Almost all shoulder surgeons would agree that reverse total shoulder is a high value treatment for patients with cuff tear arthropathy, value being defined as the clinical outcome for the patient divided by the total costs associated with the procedure.
It is a natural tendency for us to try to make a good thing better. As nicely pointed out in a recent episode of HiddenBrain (see this link), doing better is usually equated with doing more.
Importantly, there are two types of doing more.
One type is cost neutral. Examples are refinements in technique, such has modifying the approach to drilling and tapping (see this link) or the use of a humeral head autograft to improve the positioning and seating of the baseplate (see this link). If these innovations are associated with better clinical outcomes, value to the patient is increased.
The second type is cost additive. Examples are patient specific instrumentation, augmented reality, and augmented baseplates. A burden of proof lies on the advocates of such innovations to demonstrate that the increased cost is proportional to an increase the clinical outcomes realized by the patient. As a hypothetical example, let's say that the use of an augmented glenoid baseplate increases the total cost of a reverse total shoulder by 8% (+$4,000 / $50,000). Thus to be of increased value to the patient, augmented baseplates need to increase clinical outcomes by more than 8%. There are some recent data indicating the clinical value of augments in comparison to bone grafting (see this link). However there is also evidence that augmented components are associated with increased problems of baseplate seating in comparison to other techniques (see this link). Future clinical research will clarify the indications for augmented glenoid components, in other words, which patients are most likely to benefit from their use.
Another approach to improving the value of reverse total shoulder arthroplasty is reducing the price paid for the implant. Implant costs are the largest single element in the total cost of reverse shoulder arthroplasty, up to about 30% of the total. If the cost of an implant system is reduced by 10%, the value of the procedure is increased by the same amount.
Below are data from Orthopaedic Network News showing the average selling price for various reverse total shoulder arthroplasty systems.
Of note is that the selling price for orthopaedic implants is established by confidential negotiations between the vendor and the hospital, negotiations that are not transparent to the public or the patient and often not transparent to the surgeon. Smaller hospitals with lower case volumes are likely to be disadvantaged in such negotiations.
Comment: In that reverse total shoulder arthroplasty is a common, increasingly frequently performed, costly and effective procedure, it is worthwhile considering means for optimizing its value to our patients.
Comments welcome at shoulderarthritis@uw.edu
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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).
