Orthopedics

Feature Article Supplemental Data

Use and Cost of Reverse Shoulder Arthroplasty Versus Hemiarthroplasty for Acute Proximal Humerus Fractures

Cary S. Politzer, MD; Abiram Bala, MD; Thorsten M. Seyler, MD, PhD; Michael P. Bolognesi, MD; Grant E. Garrigues, MD

Abstract

Although reverse total shoulder arthroplasty (RTSA) may outperform hemiarthroplasty (HSA) for acute proximal humerus fractures (PHF), both the RTSA implant and the procedure are more expensive. The goal of this study was to compare the use and longitudinal cost of care for RTSA vs HSA for the treatment of PHF. Patients were selected from a private payer database with a surgical date between 2010 and 2015. The International Classification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM), codes were used to identify patients who underwent RTSA and HSA for PHF. The 1-year cost follow-up was guaranteed. During the study period, a total of 1038 patients underwent RTSA and 1046 patients underwent HSA for the treatment of PHF. A total of 601 patients who underwent RTSA and 431 patients who underwent HSA with at least 1 year of follow-up were matched by age and sex. The average Charlson Comorbidity Index for the RTSA and HSA groups was 4, indicating similar health status. From 2010 to 2015, the use of RTSA increased linearly (R2=0.986), whereas the use of HSA decreased linearly (R2=0.796). The average index admission cost was higher for RTSA than for HSA ($15,263 vs $14,356, respectively; mean difference [MD], $907; 95% confidence interval [CI], $58-$1760; P=.04). At 1 year postoperatively, however, no statistically significant difference was noted in cost (P=.535). The 1-year physical and occupational therapy cost per patient was higher after HSA than after RTSA (MD, $723; CI, $718–$728; P<.001), but no difference was noted in discharge disposition or 1-year revision or readmission rates. The results of this study suggest that despite the higher initial cost of RTSA, the total cost of care in the year after RTSA and HSA is similar. Therefore, RTSA should be considered in the appropriate clinical setting. [Orthopedics. 2020;43(2):119–125.]

Abstract

Although reverse total shoulder arthroplasty (RTSA) may outperform hemiarthroplasty (HSA) for acute proximal humerus fractures (PHF), both the RTSA implant and the procedure are more expensive. The goal of this study was to compare the use and longitudinal cost of care for RTSA vs HSA for the treatment of PHF. Patients were selected from a private payer database with a surgical date between 2010 and 2015. The International Classification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM), codes were used to identify patients who underwent RTSA and HSA for PHF. The 1-year cost follow-up was guaranteed. During the study period, a total of 1038 patients underwent RTSA and 1046 patients underwent HSA for the treatment of PHF. A total of 601 patients who underwent RTSA and 431 patients who underwent HSA with at least 1 year of follow-up were matched by age and sex. The average Charlson Comorbidity Index for the RTSA and HSA groups was 4, indicating similar health status. From 2010 to 2015, the use of RTSA increased linearly (R2=0.986), whereas the use of HSA decreased linearly (R2=0.796). The average index admission cost was higher for RTSA than for HSA ($15,263 vs $14,356, respectively; mean difference [MD], $907; 95% confidence interval [CI], $58-$1760; P=.04). At 1 year postoperatively, however, no statistically significant difference was noted in cost (P=.535). The 1-year physical and occupational therapy cost per patient was higher after HSA than after RTSA (MD, $723; CI, $718–$728; P<.001), but no difference was noted in discharge disposition or 1-year revision or readmission rates. The results of this study suggest that despite the higher initial cost of RTSA, the total cost of care in the year after RTSA and HSA is similar. Therefore, RTSA should be considered in the appropriate clinical setting. [Orthopedics. 2020;43(2):119–125.]

Acute proximal humerus fracture (PHF) can cause pain, immobility, decreased function, and decreased independence in activities of daily living, and it accounts for up to 5% to 10% of all fractures of the appendicular skeleton.1,2 Although many fractures can be treated nonoperatively, several procedures are useful in the surgical management of complex fractures: open reduction and internal fixation with a plate and screws, an intramedullary nail, or sutures; percutaneous pinning; hemiarthroplasty (HSA); and reverse total shoulder arthroplasty (RTSA).3

The preferred surgical option for fractures without a salvageable humeral head is HSA because of the unacceptable risk of avascular necrosis, comminution or poor bone quality that precludes internal fixation, or humeral head split with articular surface damage. However, approximately 50% of patients have poor postoperative function and pseudoparalysis because of improper tuberosity healing.4,5 To revise a poorly functioning HSA, traditionally, RTSA has been the salvage procedure, but growing evidence suggests that RTSA may provide more predictable return of function as primary treatment for PHF.6–11

A concern about RTSA has been the higher cost of the implant and procedure compared with HSA.7,12 As value-based care is implemented, the economic effect of initial and follow-up costs of intervention becomes more important.13 Many current economic studies use in-hospital reimbursement because follow-up cost is difficult to obtain, or they use Markov decision models for cost-effective analysis that provides “longer-term” follow-up on cost.14,15 However, Markov models are limited by inadequate data on postoperative reimbursement and are idealized simulations based on available evidence.

Because of the increasing fidelity and functionality of database software, it is now possible to directly query the total cost of care after index admission. The goal of this study was to evaluate the use and total cost of care for patients who underwent RTSA vs HSA for surgical treatment of PHF as well as to compare these costs at index admission and 1 year postoperatively. The authors hypothesized that the use of RTSA would increase during the study period, with a simultaneous reduction in the use of HSA. They also predicted that RTSA would be costlier than HSA at both time points, after matching for age and sex, because of higher implant and procedure costs.

Materials and Methods

The study received institutional review board approval as exempt research. Using PearlDiver Technologies (Warsaw, Indiana), the authors queried the private payer Humana database, which contains records for more than 20 million patients between 2007 and the first quarter (January–March) of 2016, with the last surgery occurring in the first quarter of 2015 to allow adequate follow-up. Although the intervention costs may vary by region and insurance provider, the use of commercial payments is considered a representation of the true cost of care incurred by institutions. The public Medicare insurance database may better approximate federal payments for value-driven purchasing initiatives, but it currently lacks cost analysis functionality.

Using the PearlDiver Boolean command language, the authors first identified all patients who underwent PHF with the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), codes for PHF (Table A, available with the online version of the article). To derive annual rates of use, defined as the total number of patients in the database who underwent each procedure, the authors selected from that cohort patients who subsequently underwent RTSA or HSA during the same hospital stay, excluding patients who were discharged with delayed surgery. Because RTSA first had an independent ICD-9-CM procedural code in 2010, this was the first study year. The RTSA and HSA procedures continue to be grouped under one Current Procedural Terminology (CPT) code.

International Classification of Diseases, 9th Revision Diagnosis (ICD-9-D) and Procedure (ICD-9-P) codes and Current Procedural Terminology (CPT) codes used in this study

Table A:

International Classification of Diseases, 9th Revision Diagnosis (ICD-9-D) and Procedure (ICD-9-P) codes and Current Procedural Terminology (CPT) codes used in this study

To decrease potential confounding in cost as a result of demographic differences, the authors proportionally matched the HSA cohort with the RTSA cohort by age and sex. The authors then calculated inhospital reimbursement for the total cost of care for each cohort by year, including any reimbursed costs, such as professional fees, implant costs, the cost of radiology studies, the cost of physical and occupational therapy, hospital and nursing facility costs, and so on. Because the authors only selected patients who underwent surgery up to the first quarter of 2015, they required a minimum of 1 complete year of reimbursement data for each patient cohort. The authors then used CPT codes to isolate common causes of greater cost of care in each cohort (Table A).

Trends in use were compared between cohorts, and the average index admission cost and total cost of care up to 1 year postoperatively were calculated. A long-term time point of 1 year was chosen to reduce variability that could obscure cost averages and conclusions. Cost growth was compared by absolute change per year, and the compound annual growth rate (CAGR) was calculated to counteract the variability in average reimbursement over time. The authors also calculated the change in Consumer Price Index from the US Department of Labor Statistics from January 2010 to March 2015 to adjust for inflation16 as well as the average Charlson Comorbidity Index, a measure of the 10-year predicted mortality rate.17

Statistical Analysis

The primary goal of this study was to report cost data. No formal sample size calculations were performed. Continuous variables were compared with Student's t test, and categorical variables were compared with Fisher's exact test and the chi-square test of independence. P<.05 was considered significant. Analyses were performed with JMP 14 for Mac (SAS, Cary, North Carolina).

Results

In the database, a total of 1038 patients underwent RTSA and 1046 patients underwent HSA for PHF from 2010 to 2015, translating to approximately 5.2 RTSA and HSA procedures each per 100,000 patients per year. Of these, 601 patients undergoing RTSA and 690 patients undergoing HSA had at least 1 year of follow-up. The average age of the RTSA cohort was higher than that of the HSA cohort (75.7 vs 73.7 years, respectively; mean difference [MD], 2.0 years; 95% confidence interval [CI], 1.0–3.0 years; P<.01). In a stepwise fashion, the authors matched the HSA cohort with the RTSA cohort by age and sex, which decreased the size of the final HSA cohort for cost analysis to 431, typically removing younger unmatched HSA patients. The average Charlson Comorbidity Index for the RTSA group was similar to that for the matched HSA group, indicating similar health status (P=.21). The demographic features and Charlson Comorbidity Index for each cohort are shown in Table 1, with 5-year age categories because of PearlDiver constraints.

Patient Demographics

Table 1:

Patient Demographics

The authors first analyzed use for both cohorts. As shown in Figure 1, total use of RTSA increased from 18 in 2010 to 329 in 2015, at an average rate of 51.8 procedures per year (Table 2; R2=0.986; P<.001), whereas total unmatched use of HSA decreased from 200 in 2010 to 98 in 2015, at an average rate of 17.0 procedures per year (Table 3; R2=0.796; P=.013). The proportion of RTSA procedures increased from 8.3% in 2010 to 77.1% in 2015, with a synchronous decline in the proportion of HSA procedures.

Trends in total use of reverse total shoulder arthroplasty (RTSA) vs hemiarthroplasty (HSA) from 2010 to 2015.

Figure 1:

Trends in total use of reverse total shoulder arthroplasty (RTSA) vs hemiarthroplasty (HSA) from 2010 to 2015.

Use and Cost of Reverse Total Shoulder Arthroplasty

Table 2:

Use and Cost of Reverse Total Shoulder Arthroplasty

Use and Cost of Hemiarthroplasty

Table 3:

Use and Cost of Hemiarthroplasty

Figure 2 shows the initial admission cost. Average admission cost for patients undergoing RTSA decreased from $16,428 in 2010 to $12,660 in the first quarter of 2015, with a calculated CAGR of −5.95% (Table 2; adjusted, −7.68%). Total index admission cost for the matched HSA cohort decreased from $15,281 in 2010 to $11,331 in the first quarter of 2015, with a CAGR of −6.80% (Table 3; adjusted, −8.51%). Cost of admission decreased 7.68% per year for RTSA and 6.80% per year for HSA after adjusting for inflation. The weighted average across all years was $15,263 for RTSA and $14,356 for HSA.

Average cost of index admission for reverse total shoulder arthroplasty (RTSA) vs matched hemiarthroplasty (HSA) in 2010 to the first quarter of 2015.

Figure 2:

Average cost of index admission for reverse total shoulder arthroplasty (RTSA) vs matched hemiarthroplasty (HSA) in 2010 to the first quarter of 2015.

As shown in Figure 3, the average 1-year cost of care for the RTSA cohort was $68,695 in 2010, which decreased to $35,546 in the first quarter of 2015, with a CAGR of −14.36% (Table 2; adjusted, −15.94%). The average 1-year cost of care for the matched HSA cohort increased from $38,432 to $40,258 during that time (Table 3; CAGR, 1.10%; adjusted, −0.77%). The weighted average within 1 year of surgery was $38,099 for RTSA and $38,834 for HSA.

Average total cost within 1 year of reverse total shoulder arthroplasty (RTSA) vs matched hemiarthroplasty (HSA) in 2010 to the first quarter of 2015.

Figure 3:

Average total cost within 1 year of reverse total shoulder arthroplasty (RTSA) vs matched hemiarthroplasty (HSA) in 2010 to the first quarter of 2015.

When admission reimbursement for RTSA over time was compared with that for HSA, a difference in CAGR of less than 1% was found before and after adjusting for inflation (adjusted, −7.68% vs −8.51%, respectively). In contrast, the difference in 1-year postoperative CAGR between RTSA and HSA was more than 15% per year (adjusted, −15.94% vs −0.77%, respectively). Although average index admission for RTSA cost more than that for HSA ($15,263 vs $14,356, respectively; MD, $907; CI, $58–$1760; P=.04), reimbursement up to 1 year postoperatively was not statistically different ($38,099 vs $38,834, respectively; MD, $735; CI, −$1590 to $3060; P=.535).

Given the higher cost of RTSA during index admission, followed by narrowing of the cost differential by 1 year postoperatively, the authors investigated possible explanations. Average length of stay was greater for the matched HSA cohort than for the RTSA cohort (4.269 vs 3.704 days, respectively; MD, 0.565 days; CI, 0.148–0.982; P=.008), which likely narrowed the index admission cost differential. No statistically significant difference was found in 1-year revision rates between RTSA and matched HSA cohorts (3.83% vs 5.10%, respectively; odds ratio [OR], 0.740; CI, 0.407–1.345; P=.328) or 1-year readmission rates (26.5% vs 29.0%, respectively; OR, 0.881; CI, 0.668–1.160; P=.373). The hospital-reported discharge disposition was not statistically different, including to a skilled nursing facility (SNF), which is known to increase the total cost of care for orthopedic patients (34.3% vs 36.9%, respectively; OR, 1.121; CI, 0.866–1.451; P=.393).18 Because of database constraints, the current authors could not assess SNF length of stay and cost. No difference was found in the proportion of patients in the RTSA and matched HSA cohorts who underwent physical and occupational therapy by 3 months postoperatively (68.6% vs 65.0%, respectively; OR, 1.18; CI, 0.90–1.53; P=.23) or 1 year postoperatively (76.9% vs 77.7%, respectively; OR, 0.95; CI, 0.71–1.28; P=.76). At 3 months, both the RTSA and HSA cohorts had 29 events related to physical and occupational therapy, and the RTSA cohort had a slightly higher cost per patient ($662 vs $620, respectively; MD, $42; CI, $36–$47; P<.01). However, at 1 year, the matched HSA cohort had more events related to physical and occupational therapy per patient compared with the RTSA cohort (73.4 vs 56.6 events, respectively; MD, 16.8 events; CI, 16.7–16.9; P<.001), and average reimbursement after 1 year was higher ($1592 vs $1231, respectively; MD, $361; CI, $356–$365; P<.001).

Discussion

The use of RTSA increased rapidly from 2010 to 2015 and is predicted to double by 2020, whereas the use of HSA decreased gradually during this period (Figure 1), supporting the authors' hypothesis. This change may be explained by a tendency for surgeons to adapt their practice to studies showing equivalent to better functional outcomes for RTSA vs HSA.19–21 The influence of fellowship-trained shoulder surgeons on trainees and non–fellowship-trained surgeons could contribute to this change as well because new fellowship-trained shoulder surgeons are 20 times as likely to use RTSA compared with HSA for the treatment of PHF.22 In addition, delay in adoption of the new RTSA ICD-9-CM code may have resulted in rapidly increased rates of RTSA use during the study period.

Because several studies show that RTSA has superior clinical outcomes and an increasing rate of use,6–11,19–23 the current authors compared the costs of RTSA vs HSA for PHF. The index admission costs of both RTSA and HSA have decreased recently. Several notable abrupt cost reductions have occurred, including index RTSA and HSA costs in 2015, total RTSA cost in 2011, and total HSA cost in 2015. These reductions may be the result of systemic changes, such as truly lower-cost implants and procedures, or they may be affected by fewer patients with extremely high costs in the previous year. Notably, the average length of stay decreased from 5.8 days in 2010 to 2.6 days in the first quarter of 2015 for RTSA and from 4.9 days in 2010 to 3.1 days in the first quarter of 2015 for HSA. Although the data were not fully assessed because of low numbers, fewer patients may have been discharged to SNF settings over time. Also, as more implants are developed for HSA and RTSA, competition for market share increases, which may decrease the cost of implants over time.

Consistent with the current findings on index admission cost, a study of the 2011 National Inpatient Survey 8 sample of RTSA vs HSA for the treatment of PHF found that the average admission cost for RTSA was $21,723 and that for HSA was $18,122. Although the database software is limited in its ability to discern each piece of the reimbursement package, the primary difference in index admission cost is likely the result of the higher costs associated with the RTSA implant and procedure. At the current authors' institution, the implant cost for RTSA is currently $6110, and that for HSA is $3509. From 2007 to 2011, Solomon et al24 found that the mean implant cost was $4160 for HSA and $13,300 for RTSA and the mean operating room cost was $5000 for HSA and $14,000 for RTSA. Thorsness et al25 reported the implant list price as $12,500 for RTSA and $8000 for HSA, and Virani et al26 reported an average RTSA implant cost of $13,288, which accounted for more than half of the hospitalization cost. The other major costs associated with RTSA were surgical suite usage (mean, $1709) and professional fee (mean, $1467).

Among the postoperative outpatient factors that were considered, the only statistically significantly different factors were the number of events and the cost of physical and occupational therapy. By 1 year postoperatively, patients in the HSA cohort used more physical and occupational therapy and had higher costs per patient than the RTSA cohort. In the limited literature, 3 main tenets of progression of postoperative rehabilitation have been suggested: (1) passive range of motion; (2) active range of motion; and (3) progressive stretching and strengthening.27 Because functional return and range of motion vary among patients, the rehabilitation program must be tailored to each patient.28 In a meta-analysis, Shukla et al9 found that RTSA performed favorably compared with HSA in forward elevation, abduction, tuberosity healing, and Constant and American Shoulder and Elbow Surgeons scores. If patients had improved return of function with RTSA, they would likely have fewer physical and occupational therapy visits by 1 year postoperatively, potentially decreased length of stay in SNF settings, and lower longer-term total cost of RTSA. Conversely, a poorly functioning HSA may require extensive physical and occupational therapy resources.

Studies involving administrative claims have inherent limitations. Because patient-specific identifiers or individualized cost data were not available, the current authors could not perform advanced statistical analysis to evaluate the effect of various fracture patterns, comorbidities, and other demographics on cost. Also, patients who were discharged with delayed surgery may have been younger and healthier than the study cohort. Surgeons with different levels of training or therapeutic paradigms could be biased toward prescribing physical and occupational therapy services, discharge to SNF settings, outpatient visits, and other postoperative services at different rates, which may have systematically skewed observations. For instance, some surgeons who perform many HSA procedures may consistently prescribe more physical and occupational therapy.

The current authors were also limited by the accuracy and detail of administrative coding for these procedures and diagnoses. The CPT code for RTSA is the same as the code for total shoulder arthroplasty and may be used more often than the ICD-9-CM code, which could have led to systematic bias. Isolating the cost of PHF and the associated treatment was not possible, and the authors could not exclude costs related to medical problems, associated or other injuries, or other surgical procedures. Instead they relied on the large number of patients in each cohort and the short postoperative follow-up to offset extraneous costs. Further, the current authors were unable to ascertain the details of revision prostheses. Although the rates for revision of shoulder arthroplasty were indistinct between groups, one group may have undergone more expensive revision procedures. Nonetheless, most revisions from HSA to RTSA were likely for tuberosity malunion or nonunion, and RTSA to RTSA revisions were likely because of prosthetic loosening or instability.29–31

Despite these limitations, this study contributes to an understanding of the total costs associated with RTSA and HSA as surgical treatment options for PHF. Further investigation is warranted to confirm whether decreased length of stay in a rehabilitation facility or in an SNF setting and decreased use of physical and occupational therapy in the RTSA group are truly the cost drivers that account for the “catchup” of HSA to RTSA total cost of care at 1 year.

Conclusion

The use of RTSA for PHF is increasing. Although RTSA has a higher admission cost compared with HSA, especially for patients older than 70 years, the total costs at 1 year are not different. Increased cost of physical and occupational therapy is a primary driver of cost for HSA. The total cost of RTSA is not higher, and in a value-based health care environment, this procedure should be considered for the management of PHF in the appropriate clinical scenario.

References

  1. Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg. 2008;17(1):42–54. doi:10.1016/j.jse.2007.03.016 [CrossRef]18308203
  2. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442(442):87–92. https://doi.org/10.1097/01.blo.0000194672.79634.78 PMID: doi:10.1097/01.blo.0000194672.79634.78 [CrossRef]16394745
  3. Chalmers PN, Slikker W III, Mall NA, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014;23(2):197–204. doi:10.1016/j.jse.2013.07.044 [CrossRef]
  4. Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg Am. 2003;85(7):1215–1223. https://doi.org/10.2106/00004623-200307000-00006 doi:10.2106/00004623-200307000-00006 [CrossRef]12851345
  5. Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Molé D. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11(5):401–412. https://doi.org/10.1067/mse.2002.124527 PMID: doi:10.1067/mse.2002.124527 [CrossRef]12378157
  6. Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg. 2015;23(3):190–201. https://doi.org/10.5435/JAAOS-D-13-00190 PMID: doi:10.5435/JAAOS-D-13-00190 [CrossRef]25630370
  7. Garrigues GE, Johnston PS, Pepe MD, Tucker BS, Ramsey ML, Austin LS. Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients. Orthopedics. 2012;35(5):e703–e708. https://doi.org/10.3928/01477447-20120426-25 PMID: doi:10.3928/01477447-20120426-25 [CrossRef]22588413
  8. Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. Reverse shoulder arthroplasty versus hemiarthroplasty for treatment of proximal humerus fractures. J Shoulder Elbow Surg. 2015;24(10):1560–1566. doi:10.1016/j.jse.2015.03.018 [CrossRef]25958208
  9. Shukla DR, McAnany S, Kim J, Overley S, Parsons BO. Hemiarthroplasty versus reverse shoulder arthroplasty for treatment of proximal humeral fractures: a meta-analysis. J Shoulder Elbow Surg. 2016;25(2):330–340. doi:10.1016/j.jse.2015.08.030 [CrossRef]
  10. Gulotta LV. Reverse shoulder arthroplasty provided better functional outcomes than hemiarthroplasty for acute proximal humeral fractures. J Bone Joint Surg Am. 2015;97(10):861. https://doi.org/10.2106/JBJS.9710.ebo103 PMID: doi:10.2106/JBJS.9710.ebo103 [CrossRef]25995500
  11. Namdari S, Horneff JG, Baldwin K. Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. J Bone Joint Surg Am. 2013;95(18):1701–1708. https://doi.org/10.2106/JBJS.L.01115 PMID: doi:10.2106/JBJS.L.01115 [CrossRef]24048558
  12. Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(1):91–97. doi:10.1016/j.jse.2014.08.026 [CrossRef]
  13. Nwachukwu BU, Schairer WW, O'Dea E, McCormick F, Lane JM. The quality of cost-utility analyses in orthopedic trauma. Orthopedics. 2015;38(8):e673–e680. https://doi.org/10.3928/01477447-20150804-53 PMID: doi:10.3928/01477447-20150804-53 [CrossRef]26270752
  14. Osterhoff G, O'Hara NN, D'Cruz J, et al. A cost-effectiveness analysis of reverse total shoulder arthroplasty versus hemiarthroplasty for the management of complex proximal humeral fractures in the elderly. Value Health. 2017;20(3):404–411. https://doi.org/10.1016/j.jval.2016.10.017 PMID: doi:10.1016/j.jval.2016.10.017 [CrossRef]28292485
  15. Coe MP, Greiwe RM, Joshi R, et al. The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012;21(10):1278–1288. https://doi.org/10.1016/j.jse.2011.10.010 PMID: doi:10.1016/j.jse.2011.10.010 [CrossRef]22265767
  16. Crawford MC, Church J, Akin BJ. CPI Detailed Report. Washington, DC: US Department of Labor: Bureau of Labor Statistics; 2017.
  17. Charlson ME, Pompei P, Ales KL, MacK-enzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383. https://doi.org/10.1016/0021-9681(87)90171-8 PMID: doi:10.1016/0021-9681(87)90171-8 [CrossRef]3558716
  18. Sibia US, Turcotte JJ, MacDonald JH, King PJ. The cost of unnecessary hospital days for Medicare joint arthroplasty patients discharging to skilled nursing facilities. J Arthroplasty. 2017;32(9):2655–2657. https://doi.org/10.1016/j.arth.2017.03.058 PMID: doi:10.1016/j.arth.2017.03.058 [CrossRef]28455180
  19. Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am. 2013;95(22):2050–2055. https://doi.org/10.2106/JBJS.L.01637 PMID: doi:10.2106/JBJS.L.01637 [CrossRef]24257664
  20. Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures: a blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg. 2014;23(10):1419–1426. https://doi.org/10.1016/j.jse.2014.06.035 PMID: doi:10.1016/j.jse.2014.06.035 [CrossRef]25086490
  21. Ferrel JR, Trinh TQ, Fischer RA. Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: a systematic review. J Orthop Trauma. 2015;29(1):60–68. https://doi.org/10.1097/BOT.0000000000000224 PMID: doi:10.1097/BOT.0000000000000224 [CrossRef]
  22. Acevedo DC, Mann T, Abboud JA, Getz C, Baumhauer JF, Voloshin I. Reverse total shoulder arthroplasty for the treatment of proximal humeral fractures: patterns of use among newly trained orthopedic surgeons. J Shoulder Elbow Surg. 2014;23(9):1363–1367. https://doi.org/10.1016/j.jse.2014.01.005 PMID: doi:10.1016/j.jse.2014.01.005 [CrossRef]24725893
  23. Wang J, Zhu Y, Zhang F, Chen W, Tian Y, Zhang Y. Meta-analysis suggests that reverse shoulder arthroplasty in proximal humerus fractures is a better option than hemiarthroplasty in the elderly. Int Orthop (SICOT). 2016;40(3):531–539. https://doi.org/10.1007/s00264-015-2811-x PMID: doi:10.1007/s00264-015-2811-x [CrossRef]
  24. Solomon JA, Joseph SM, Shishani Y, et al. Cost analysis of hemiarthroplasty versus reverse shoulder arthroplasty of fractures. Orthopedics. 2016;39(4):230–234. https://doi.org/10.3928/01477447-20160610-03 PMID: doi:10.3928/01477447-20160610-03 [CrossRef]27322171
  25. Thorsness R, Shields E, Iannuzzi JC, Zhang L, Noyes K, Voloshin I. Cost drivers after surgical management of proximal humerus fractures in Medicare patients. J Orthop Trauma. 2016;30(5):262–268. https://doi.org/10.1097/BOT.0000000000000513 PMID: doi:10.1097/BOT.0000000000000513 [CrossRef]
  26. Virani NA, Williams CD, Clark R, Polikandriotis J, Downes KL, Frankle MA. Preparing for the bundled-payment initiative: the cost and clinical outcomes of reverse shoulder arthroplasty for the surgical treatment of advanced rotator cuff deficiency at an average 4-year follow-up. J Shoulder Elbow Surg. 2013;22(12):1612–1622. https://doi.org/10.1016/j.jse.2013.01.003 PMID: doi:10.1016/j.jse.2013.01.003 [CrossRef]23566674
  27. Boardman ND III, Cofield RH, Bengtson KA, Little R, Jones MC, Rowland CM. Rehabilitation after total shoulder arthroplasty. J Arthroplasty. 2001;16(4):483–486. https://doi.org/10.1054/arth.2001.23623 PMID: doi:10.1054/arth.2001.23623 [CrossRef]11402412
  28. Boudreau S, Boudreau ED, Higgins LD, Wilcox RB III, . Rehabilitation following reverse total shoulder arthroplasty. J Orthop Sports Phys Ther. 2007;37(12):734–743. https://doi.org/10.2519/jospt.2007.2562 PMID: doi:10.2519/jospt.2007.2562 [CrossRef]
  29. Glanzmann MC, Kolling C, Schwyzer HK, Audigé L. Conversion to hemiarthroplasty as a salvage procedure for failed reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25(11):1795–1802. https://doi.org/10.1016/j.jse.2016.03.011 PMID: doi:10.1016/j.jse.2016.03.011 [CrossRef]27260994
  30. Williams PN, Trehan SK, Tsouris N, et al. Functional outcomes of modular conversion of hemiarthroplasty or total to reverse total shoulder arthroplasty. HSS J. 2017;13(2):102–107. https://doi.org/10.1007/s11420-017-9546-8 PMID: doi:10.1007/s11420-017-9546-8 [CrossRef]28690459
  31. Abdel MP, Hattrup SJ, Sperling JW, Cofield RH, Kreofsky CR, Sanchez-Sotelo J. Revision of an unstable hemiarthroplasty or anatomical total shoulder replacement using a reverse design prosthesis. Bone Joint J. 2013;95-B(5):668–672. https://doi.org/10.1302/0301-620X.95B5.30964 PMID: doi:10.1302/0301-620X.95B5.30964 [CrossRef]23632679

Patient Demographics

CharacteristicNo.P

Reverse Total Shoulder ArthroplastyMatched Hemiarthroplasty
Age
  <65 y42 (7.0%)34 (7.9%).70
  65–69 y92 (15.3%)65 (15.1%).93
  70–74 y125 (20.8%)90 (20.9%).98
  75–79 y150 (25.0%)107 (24.8%).96
  80–84 y103 (17.1%)72 (16.7%).87
  85–89 y60 (10.0%)43 (10.0%)1.0
  ≥90 y29 (4.9%)21 (4.9%).97
Sex
  Female515 (85.7%)371 (86.1%).87
  Male86 (14.3%)60 (13.9%).87
Charlson Comorbidity Index
  091 (15.1%)64 (14.8%).90
  1108 (18.0%)65 (15.1%).22
  286 (14.3%)55 (12.8%).48
  3+316 (52.6%)247 (57.3%).13
  Total601431

Use and Cost of Reverse Total Shoulder Arthroplasty

YearNo.Cost


Total UseUse With 1-Year Follow-upAverage Index AdmissionAverage Total Admission + Within 1 Year
20101814$16,428.15$68,694.92
20117954$15,556.30$37,367.98
201212096$16,062.82$39,564.36
2013199149$15,509.91$36,790.91
2014293217$15,516.42$37,586.55
201532977a$12,660.46a$35,546.25a
Total/average1038601$15,263.27$38,098.86

Use and Cost of Hemiarthroplasty

YearNo.Cost


Total UseUse With 1-Year Follow-upaAverage Index AdmissionAverage Total Admission + Within 1 Year
201020095$15,281.37$38,431.63
201121991$14,054.53$35,297.92
201219887$14,600.65$44,509.91
201317792$13,858.44$37,086.52
201415461$14,267.23$39,044.92
2015985b$11,331.10b$40,258.00b
Total/average1046431$14,356.09$38,833.84

International Classification of Diseases, 9th Revision Diagnosis (ICD-9-D) and Procedure (ICD-9-P) codes and Current Procedural Terminology (CPT) codes used in this study

Diagnosis/ProcedureCode
Acute proximal humerus fractureICD-9-D-812.00, ICD-9-D-812.01, ICD-9-D-812.03, ICD-9-D-812.09, ICD-9-D-812.10, ICD-9-D-812.11, ICD-9-D-812.13, and ICD-9-D-812.19
Reverse total shoulder arthroplastyICD-9-P-81.88
Shoulder hemiarthroplastyICD-9-P-81.81
Physical and occupational therapyCPT-97001, CPT-97002, CPT-97003, CPT-97004, CPT-97010, CPT-97012, CPT-97014, CPT-97016, CPT-97018, CPT-97022, CPT-97024, CPT-97026, CPT-97028, CPT-97032, CPT-97033, CPT-97034, CPT-97035, CPT-97036, CPT-97039, CPT-97110, CPT-97112, CPT-97113, CPT-97116, CPT-97124, CPT-97139, CPT-97140, CPT-97150, CPT-97530, CPT-97532, CPT-97533, CPT-97535, CPT-97537, CPT-97542, CPT-97597, CPT-97598, CPT-97602, CPT-97605, CPT-97606, CPT-97750, CPT-97755, CPT-97760, CPT-97761, CPT-97762, CPT-97799, CPT-G0281, CPT-G0283, and CPT-G0329
Authors

The authors are from the Department of Orthopaedic Surgery (CSP), University of California San Diego, and the Department of Orthopaedic Surgery (AB), Stanford University Health System, Palo Alto, California; and the Department of Orthopaedic Surgery (TMS, MPB), Division of Adult Reconstruction, Duke University Health System, and the Department of Orthopaedic Surgery (GEG), Shoulder Reconstruction Section, Rush University Health System, Durham, North Carolina.

Drs Politzer and Bala have no relevant financial relationships to disclose. Dr Seyler is a paid consultant for Heraeus, Pfizer, Smith & Nephew, and Total Joint Orthopedics, Inc; has received research support from Biomet, KCl, MedBlue Incubator Inc, and Reflexion Health Inc; and receives royalties from Total Joint Orthopedics, Inc. Dr Bolognesi is a paid consultant for Total Joint Orthopedics, Inc, and AOA Omega; has received research support from Biomet, DePuy, and Zimmer; holds stock in Total Joint Orthopedics, Inc, and Amedica; and receives royalties from Total Joint Orthopedics, Inc, and Zimmer. Dr Garrigues is a paid consultant for Arthrex, Inc, DJ Orthopaedics, SouthTech, Zimmer, Mitek, and Tornier; has received research support from Tornier; receives royalties from DJ Orthopaedics and Tornier; and holds stock in Genesys.

Correspondence should be addressed to: Cary S. Politzer, MD, Department of Orthopaedic Surgery, University of California San Diego, 200 Arbor Dr, San Diego, CA 92003 ( cspolitzer@ucsd.edu).

Received: December 14, 2018
Accepted: February 11, 2019
Posted Online: January 13, 2020

10.3928/01477447-20200107-06

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