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Gill VS, Haglin JM, Tummala SV, Lin E, Cancio-Bello A, Hattrup SJ, Tokish JM. Regional variation from 2013 to 2021 in primary total shoulder arthroplasty utilization, reimbursement, and patient populations. J Shoulder Elbow Surg 2024:S1058-2746(24)00353-7. [PMID: 38754542 DOI: 10.1016/j.jse.2024.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/29/2024] [Accepted: 03/25/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Total shoulder arthroplasty (TSA), encompassing both anatomical and reverse TSA, has increased in popularity worldwide. The purpose of this study was to assess how TSA utilization, reimbursement, surgeon practices, and patient populations have evolved within the Medicare population from 2013 to 2021 at a national and regional level. METHODS The Medicare Physician and Other Practitioners dataset was queried for all episodes of primary TSA (CPT-23472), both anatomic and reverse, between years 2013 and 2021. TSA utilization was assessed as volume per 10,000 Medicare beneficiaries. Average inflation-adjusted reimbursement, physician practice styles, and patient demographics of each TSA surgeon were extracted each year. Data were stratified geographically based on US census classifications and rural-urban commuting codes. Kruskal-Wallis and multivariate regressions were utilized to determine differences between regions. RESULTS Between 2013 and 2021 TSA utilization increased by 121.8%, nationally. The increase was greatest in the Northeast (+147.2%) and least in the Midwest (+115.5%). Average TSA reimbursement declined by 8.8% nationally, with the least decline in the Northeast (6.4%) and the greatest decline in the Midwest (-11.9%). In 2021, the Midwest had the highest TSA utilization (18.1/10,000), while having the lowest average reimbursement ($1108.59; P < .001). The Northeast had the lowest utilization (11.5/10,000) and highest reimbursement ($1223.44; P < .001) in 2021. Nationally, the number of Medicare beneficiaries per surgeon performing shoulder arthroplasty declined by 5.9%, while the average number of TSAs per surgeon (+8.5%) and average number of billable services per beneficiary (+16.6%) both increased. Surgeons in the South performed the most services per beneficiary in 2021 (9.0; P < .001). The average comorbidity burden of patients was decreased by 4.8% between 2013 and 2021, with the West having the healthiest patients in 2021. Higher patient comorbidities were associated with lower physician reimbursement nationally (P < .001). CONCLUSION This study demonstrates that TSA utilization in the Medicare population has more than doubled between 2013 and 2021, while average inflation-adjusted reimbursement has declined by nearly 10%. The Midwest has the highest per-capita TSA utilization, while simultaneously having the lowest average reimbursement per TSA. Over time, TSA surgeons are seeing fewer and healthier beneficiaries but performing more services per beneficiary. Additionally, increased patient complexity may be associated with lower reimbursement. Together, these findings are concerning for long-term equitable access to care within shoulder surgery.
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Affiliation(s)
- Vikram S Gill
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA; Mayo Clinic Alix School of Medicine, Phoenix, AZ, USA.
| | - Jack M Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Eugenia Lin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - John M Tokish
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
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Turnbull LM, Hao KA, Srinivasan RC, Wright JO, Wright TW, Farmer KW, Vasilopoulos T, Struk AM, Schoch BS, King JJ. Does achieving clinically important thresholds after first shoulder arthroplasty predict similar outcomes of the contralateral shoulder? J Shoulder Elbow Surg 2024; 33:880-887. [PMID: 37690587 DOI: 10.1016/j.jse.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/30/2023] [Accepted: 08/06/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the first TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA. METHODS We performed a retrospective review of a prospectively collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score for the first TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after second contralateral TSA, we performed multivariable logistic regression adjusted for age at second surgery, sex, BMI, and type of first and second TSA. RESULTS Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after first TSA was not associated with greater odds of achieving thresholds after second TSA when success was evaluated by the MCID, SCB, and 30% MPI. In contrast, exceeding the PASS after first TSA was associated with 5.9 times greater odds (95% confidence interval 2.5-14.4, P < .001) of exceeding the PASS after second TSA. Overall, patients who exceeded the PASS after first TSA exceeded the PASS after second TSA at a higher rate (71% vs. 29%, P < .001); this difference persisted when stratified by type of prosthesis for first and second TSA. CONCLUSIONS Patients who achieve the ASES score PASS after first TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type.
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Affiliation(s)
- Lacie M Turnbull
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Jonathan O Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Kevin W Farmer
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Terrie Vasilopoulos
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA; Department of Anesthesiology, University of Florida, Gainesville, FL, USA
| | - Aimee M Struk
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA.
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Polascik BA, Chopra A, Hurley ET, Levin JM, Rodriguez K, Stauffer TP, Lassiter TE, Anakwenze O, Klifto CS. Outcomes after bilateral shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2023; 32:861-871. [PMID: 36567015 DOI: 10.1016/j.jse.2022.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/22/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
Abstract
The purpose of this systematic review was to report outcomes after bilateral shoulder arthroplasty including bilateral total shoulder arthroplasty (TSA), bilateral reverse shoulder arthroplasty (RSA), and ipsilateral TSA with contralateral RSA (TSA/RSA). Two reviewers independently performed a PRISMA-guided systematic search using MEDLINE/PubMed, Embase, and Cochrane Database of Systematic Reviews up to May 11, 2021. The databases were queried using the following search terms: (["bilateral" OR "contralateral"] AND "shoulder" AND ["arthroplast∗" OR "replacement"]). A total of 486 titles/abstracts were screened for eligibility and 19 studies were included in the final analysis. Risk of bias was assessed using Methodological Index for Nonrandomized Studies and Modified Coleman Methodology scores. Analysis compared overall results for bilateral shoulder arthroplasty and sub-group analyses compared TSA (all shoulders from bilateral TSA patients and the TSA shoulder in TSA/RSA patients) to RSA (all shoulders from bilateral RSA patients and the RSA shoulder in TSA/RSA patients), first shoulder arthroplasty to second contralateral shoulder arthroplasty, and interval between arthroplasty (IBA) <20 months to IBA ≥20 months. Nineteen studies analyzed bilateral TSA (n = 3), bilateral RSA (n = 7), and TSA/RSA (n = 8). The mean Methodological Index for Nonrandomized Studies was 18 and mean Modified Coleman Methodology Score was 74, with 63.2% of studies demonstrating level III evidence. A total of 2729 patients (30.4% male; mean age 72.2 years, mean follow-up 47.3 months, mean IBA 20 months) were analyzed. Postoperative forward flexion (142.0° vs. 129.6°), external rotation (ER) (42.5° vs. 25.6°), and internal rotation (60% reaching T12-T8 vs 85.7% reaching L3-L1) were higher for TSA when compared to RSA. Patient reported outcome measures such as Constant-Murley (73.2 vs. 59.2), American Shoulder and Elbow Surgeons (87.9 vs. 77.7), and Single Assessment Numeric Evaluation (SANE) (86.9 vs. 67.8) were higher for TSA when compared to RSA. Patients with IBA ≥20 months demonstrated greater ER and patient satisfaction than patients with IBA <20 months. Postoperative complication rates were 15.1% for TSA and 10.6% for RSA, while reoperation and revision rates were 13.7% for TSA and 7.1% for RSA. Bilateral shoulder arthroplasty results in improvements in motion, strength, pain, function, and high satisfaction. Bilateral TSA is associated with greater improvement in motion and function than bilateral RSA but higher complication, reoperation, and revision rates. IBA ≥20 months is associated with greater ER and satisfaction than IBA <20 months.
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Affiliation(s)
| | - Aman Chopra
- School of Medicine, Georgetown University, Washington, DC, USA
| | - Eoghan T Hurley
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | | | | | - Tally E Lassiter
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Oke Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
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Suttmiller AMB, Elwell JA, Roche C, Carofino BC. Side-to-side differences in postoperative function and patient satisfaction after bilateral total shoulder arthroplasties. J Shoulder Elbow Surg 2022; 31:1789-1795. [PMID: 35331855 DOI: 10.1016/j.jse.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND As the number of anatomic and reverse total shoulder arthroplasty (TSA) procedures increase, there will be a natural increase in patients who undergo staged bilateral TSA procedures. Bilateral TSAs have been shown to improve patient outcomes; however, it is unknown whether these patients experience side-to-side differences in clinical outcomes and satisfaction between shoulders. Understanding these differences is imperative for accurate patient and provider expectations. METHODS An international multicenter registry was used to identify patients who underwent staged bilateral TSAs from April 2007 to October 2019 with a minimum of 2-year follow-up. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) outcomes and satisfaction ratings were compared between dominant and nondominant shoulders, and first and second arthroplasties. Side-to-side differences in postoperative ASES and unequal satisfaction ratings were also explored by using regression analyses to identify potential factors influencing these differences. RESULTS A total of 60 patients (22 bilateral anatomic TSAs, 38 bilateral reverse TSAs) were identified for inclusion. Group analyses revealed that bilateral TSA patients demonstrated similar functional outcomes and satisfaction regardless of dominance and surgery sequence. Type of TSA, specifically bilateral reverse TSAs, significantly predicted greater side-to-side differences in postoperative ASES scores (P = .025), indicating reverse TSA patients demonstrated greater between-sides differences in postoperative functional outcomes compared with those undergoing anatomic TSAs. Additionally, a larger proportion of bilateral reverse TSA patients reported unequal satisfaction between shoulders (31.6%) compared with anatomic TSA patients (9.1%). Logistic regression analysis revealed that greater side-to-side differences in postoperative ASES scores were found to increase the likelihood of reporting unequal satisfaction between shoulders (odds ratio 1.11, P < .001), which may explain this outcome. CONCLUSIONS Most patients who undergo bilateral TSAs can expect similar outcomes on both shoulders regardless of dominance and surgery sequence. However, we did find patients who had discordant results between shoulders. Those who underwent reverse TSAs more frequently reported unequal satisfaction with their TSA procedures, which is likely due to larger side-to-side differences in postoperative function. It is unclear why these differences occurred, but this information may be important for providers to remember when counseling these patients for accurate postoperative expectations.
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