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Initial surgery more cost effective for first-time shoulder dislocations
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Results of the first cost-effectiveness analysis performed on first-time shoulder dislocations showed that at a willingness to pay of $25,000 per quality-adjusted life year, initial surgery was more cost effective for all of the cohorts in this study.
“Cost-effectiveness analysis is an old research technique, but one that is relatively unfamiliar to many orthopedic surgeons,” Timothy S. Crall, MD, said during his presentation at the Arthroscopy Association of North America 2012 Annual Meeting. The study was conducted at Taos Orthopaedic Institute, in Taos, N.M.
As health care resources shift, he said cost-effectiveness analyses will become increasingly important.
“This is critical in our new era of ever-decreasing health care resources in which we are going to have to justify the value of our treatments to both payers and patients,” Crall said.
This type of analysis factors in the quality of life of various disease states and how much it costs to achieve those states. Cost effectiveness is usually assigned a unit of dollars per quality-adjusted life year (QALY), Crall said.
The critical terms for a cost-effectiveness analysis are:
- dominant — a treatment that is more effective and costs less;
- preferred — a treatment that is more cost effective (i.e., a lower cost per QALY); and
- willingness to pay — if a treatment is more effective but costs more, how much are patients and payers willing to pay to secure the extra QALYs?
After creating a model, Crall and colleagues completed a sensitivity analysis to define the model’s uncertainty. They validated it by comparing it to external data, he said.
“We compared it against four different parameters from well-known published series from Kirkley and Hovelius,” Crall said. “In each case, our model closely reflected the real-world scenario of shoulder instability.”
The sensitivity analysis revealed robust outcomes, Crall said. For 15-year-old boys and girls as well as 25-year-old men, initial surgery was the dominant strategy. In contrast, initial observation was the preferred strategy for 25-year-old women and 35-year-old participants regardless of gender.
“After one recurrent dislocation, however, surgery became the dominant treatment for all cohorts that were studied in the model,” Crall said.
Overall uncertainty for this model was low.
“For example, there was a less than one in 10,000 chance that the model would recommend an inferior treatment strategy for 35-year-old patients.”
The study had some limitations, Crall said. The outputs were only as strong as the inputs. The authors did not factor in indirect costs to patients (i.e., time off work, transportation, etc.) or the possible cost of arthritis.
This is the first cost-effectiveness analysis for first-time anterior shoulder dislocation, Crall said.
“There was a previously published instability model that showed similar cohort results to ours …, however, they did not perform a cost analysis,” he said. – by Colleen Owens
References:
- Crall TS, Bishop J, Guttman D, et al. Cost-effectiveness analysis: Surgical vs. nonoperative treatment for first-time anterior shoulder dislocations. Presented during the Arthroscopy Association of North America 2012 Annual Meeting. May 16-19. Orlando, Fla.
For more information:
- Timothy S. Crall, MD, can be reached at Mammoth Hospital’s Sierra Park Orthopedic & Sports Medicine Clinic, 85 Sierra Park Road Mammoth Lakes, CA 93546; email: timothy.crall@mammothhospital.com.
- Disclosure: Crall has no relevant financial disclosures.
Perspective
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Ronald A. Navarro, MD
Crall, Bishop, Guttman and colleagues performed a cost-effectiveness analysis on a group of primary dislocators, using probabilistic sensitivity. Although their work shows initial surgery was a dominant strategy with low uncertainty in many cohorts and becomes dominant in the rest studied after one recurrent dislocation, they were unable to factor in critical indirect costs that would likely impart greater importance to the initial surgery (for example, time lost from work and long-term disability/arthritis). Studies like these will no doubt be more important in the future as the health care dollar becomes parsed more thinly.
Some argue that quality-adjusted life year (QALY) studies place more value on physical pain or disability over mental health, so this should be taken into account in future studies. The concept of willingness-to-pay has wanting value in a health care environment where the payer is less often the patient but more often an employer or the government, while the QALY is a disease-burden assessment specific to the patient (resulting in a bit of a disconnect or mismatch).
As more payment burden becomes shifted to the patient, studies like that of Crall will gain even more import, and the authors should be lauded for their use of a novel economic analysis to assess ultimate value of this surgical intervention.
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