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Reverse total shoulder may be a viable alternative to hemiarthroplasty
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SAN DIEGO — Reverse shoulder arthroplasty could be a cost-effective alternative to hemiarthroplasty for patients with cuff tear arthropathy, according to the results of a study presented here.
 Marcus P. Coe |
Marcus P. Coe, MD, discussed his group’s findings at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons.
“Hemiarthroplasty has been around for longer,” Coe said. “Reverse total shoulder is relatively new, and thus has less long-term follow-up. Hemiarthroplasty has been shown to provide consistent pain relief, but only modest functional improvement. The functional improvement of reverse is thought to be higher. However, that is at the cost of potentially greater complications. Finally, the reverse total shoulder costs more.”
For their study, Coe and his colleagues aimed to compare the cost effectiveness of the two treatments. “Cost-effectiveness analysis is typically used to study those interventions that improve health, but at a greater cost,” he said.
A cost-effectiveness model
The group used a Markov decision model, and outcome and complication probabilities from existing literature. Costs in the study were based on average Medicare reimbursement and implant prices.
The investigators derived utilities from the responses of 33 patients at a single institution to health state surveys (SF-6D and Euroqol-5D). The patients, underwent either reverse shoulder arthroplasty or hemiarthroplasty for cuff tear arthropathy. The group used incremental cost-effectiveness ratios to compare the treatments.
Coe reported the incremental cost-effectiveness ratio of reverse shoulder arthroplasty compared to hemiarthroplasty was $80,757 per quality adjusted life-year (QALY).
“In our case, the model was most sensitive to complication rates and utility,” Coe said. “Those had the most outcomes in the model. It was less sensitive to revision rates, age and varying implant price.”
With a price lower than $14,875, the incremental cost effectiveness ratio of reverse shoulder arthroplasty was reported to be less than $100,000 per QALY – meaning, Coe said, an implant price below $14,875 makes reverse shoulder arthroplasty a cost-effective solution relative to hemiarthroplasty.
Further examination warranted
Coe noted that the cost-effectiveness of reverse shoulder arthroplasty depends upon health utility gained from the operation, as well as utility lost due to complications from the procedure. He said further examination is warranted to determine the clinical and quality-of-life outcomes for the two treatments.
“Using $100,000 as a cutoff for cost-effectiveness, reverse total shoulder is a cost-effective alternative to hemiarthroplasty for cuff tear athropathy,” he said. “Further head-to-head, high-level studies should be designed to examine those variables.”
Reference:
- Coe MP, et al. Reverse total shoulder vs. hemiarthroplasty for cuff tear arthropathy: A cost-effectiveness analysis. Paper 366. Presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 15-19, 2011. San Diego.
This paper is representative of the global issue of how to best address innovation. Industry is incentivized to innovate based on the clinical problems, as well as the likelihood that they are going to receive increased remuneration, and profits by developing said innovation.
Realize that 25 or 30 years ago, when hemiarthroplasty and total shoulder implants were developed, they were very expensive. Reverse total shoulder arthroplasty clearly now fills a void for patients who in the past, prior to its development, really would have had no options for treatment. Hemiarthroplasty was a poor option with regards to function. Now, you have the opportunity to really give patients a legitimate and scientifically proven method.
I thought the $100,000 outlay was a little arbitrary, but you have to assume some standard expenditure for the analysis to be valid. Having said all that, the results of total shoulder arthroplasty are proof that it is hard to argue against its use based on tens of thousands of dollars.
– Riley J. Williams, MD
Moderator
Disclosure: He receives royalties from Arthrex, research or institutional support from Smith & Nephew, and royalties from Springer.
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