Monday, November 18, 2013

The value of total shoulder arthroplasty - the 4Ps

Preparing for the bundled-payment initiative: the cost and clinical outcomes of total shoulder arthroplasty for the surgical treatment of glenohumeral arthritis at an average 4-year follow-up

This study represents a concerted effort to determine value in shoulder arthroplasty. It is an important study as much for the methodology as for the results.

The authors have tried to manage the 4Ps (the problem, the patient, the procedure, and the physician). Specifically, the procedure and the physician were relative 'constants', however they also studied the year the procedure was performed. Of note is that these procedures were performed by a high volume surgeon with over 15 years of experience. The problem as well was relatively narrowly defined: moderate to severe shoulder pain, reduced ability to perform daily function, physical examination that showed consistent reduction of shoulder motion, evidence of glenohumeral arthritis on imaging studies, and failed nonoperative management (including medical management, physical therapy, and cortisone injections). They explored the influence of patient factors as reflected by age, gender, and SF 36 scores. For example the number of comorbidities ranged from 0 to 11, the age ranged from 35 to 89, the diagnoses ranged from osteoarthritis to post traumatic arthritis, and about half of the patients were males - each of these factors has been shown previously to affect the results of shoulder arthroplasty.

We were especially interested in the methodology for collecting cost data, spanning the period from the preoperative orthopaedic clinic visit to the last follow-up clinic visit recorded in the study (mean, 48 months, divided into (1) the pre- hospitalization period, (2) the hospitalization period, and (3) the post- hospitalization period. Data were obtained from the Decision Support Department of the hospital, including the cost of materials, personnel, resource utilization, rent, and other factors necessary to perform a specific aspect of patient care. Costs that accrued outside the hospital system were defined for each patient by the year-specific regional Medicare reimbursement. They recognized, but did not measure indirect costs such as the cost of lost wages and productivity.

Importantly, the cost of additional treatment for all complications that occurred during the study period was determined. This did open the possibility that more recent surgeries would have lower complication rates in part because of shorter followup periods.

To be included, patients had to complete both preoperative and minimum 2-year postoperative independent third-party isometric strength testing. Of 179 primary TSAs, 83 shoulders met the inclusion criteria for the study. These patients had symptoms for a mean of 5.7 years. The most common reason for non-participation was failure to locate (41 of 96).

Clinical outcomes were improved for the majority of patients. Interestingly two of the three major complications were neurologic - one a plexus palsy that required 2.5 years for resolution and another with reflex sympathetic dystrophy that did not respond to treatment.

The mean 4-year cost was $17,587, with the hospitalization accounting for 88% of this cost. The surgeon appears to have been able to obtain services at quite low costs: shoulder CT for $245, EKG for $14, medicine consult for $107, Chest film for $31, implant for $6643, and anesthesiologist for $400. These costs suggest that some tough negotiating has been done to minimize the expense of the procedure.

During the pre- hospitalization period, the shoulder computed tomography scan was the most expensive component of care, accounting for 37% of the cost of care for that period. We do not obtain CT scans routinely in that the great part of what we need to know can be identified on plain films - thus elimination of the preoperative CT may represent another possible cost saving. Home health care was the most expensive part of the post operative care, but this may actually have been a cost saving by minimizing the length of stay, which averaged 2 days.

Fiscal year was found to be responsible for the greatest fluctuation in total cost (P < .001). This is a very important finding the cause of which is unclear. The costs were higher at the start of the study, then lower then back up again.

Costs were lowest for patients with greater improvements in shoulder function, higher preoperative social functioning scores on the Short Form 36, and female gender .

The bottom line is that this study sets a bar, both for methodology and for cost containment. It will be of interest to see how subsequent studies compare. It also shows that there are unexpected variations in cost (fiscal year) as well as ones that are easier to understand (social functioning and gender). A final comment is that social functioning continues to appear as an important determinant of the result, one to which we need to consider in our preoperative discussions with our patients.

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