Salvage conversion reoperation RTSA to HA0.350.28–0.4210
  Staying with RTSA 20.310.24–0.3710
Health state utilities
  Baseline0.460.37–0.55
  PT0.700.56–0.8433
  AD-BT with no complications0.640.51–0.7730,34–36
  AD-BT with morbidities0.590.47–0.7130,34–36
  HA with no complications0.700.56–0.8437,38
  HA with morbidities0.650.52–0.7837,38
  Reoperation HA with no complications0.630.50–0.7637,38
  Reoperation HA with morbidities0.580.46–0.7037,38
  Reoperation HA 20.560.45–0.6737,38
  RTSA with no complications0.750.60–0.908,26,32,39
  RTSA with morbidities0.700.56–0.848,26,32,39
  Reoperation RTSA with no complications0.680.54–0.828,24–26
  Reoperation RTSA with morbidities0.630.50–0.768,24–26
  Conversion RTSA with no complications0.580.46–0.7032,40
  Conversion RTSA with morbidities0.530.42–0.6432,40
  Reoperation RTSA 20.610.49–0.738,24–26
  Perioperative death0.00-
  Natural death0.00-
Markov model transition rates (annual)
  PT utility return to baseline0.050.04–0.068,24–26
  AD-BT utility return to baseline0.050.04–0.068,24–26
  HA utility return to baseline (years 1–6)0.020.016–0.0248,24–26
  HA utility return to baseline (years 7+)0.080.06–0.098,24–26
  RTSA utility return to baseline (years 1–6)0.020.016–0.02428
  RTSA utility return to baseline (years 7+)0.080.06–0.0928
  HA implant failure0.0040.003–0.00518,27
  RTSA implant failure0.010.004–0.00628
  Death from implant failure reoperation0.010.008–0.01211,31
  Natural deathBy year-
Other
  Start age70.00-
  Stop age99.00-

PT, AD-BT, HA, and RTSA Summary Costsa, With Contributing Itemized Costs

Model VariableBase CaseSensitivity Analysis RangeSource(s) Description, Explanation
Summary costs: outpatient
  Physical therapy$3547$2800–$4300Ambulatory surgical care, physician
  AD-BT with no complications$5063$4100–$6100Ambulatory surgical care, surgeon, laboratory tests, drugs
  AD-BT with morbidities$6397$5100–$7700Ambulatory surgical care, surgeon, laboratory tests, drugs
Summary costs: inpatient
  HA with no complications$17,380$13,900–$20,900Facility, provider, implant, ancillary services
  HA with morbidities$19,683$15,700–$23,600Facility, provider, implant, ancillary services
    Reoperation HA with no complications$15,062$12,000–$18,100Facility, provider, implant, ancillary services
    Reoperation HA with morbidities$17,462$14,000–$21,000Facility, provider, implant, ancillary services
      Reoperation HA 2$24,597$19,700–$29,500Facility, provider, implant, ancillary services
      Salvage conversion reoperation RTSA to HA$30,774$24,600–$36,900Facility, provider, implant, ancillary services
  RTSA with no complications$23,656$18,900–$28,400Facility, provider, implant, ancillary services
  RTSA with morbidities$25,959$20,800–$31,200Facility, provider, implant, ancillary services
    Reoperation RTSA with no complications$21,239$17,000–$25,500Facility, provider, implant, ancillary services
    Reoperation RTSA with morbidities$23,639$18,900–$28,400Facility, provider, implant, ancillary services
      Reoperation RTSA 2$30,774$24,600–$36,900Facility, provider, implant, ancillary services
    Conversion RTSA with no complications$21,338$17,100–$25,600Facility, provider, implant, ancillary services
    Conversion RTSA with morbidities$23,737$19,000–$28,500Facility, provider, implant, ancillary services
      Conversion reoperation HA to RTSA$30,873$24,700–$37,000Facility, provider, implant, ancillary services
Itemized outpatient: ambulatory surgical care
  AD-BT with no complications$2064$1700–$250029822: arthroscopy, shoulder, surgical; debridement, limited
  AD-BT with morbidities$3337$2700–$400029823: arthroscopy, shoulder, surgical; debridement, extensive
  Established patient outpatient visit (Level 3)$150$120–$18099213: ×2 at $75.13 base rate for 2 HA and RTSA outpatient visits
Itemized outpatient: physician fee schedule
  Physical therapy$3547$2800–$430097110: 30 hours (×120 15-min blocks at $29.56 per block)
  Physical therapy post-AD-BT, HA, RTSA$2365$1900–$280097110: 20 hours (×80 15-min blocks at $29.56 per block)
  AD-BT with no complications$569$460–$68029822: arthroscopy, shoulder, surgical; debridement, limited
  AD-BT with morbidities$621$500–$74029823: arthroscopy, shoulder, surgical; debridement, extensive
  Established patient outpatient visit (Level 3)$99$80–$12099213: ×2 at $75.13 base rate for 2 HA and RTSA outpatient visits
Shoulder radiograph (perioperative and follow-up)$283$230–$34073030: ×2 at $31.26 inpatient rate and ×4 at $55.04 outpatient rate
Itemized laboratory tests
  Complete blood cell count with differential$220–085025: pre- and postoperatively
  Coagulation time$12$9.6–$1485347: pre- and postoperatively
  Comprehensive metabolic panel$30$24–$3680053: pre- and postoperatively
  Culture screen only$9.30$7.50–$1187081: any operation with morbidity
Itemized Part B drugs
  Hydromorphone injection, 4 mg$1.700–0J1170: $1.696 per 4 mg
  Hydromorphone injection, 30 mg$130–0J1170: $1.696 per 4 mg

Itemized Inpatient Costsa

Model VariableBase CaseSensitivity Analysis RangeSource(s) Description and Explanation
Itemized inpatient: Medicare PPS (MS-DRGs)
  HA with no complications$11,228$9000–$13,500484: major joint and limb reattachment procedures of UE without CC/MCC
  HA with morbidities$13,522$10,800–$16,200483: major joint and limb reattachment procedures of UE with CC/MCC
    Reoperation HA with no complications$8760$7000–$10,500517: other MSK and connective tissue OR procedure without CC/MCC
    Reoperation HA with morbidities$11,150$8900–$13,400516: other MSK and connective tissue OR procedure with CC
      Reoperation HA 2$18,209$14,600–$21,900515: other MSK and connective tissue OR procedure with MCC
      Salvage conversion reoperation RTSA to HA$18,209$14,600–$21,900515
  RTSA with no complications$11,228$9000–$13,500484
  RTSA with morbidities$13,522$10,800–$16,200483
    Reoperation RTSA with no complications$8760$7000–$10,500517
    Reoperation RTSA with morbidities$11,150$8900–$13,400516
      Reoperation RTSA 2$18,209$14,600–$21,900515
    Conversion RTSA with no complications$8760$7000–$10,500517
    Conversion RTSA with morbidities$11,150$8900–$13,400516
      Conversion reoperation HA to RTSA$18,209$14,600–$21,900515
Itemized inpatient: physician fee schedule (CPT)
  HA with no complications$1207$970–$140023470: arthroplasty, glenohumeral joint; hemiarthroplasty
  HA with morbidities$1207$970–$140023470
    Reoperation HA with no complications$1207$970–$140023470
    Reoperation HA with morbidities$1207$970–$140023470
      Reoperation HA 2$1207$970–$140023470
      Salvage conversion reoperation RTSA to HA$1495$1200–$180023472: arthroplasty, glenohumeral joint; total shoulder
  RTSA with no complications$1495$1200–$180023472
  RTSA with morbidities$1495$1200–$180023472
    Reoperation RTSA with no complications$1495$1200–$180023472
    Reoperation RTSA with morbidities$1495$1200–$180023472
      Reoperation RTSA 2$1495$1200–$180023472
    Conversion RTSA with no complications$1495$1200–$180023472
    Conversion RTSA with morbidities$1495$1200–$180023472
      Conversion Reoperation HA to RTSA$1495$1200–$180023472
Itemized inpatient: anesthesia (CPT)b
  HA with no complications$271$220–$33000450: 5 base units; 1.5 h (6× 15-min blocks)
  HA with morbidities$271$220–$33000450: 5 base units; 1.5 h (6× 15-min blocks)
    Reoperation HA with no complications$345$280–$41000452: 6 base units; 2 h (8× 15-min blocks)
    Reoperation HA with morbidities$345$280–$41000452: 6 base units; 2 h (8× 15-min blocks)
      Reoperation HA 2$345$280–$41000452: 6 base units; 2 h (8× 15-min blocks)
      Salvage conversion reoperation RTSA to HA$345$280–$41000452: 6 base units; 2 h (8× 15-min blocks)
  RTSA with no complications$370$300–$44000450: 5 base units; 2.5 h (10× 15-min blocks)
  RTSA with morbidities$370$300–$44000450: 5 base units; 2.5 h (10× 15-min blocks)
    Reoperation RTSA with no complications$345$280–$41000452: 6 base units; 2 h (8× 15-min blocks)
    Reoperation RTSA with morbidities$345$280–$41000452: 6 base units; 2 h (8× 15-min blocks)
      Reoperation RTSA 2$345$280–$41000452: 6 base units; 2 h (8× 15-min blocks)
    Conversion RTSA with no complications$444$360–$53000452: 6 base units; 3 h (12× 15-min blocks)
    Conversion RTSA with morbidities$444$360–$53000452: 6 base units; 3 h (12× 15-min blocks)
      Conversion reoperation HA to RTSA$444$360–$53000452: 6 base units; 3 h (12× 15-min blocks)
Itemized HA and RTSA implants
  HA implant$4597$3700–$5500Averaged costs from implant manufacturers' quotes
  RTSA implant$10,486$8400–$12,600Averaged costs from implant manufacturers' quotes

Costa, Effectiveness, and Incremental Values for the 3 Treatment Options on the Cost-efficiency Analysis

Treatment OptionCostIncremental CostEffectiveness (QALY)Incremental Effectiveness (QALY)Incremental C/E ($/QALY)
AD-BT$5503-6.7--
PT$7180$16777.00.3$4719
RTSA$23,767$16,5877.70.7$25,522
Authors

The authors are from the Department of Orthopedic Surgery (JRK, EVC), Stanford University Medical Center, and the School of Medicine (ATS), Stanford University, Palo Alto, California.

Drs Kang and Sin have no relevant financial relationships to disclose. Dr Cheung is a paid consultant for Exactech.

This study was supported by the Stanford Medical Scholars Fellowship Program (A.T.S.).

Correspondence should be addressed to: Emilie V. Cheung, MD, Department of Orthopedic Surgery, Stanford University Medical Center, 450 Broadway St, MC 6342, Redwood City, CA 94063 ( evcheung@stanford.edu).

Received: March 07, 2016
Accepted: July 28, 2016
Posted Online: September 30, 2016

10.3928/01477447-20160926-06

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