Tuesday, November 26, 2013

Does rotator cuff repair save the U.S. money?

Some of our most distinguished colleagues set out to model the societal and economic value of rotator cuff repair.

As they point out rotator cuff tears are common in the United States, but the effect of cuff tears on earnings, missed workdays, and disability payments has not been well defined. As they point out in the introduction, long-term clinical studies of cost effectiveness 'do not exist'. This is a sad commentary on the state of clinical research in that hundreds of thousands of cuff repairs are performed each year, providing a huge opportunity for long term studies of the actual costs of cuff tears as well as the effectiveness of operative and non-operative management of different types of cuff tears in different types of patients using different techniques by different providers (see the 4Ps).

In the absence of real data, the authors' goal was to estimate the value of surgical treatment for full-thickness rotator cuff tears from a societal perspective using a Markov decision model of the lifetime direct and indirect costs (e.g. inability to work, lower wages, missed workdays, disability payments) associated with surgical and continued nonoperative treatment for symptomatic full-thickness rotator cuff tears. Patients with a symptomatic full-thickness rotator cuff tear 'underwent' either open or arthroscopic rotator cuff repair or continued to receive nonoperative treatment. After one year, all rotator cuff repairs resulted in either (1) healed rotator cuff repair (symptomatic and asymptomatic), (2) asymptomatic retear, (3) symptomatic retear, or (4) death; shoulders treated without surgery resulted in either (1) symptomatic tear, (2) asymptomatic tear, or (3) death.

The model indicated that surgical treatment results in an average improvement of 0.62 QALY. The model suggested that the age-weighted mean total societal savings from rotator cuff repair compared with nonoperative treatment was $13,771 over the lifetime of the patient. Savings ranged from + $77,662 for patients who are thirty to thirty-nine years old to - $11,997 for those who are seventy to seventy-nine years old.

The model concluded that "rotator cuff repair is cost-effective for all populations" and "The estimated lifetime societal savings of the approximately 250,000 rotator cuff repairs performed in the U.S. each year was $3.44 billion." This is a staggering figure.

Because actual data were not available for many of the key elements in the model, values were based on Level V assumptions. As the authors point out 'evidence to support some of the model assumptions is limited.'These assumptions had a strong influence on the results. Here are some considerations of the assumptions used:

(1) It was assumed that all symptomatic full-thickness rotator cuff tears assigned to the repair group were repairable, whereas this does not seem to be the common experience
(2) The model recognizes that healed repairs can be symptomatic or asymptomatic, but does not assume any disability if the healed repair is symptomatic, whereas we have all seen patients who are unable to return to work after a symptomatic "successful" cuff repair.
(3) The long term retear rate after cuff repair was assumed to be 2%, whereas a recent post found retear rates after one year approximating 10%.
(4) Patient outcomes for all repairs were assumed to be the same as those of seventy-three patients who underwent surgery at a large orthopaedic surgery group; presumably those cases represented careful selection of patients, of reparable cuff tears, and excellent surgical technique by a well trained shoulder surgeon, whereas many patients with cuff tears are not prime surgical candidates, have irreparable cuff tears and may be cared for by surgeons who are not specialized in shoulder (see the 4Ps: problem, patient, procedure, physician).
(5) It was assumed that workers lost an average of twenty-eight additional days as a result of rotator cuff repair compared with those undergoing non-operative treatments, whereas recent data suggests that repairs should be protected from loading for up to six months after surgery. In that many cuff tears occur in those with physical laboring jobs, the 28 days seems like a short interval for return to work. Furthermore, it is not clear that cuff tears treated with non-operative management need to miss work at all.
(6) The model assumed complication rates of stiffness (2.5%) and of infection (0.1%) following rotator cuff repair, whereas some studies have reported a complication rate of 10.6% of which the most common was persistent stiffness.
(7) The model used an expensive approach to non-operative management costing $1802, whereas there is substantial evidence that an inexpensive home program provides an effective method for non-operative management.
(8) The model assumes that only 5% of asymptomatic retears following repair become symptomatic annually, whereas it assumes that 8.8% of asymptomatic tears managed non-operatively become symptomatic per year.

These and other assumptions led the model to conclude that "rotator cuff repair produces societal cost savings for patients under the age of sixty-one years and is cost-effective for all patients". However, it is easy to see that different assumptions might have led to a different answer. 

It may be worthwhile to reflect on whether this model addresses the right question. No one would doubt that a successful rotator cuff repair that returns a worker to work is a good thing for that person and for society. On the other hand non-operative management can be of value to many patients. The real question is 'how do we decide which rotator cuff tears in which patients will benefit from rotator cuff repair and the critical post-operative rehabilitation period that must follow?'. The model's conclusion that 'rotator cuff repair is cost-saving across all patients' does not change the fact that many cuff tears are not reparable and that many patients with cuff tears are not good candidates for cuff repair. 

In terms of guidance, the model leaves us with the quizzical statement "Although rotator cuff repair is cost-saving across all patients, nonoperative treatment is the preferred strategy for a large number of patients. "

Consultation for those who live a distance away from Seattle.

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