Cost-Utility Analysis of Arthroscopic Rotator Cuff Repair: A Prospective Health Economic Study Using Real-World Data

Bringing Patient-Reported Outcome Measures (PROMs) Into Practice: A Review of the Latest Developments in PROM Use in the Evaluation and Treatment of Carpal Tunnel Syndrome

As health care systems globally shift toward optimizing value, defined as health outcomes achieved per dollar spent across a full cycle of care, there has been increasing focus on using patient-reported outcome measures (PROMs) to gauge success. Patient-reported outcome measures are validated questionnaires that allow patients to share their health status across several domains (eg, pain or physical function). This trend has been particularly notable in hand surgery, with PROM use investigated for many common hand conditions, including carpal tunnel syndrome, Dupuytren contracture, trigger finger, osteoarthritis, and wrist ganglion. The purpose of this article is to review recent developments in the use of PROM instruments, including the Boston Carpal Tunnel Questionnaire; Michigan Hand Outcomes Questionnaire; Disabilities of the Arm, Shoulder, and Hand; and Patient-Reported Outcomes Measurement Information System, for the evaluation and treatment of patients with carpal tunnel syndrome. The considerable progress in establishing PROMs for use in carpal tunnel syndrome is reviewed, and future improvements are proposed to standardize PROM use and bring PROMs into day-to-day clinical practice for individualized patient treatment decision-making and counseling.

Cost-Utility Analysis of Thumb Carpometacarpal Resection Arthroplasty: A Health Economic Study Using Real-World Data

PURPOSE

Knowledge about the costs and benefits of hand surgical interventions is important for surgeons, payers, and policy makers. Little is known about the cost-effectiveness of surgery for thumb carpometacarpal osteoarthritis. The objective of this study was to examine patients' quality of life and economic costs, with focus on the cost-utility ratio 1 year after surgery for thumb carpometacarpal osteoarthritis compared with that for continued nonsurgical management.

METHODS

Patients with thumb carpometacarpal osteoarthritis indicated for resection arthroplasty were included in a prospective study. The quality of life (using European Quality of Life-5 Dimensions-5 Level), direct medical costs, and productivity losses were assessed up to 1 year after surgery. Baseline data at recruitment and costs sustained over 1 year before surgery served as a proxy for nonsurgical management. The total costs to gain 1 extra quality-adjusted life year and the incremental cost-effectiveness ratio were calculated from a health care system and a societal perspective.

RESULTS

The mean European Quality of Life-5 Dimensions-5 Level value for 151 included patients improved significantly from 0.69 to 0.88 (after surgery). The productivity loss during the preoperative period was 47% for 49 working patients, which decreased to 26% 1 year after surgery. The total costs increased from US $20,451 in the preoperative year to US $24,374 in the postoperative year. This resulted in an incremental cost-effectiveness ratio of US $25,370 per quality-adjusted life year for surgery compared with that for simulated nonsurgical management.

CONCLUSIONS

The calculated incremental cost-effectiveness ratio was clearly below the suggested Swiss threshold of US $92,000, indicating that thumb carpometacarpal surgery is a cost-effective intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analyses II.

Pilots After Shoulder Surgery and Rehabilitation in a Dedicated Musculoskeletal Rehabilitation Unit of a Major Airline Returned to Work Earlier When Compared to Standard Rehabilitation by External Providers

Purpose

The purpose of this study was to compare the time to return to work (RTW) for pilots who underwent shoulder surgery and underwent rehabilitation within a dedicated musculoskeletal rehabilitation (MSK) unit of a major airline to a group of pilots who had standard rehabilitation and to calculate cost savings.

Methods

The database of Emirates Airline was searched for all ICD-10 codes relating to shoulder pathology. Pilots who had shoulder surgery between January 2017 and June 2021 were included. Pilots who had previous shoulder surgery, underwent fracture surgery, joint replacement, revision surgery, or conservative treatment were excluded. The time between suspension and reinstatement of their license was defined as RTW. Cost savings were calculated on the basis of the median salary and rosterable fraction of a commercial airline pilot. RTW compared between a group undergoing rehabilitation in the MSK unit and a group receiving standard rehabilitation by external providers. Group allocation for either attending MSK unit or standard rehabilitation occurred randomly and according to the individual pilots preferences.

Results

The MSK unit treated 36 pilots (36 males/0 females, mean age 45.4 ± 9.4), and 18 pilots (17 males/1 female, mean age 50.3 ± 7.3) were treated by external physical therapist providers. Patients treated by the MSK unit returned to work at a mean of 85.3 ± 32.8 days, and patients treated by external providers returned to work at a mean of 117.9 ± 42.5days (P = .02). The cost savings for pilots treated by the MSK unit were calculated to be $27,948 USD per patient.

Conclusions

The results of this study showed that pilots’ after shoulder surgery RTW times range between 85 to 118 days. Rehabilitation in a dedicated MSK unit reduced the return to flying duties by 39%. Pilots treated by the MSK unit returned to work by a mean of 33 days earlier with cost savings of $27,948 USD per pilot.

Cost-utility analysis of total shoulder arthroplasty: a prospective health economic study using real-world data

BACKGROUND

With increasing health care expenditures, knowledge about the benefit and costs of surgical interventions such as total shoulder arthroplasty (TSA) becomes important for orthopedic surgeons, social insurance programs, and health policy decision makers. We examined the impact of TSA on quality of life (QOL), direct medical costs, and productivity losses and evaluated the cost-utility ratio of TSA compared with ongoing nonoperative management using real-world data.

METHODS

Patients with shoulder osteoarthritis and/or rotator cuff tear arthropathy indicated for anatomic or reverse TSA were included in this prospective study. QOL (European Quality of Life 5 Dimensions 5-Level questionnaire) and shoulder function (Constant score; Shoulder Pain and Disability Index; short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and Subjective Shoulder Value) were assessed preoperatively and up to 2 years postoperatively. Health insurance companies provided all-diagnosis direct medical costs for 2018 in Swiss francs (CHF), where 1 CHF was equivalent to US $1.02. Indirect costs were assessed using the Work Productivity and Activity Impairment Questionnaire. Baseline data at recruitment and the total costs of the preoperative year served as a proxy for nonoperative management. The incremental cost-effectiveness ratio (ICER) was calculated as the total costs to gain 1 extra quality-adjusted life-year (QALY) based on both the health care system perspective and societal perspective. The relationship between QOL and shoulder function was assessed by regression analysis.

RESULTS

The mean preoperative utility index for the European Quality of Life 5 Dimensions 5-Level questionnaire of 0.68 for a total of 150 patients (mean age, 71 years; 21% working; 58% women) increased to 0.89 and 0.87 at 1 and 2 years postoperatively, respectively. Mean direct medical costs were 11,771 CHF (preoperatively), 34,176 CHF (1 year postoperatively), and 11,763 CHF (2 years postoperatively). The ICER was 63,299 CHF/QALY (95% confidence interval, 44,391-82,206 CHF/QALY). The mean productivity losses for 29 working patients decreased from 40,574 CHF per patient (preoperatively) to 26,114 CHF at 1 year postoperatively and 10,310 CHF at 2 years postoperatively. When considering these productivity losses, the ICER was 35,549 CHF/QALY (95% confidence interval, 12,076-59,016 CHF/QALY). QOL was significantly associated with shoulder function (P < .001).

CONCLUSION

Using real-world direct medical cost data, we calculated a cost-utility ratio of 63,299 CHF/QALY for TSA in Switzerland, which clearly falls below the often-suggested 100,000-CHF/QALY threshold for acceptable cost-effectiveness. In view of productivity losses, TSA becomes highly cost-effective with an ICER of 35,546 CHF/QALY.

Cost analysis and complication rate comparing open, mini-open, and all arthroscopic rotator cuff repair

Hypothesis/Background

Value-based healthcare delivery models are becoming increasingly common and are driving cost effectiveness initiatives. Rotator cuff repair (RCR) is a commonly performed procedure with some variations on the specific surgical technique. The purpose of this study was to perform a comprehensive analysis of the cost, complications, and readmission rates of 3 categories of RCR techniques (open [oRCR], combined arthroscopically assisted and mini-open [CRCR], and all arthroscopic [ARCR]) at a high-volume institution.

Methods

All RCR procedures performed by 2 fellowship-trained shoulder surgeons at a single institution between 2012 and 2017 were retrospectively identified. These consisted of oRCR, CRCR, and ARCR repair techniques. One surgeon performed oRCR and CRCR, and the second surgeon performed ARCR. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation.

Results

The cohort consisted of 95 oRCR, 233 CRCR, and 287 ARCR. Median standardized costs were as follows: preoperative evaluation $486.03; index surgical hospitalization oRCR $9,343.10, CRCR $10,057.20, and ARCR $10,330.60; and postoperative care $875.02. Preoperative and postoperative costs did not vary based on the type of RCR performed. However, significant differences were observed among index surgical costs (P = .0008). The highest standardized cost for hospitalization for both the CRCR group and the ARCR group was related to the cost of the operating room and the implants. The 90-day complication, reoperation, and readmission rates were 1.1%, 1.1%, and 2.1% in the open group; 0.8%, 0.8%, and 1.7% in the combination group; 0%, 0%, and 1.7% in the all arthroscopic group, respectively. There were no significant differences among the 3 surgical procedures with respect to complication (P = .26), reoperation (P = .26), and readmission rates (P = .96).

Discussion/Conclusions

In this investigation, the median standardized costs for RCR inclusive of 60-day workup and 90-day postoperative care were $10,704.15, $11,418.25, and $11,691.65 for oRCR, CRCR (average added cost $714.10), and ARCR (added cost $987.50), respectively. The group complication, reoperation, and readmission rate were 0.5%, 0.5%, and 1.8% with no significant differences between the varying techniques, respectively. This retrospective cost analysis and complication profile may serve as a useful reference as surgeons consider engaging in bundled payment for RCR. As value based initiatives continue to progress, implant cost may serve as an actionable area for cost reduction.

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study

INTRODUCTION

In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective.

METHODS AND ANALYSIS

A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated.

ETHICS AND DISSEMINATION

This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study.

TRIAL REGISTRATION NUMBER

NCT04321005.

PROTOCOL VERSION

Version 2 (13 December 2019).

Validity, responsiveness and minimal important change of the EQ-5D-5L in patients after rotator cuff repair, shoulder arthroplasty or thumb carpometacarpal arthroplasty

PURPOSE

The aim was to investigate the measurement properties of the EQ-5D-5L utility index in patients after arthroscopic rotator cuff repair (RCR), total shoulder arthroplasty (TSA) or thumb carpometacarpal (CMC I) arthroplasty.

METHODS

In this prospective study, all patients completed the EQ-5D-5L before surgery and 6 months and 1 year after surgery. In addition, RCR patients completed the Oxford Shoulder Score (OSS), TSA patients completed the Shoulder Pain and Disability Index (SPADI) and CMC I patients completed the brief Michigan Hand Outcomes Questionnaire (brief MHQ) at each designated time point. Construct validity (Pearson's correlation coefficient, r), responsiveness (effect size), minimal important difference (MID), minimal important change (MIC), and floor and ceiling effects of the EQ-5D-5L were determined. To test discriminative ability, EQ-5D-5L utility indices of patients who were in a patient acceptable symptom state (PASS) or not at follow-up were compared using the Mann-Whitney U test.

RESULTS

We included 153 RCR, 150 TSA, and 151 CMC I patients. The EQ-5D-5L utility index correlated with the OSS (r = 0.73), SPADI (r = - 0.65) and brief MHQ (r = 0.61). The effect sizes were 1.3 (RCR and CMC I group) and 1.1 (TSA). The MID and MIC ranged from 0.027 to 0.209. Ceiling effects were found. The EQ-5D-5L utility index differed significantly between patients being in a PASS versus patients who were not in a PASS.

CONCLUSION

The EQ-5D-5L utility index shows good construct validity, responsiveness and discriminative ability in patients after arthroscopic RCR, TSA and CMC I arthroplasty and is suitable to quantify quality of life.

CLINICAL TRIAL REGISTRATION

This auxiliary analysis is part of a primary study that was originally registered at ClinicalTrials.gov (NCT01954433) on October 1, 2013.