Total Shoulder Arthroplasty - how valuable is it?

Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty

These authors analyzed 92 patients with glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty performed by an individual surgeon using a a press-fit, short-stem anatomic humeral component and a hybrid, all-polyethylene, pegged glenoid implant and that had 1-year follow-up with respect to their health-related quality-of-life (HRQoL) scores and patient-reported outcome measures (PROMs): Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function.

There were significant improvements in all PROMs and HRQoL scores (p < 0.001) at 1 year after the surgical procedure.

The changes in VAS QoL (very weak to moderate), EQ-5D (weak), and SF-6D (weak) were significantly correlated (p < 0.05) with the changes in PROMs, demonstrating comparably acceptable validity. 

 There were large effect sizes in the VAS QoL (1.843), EQ-5D (1.186), and SF-6D (1.084) and large standardized response mean values in the VAS QoL (1.622), EQ-5D (1.230), and SF-6D (1.083), demonstrating responsiveness. The effect sizes of all PROMs were larger than those of the HRQoL scores.

Comment: In this well-done study, the authors point out that shoulder patient reported outcome metrics cannot be used in an analysis of comparative value of shoulder arthroplasty relative to other orthopaedic and nonorthopaedic conditions. 

Measurement of quality-adjusted life-years (QALYs a summary measure of health outcome that combines the impact of a treatment on a patient’s length of life) and health-related quality of life (HRQoL) can be used to compare alternative treatments of a specific condition, as well as treatments of disparate conditions. QALYs can be used with costs (direct and indirect) to determine cost utility (monetary cost/QALY), which can be used to perform cost utility analysis to compare, say a total shoulder to a rhinoplasty. 

It is not surprising to see a lack of tight correlation between patient reported outcome metrics and measures of health-related quality of life measures: they do not measure the same thing. The PROMS are used to measure the change in patient-assessed shoulder comfort and function. In this study the SST changed from 3 preoperatively to 10 postoperatively. This is exactly the same change documented in many different case series by different surgeons using different makes of implants. It is very reassuring to see consistently large effect sizes for the PROMs.

On the other hand, one could expect the HRQoL to have a strong correlation with the SST only if the shoulder operated on was the only factor affecting the patients health-related quality of life. Consider the patient who has a SST 3=>10 after a shoulder arthroplasty, but who at one year comes in  saying "now my other shoulder (or my hip or my knee or my back)  is killing me" or "I fell and broke my wrist" or "I now have cancer or ....". This is why the effect sizes are smaller for the HRQoL than for the PROM.

As shoulder surgeons we are responsible for an important, but only one part of a patient's health equation. The measure of our success is the value of our treatment, that is the benefit the patient realizes from our intervention divided by the cost of our evaluation and treatment (i.e. change in SST decided by the sum of preoperative imaging, implants, hospital costs, professional fees, rehabilitation and complications). In that the numerator seems pretty standard, optimization of this quotient is most effected by the denominator.

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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Cost-effectiveness and health-care value analysis - the elephant in the room

Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty

These authors evaluated Health-related quality-of-life (HRQoL) scores and patient-reported outcome measures (PROMs) in 93 patients at year after anatomic shoulder arthroplasty for advanced glenohumeral osteoarthritis to establish values of HRQoL scores that can be used for cost effectiveness and value analysis and to assess relationships between HRQoL scores and shoulder and upper-extremity PROMs. 

Preoperative and postoperative functional outcomes were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function. Health utility was assessed with the EuroQol-5 Dimensions (EQ-5D), Short Form-6 Dimensions (SF-6D), and VAS Quality of Life (VAS QoL). 

There were significant improvements in all PROMs and HRQoL scores (p < 0.001) at 1 year after the surgical procedure. 

Each of the metrics showed a large effect size and standardized response mean

The changes in VAS QoL and EQ-5D were significantly correlated with the changes in most PROMs, but the correlation was only weak to moderate.

The authors concluded that PROMs and HRQoL scores are not interchangeable, and studies of the cost-effectiveness and value of shoulder arthroplasty should incorporate both shoulder and upper-extremity PROMs and HRQoL scores. 

Comment: The value of a treatment is defined as the benefit to the patient divided by the cost of rendering that treatment. This article demonstrates that we have robust tools for evaluating the benefit to the patient of shoulder arthroplasty, both with respect to the improvement in patient self-assessed comfort and function (PROMS) and in the quality of life (HRQoL).

For determining the cost-effectiveness and value of treatment, the challenge is the difficulty in measuring the cost of care, the denominator of the value equation.

One recent study demonstrated the complexity of this assessment: 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

The pre-hospitalization, hospitalization, and posthospitalization periods accounted for 3.5%, 88.4%, and 8.1% of the 4-year total cost of TSA, respectively. Within the pre-hospitalization period, the shoulder computed tomography scan was the most expensive component of care (37% of pre-hospitalization cost). During the hospitalization period, as well as during the entire 4-year study period, the operating room was the most expensive area (81% of hospitalization cost and 71% of total cost). Within the operating room, the implants were the single most expensive component of care (43% of hospitalization cost and 38% of total cost). The surgeon’s fee was $1,470 and was responsible for 8% of total cost. In the post-hospitalization period, home health care was the most expensive component of care (70% of post-hospitalization cost).

What emerges from that study is that 38% of the total cost is the cost of the implants used.

In a recent article, An analysis of costs associated with shoulder arthroplasty, the authors pointed out that the implant brand was a major factor the the cost of shoulder arthroplasty, however, as they stated "Because actual implant costs were the result of confidential contractual negotiations, actual dollar amounts could not be published nor could the brand names be published adjacent to their relative costs."

The most modifiable variable in the value of shoulder arthroplasty is the cost of the implant, yet because of the confidentiality of contract negotiations, the actual cost data are not available for analysis. We are aware of a major medical center that requires that implant vendors offer implant charges that are at the 25th percentile of the charges across the country. This means that, all other things being equal, the value of shoulder arthroplasty at that medical center would be substantially higher than average because their costs are less.

We conclude that we have a good tool-set for measuring the effectiveness of shoulder arthroplasty, but as a specialty, we do not have a meaningful way of measuring the cost of providing this procedure, especially with respect to implant costs, the elephant in the room.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

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