Saturday, May 11, 2013

Value in shoulder surgery

Value-based shoulder surgery: practicing outcomes-driven, cost-conscious care

This thoughtful article points to (1) the substantial role shoulder surgery plays in health care economics, (2) the disorganized state of outcomes measurement in shoulder shoulder surgery, and (3) the difficult in getting our arms around the full costs of our surgical care. 

One can imagine a world in which it is required to document the value (benefit/cost) of surgical care before it will be funded. Even a casual glance at the Cochrane Reviews (which seeks evidence on "How do you know if one treatment will work better than another, or if it will do more harm than good?") shows very little evidence in support of common shoulder procedures. 

Our specialty has a tendency to pursue more expensive approaches in the evaluation and management of shoulder disorders -  CTs rather than plain films, surgery rather than rehab, patient-specific instruments, computer-guided surgery, more and more expensive implants - often without evidence that the increase in cost produces an increase in the benefit to the patient.

It seems that the challenge should be approached, as in Gulliver's Travels from the big end (Brobdingnag) of national organizations and the little end (Lilliput) by each individual surgeon. The former might include insistance on firm evidence in support of more expensive approaches before funding them, having Medicare put out shoulder prostheses for bid in search of a major 'group discount', and mandatory reporting of revision surgeries to a national databse. The latter might include consideration of the incremental value to the patient of each incremental dollar spent (does this patient really need surgery, does this patient really need a CT, does this patient really need a 4th generation implant). 

Finally, our approach to optimizing the value of shoulder care needs to recognize that the result is strongly influenced by each of the 4 "P"s:

1.Physician (e.g. training, case volume, team)
2.Patient (e.g. age, smoker, health, pain medications, depression, work-related)
3.Problem (e.g. degenerative arthritis, cuff tear arthropathy, failed prior arthroplasty, pathoanatomy)
4.Procedure (e.g. anatomic, reverse, CTA, prosthesis, subscapularis management, rehab)

We will be better able to provide value when we better understand the effects of the combination of these elements that surround each episode of care.

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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