What is the value of total shoulder arthroplasty - how can it be improved?

The value of a procedure to patients can be defined as quality of care divided by the costs associated with the procedure. Measures of quality include improvements in patient reported outcomes along with intra- and postoperative complications.

The authors of Measuring Patient Value after Total Shoulder Arthroplasty sought calculate the patient value delivered by total shoulder arthroplasty (TSA) for 116 consecutive TSAs.

Patient value was defined as quality of care divided by direct costs of surgery; the preoperative costs (i.e. imaging, planning) and postoperative costs (i.e. physical therapy) were not assessed.

Compared to a reference threshold of 1.0, ninety patients (78%) had a quality of care ≥1.0 and 61 patients (53%) had direct costs related to surgery ≤1.0. 

The average value delivered to patients was higher for non-smokers, for those receiving anatomic TSA (as opposed to reverse TSA),  those with higher pre-operative pain, and lower pre-operative function.

43% of the patients were in the highest value (green) rectangle below, while 13% were in the lowest value (red) rectangle.

19% of the patients had intraoperative or postoperative complications. 

 

Comment: The average value delivered to patients was higher for non-smokers, for those receiving anatomic TSA (as opposed to reverse TSA),  those with higher pre-operative pain, and lower pre-operative function. While not discussed in this publication, it seems likely that patients having complications would be likely to have both higher costs and poorer outcomes. If having a complication resulted in patients being in the red rectangle, avoiding complications might be a most effective means of optimizing value.

As suggested in Innovations in the Realm of Shoulder Arthroplasty the incremental preoperative, intraoperative and postoperative costs associated with preoperative planning, navigation, artificial intelligence, augmented reality, new prosthetic designs, custom augments, and three dimensional printing might be justified by actual improved outcomes in selected patients with certain complex pathologies......but perhaps not in shoulders with routine arthritic anatomy

Careful clinical research will be necessary to identify which patients are likely to achieve better outcomes with which of these technologies leading to the establishment of what the American Academy of Orthopaedic Surgeons refers to as clinical practice guidelines and appropriate use criteria.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).