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.
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
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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