Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty

Early outcome of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for treatment of advanced glenohumeral osteoarthritis

INTRODUCTION

Long-term outcomes of anatomic total shoulder arthroplasty (aTSA) can be compromised by glenoid loosening and failure. The purpose of this study was to evaluate the short- and midterm outcomes of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for the treatment of advanced glenohumeral osteoarthritis, and to identify associations between preoperative factors and outcomes.

METHODS

Forty-nine shoulders (mean age 60 ± 7 years) with minimum 2-year follow-up (mean 4.6 ± 1.7) were evaluated. Forty-three (87.8%) were male. Thirteen (26.5%) had previous nonarthroplasty shoulder surgery. There were 19 (38.8%) Walch type A and 30 (61.2%) type B glenoids. Pre- and postoperative shoulder motion, patient-reported outcomes (PROMs), and health-related quality of life (HRQoL) were assessed. Pre- and postoperative plain radiographs were evaluated. Mixed effects models were used to investigate factors associated with outcomes.

RESULTS

Active forward elevation and active external rotation improved from 111.7° ± 23.8° to 139.2° ± 21.1° and 13.3° ± 20.7° to 38.7° ± 14.7°, respectively (P < .001). The mean American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), Simple Shoulder Test (SST), and visual analog scale (VAS) shoulder pain scores at the most recent follow-up were 86.6 ± 19.9, 10.1 ± 14.1, 10.5 ± 2.2, and 1.5 ± 2.3, respectively. The mean changes of PROMs were significant and exceeded the minimal clinically important difference for aTSA. The percentage maximal possible improvement for ASES, DASH, and SST were greater than 75%. Male sex (P < .008) and not having prior shoulder surgery (P < .04) were significantly associated with better absolute and greater change in PROMs. Age, preoperative shoulder motion, and Walch glenoid classification were not associated with PROMs. Five (10.2%, 95% confidence interval [CI] 1.8%-18.6%) patients underwent revision for pain. Three additional patients were dissatisfied at final follow-up without undergoing revision, resulting in 16.7% (95% CI 6.1%-27.2%) of patients being dissatisfied with their outcome after their initial RnR. Mean Short Form-6 Dimensions scores improved from 0.66 ± 0.12 to 0.77 ± 0.13 and mean EuroQol-5 Dimensions scores improved from 0.68 ± 0.20 to 0.85 ± 0.17 (P < .001). Improvement in HRQoL was significantly associated with nondominant arm treatment, increased age, and greater preoperative SST score. Annual medialization of the humeral head center of rotation was 0.56 ± 1.6 mm/yr. No radiographic measure was associated with long-term PROMs.

CONCLUSION

Ream and Run can provide significant and clinically important improvement in PROMs and HRQoL for a high percentage of patients at short- and midterm follow-up. This procedure is an appropriate alternative to aTSA in select patients.

Clinical and radiographic assessment of peripheral joints in controlled acromegaly

PURPOSE

Acromegalic arthropathy is a well-known phenomenon, occurring in most patients regardless of disease status. To date, solely hips, knees, hands, and spinal joints have been radiographically assessed. Therefore, this study aimed to assess the prevalence of joint symptoms and radiographic osteoarthritis (OA) of new, and established peripheral joint sites in well-controlled acromegaly.

METHODS

Fifty-one acromegaly patients (56% female, mean age 64 ± 12 years) in long-term remission for 18.3 years (median, IQR 7.2-25.4) were included. Nineteen patients currently received pharmacological treatment. Self-reported joint complaints were assessed using standardized interviews. Self-reported disability of the upper and lower limbs, and health-related quality of life (HR-QoL) were evaluated using validated questionnaires. Radiographic OA [defined as Kellgren & Lawrence (KL) ≥ 2] was scored using (modified) KL methods.

RESULTS

Radiographic signs of OA were present in 46 patients (90.2%) with ≥ 2 joints affected in virtually all of these patients (N = 44; 95.7%). Radiographic MTP1 OA was as prevalent as radiographic knee OA (N = 26, 51.0%), and radiographic glenohumeral OA was similarly prevalent as hip OA [N = 21 (41.2%) vs. N = 24 (47.1%)]. Risk factors for radiographic glenohumeral OA were higher pre-treatment IGF-1 levels [OR 1.06 (1.01-1.12), P = 0.021], and current pharmacological treatment [OR 5.01 (1.03-24.54), P = 0.047], whereas no risk factors for MTP1 joint OA could be identified.

CONCLUSION

Similar to previously-assessed peripheral joints, clinical and radiographic arthropathy of the shoulder and feet were prevalent in controlled acromegaly. Further studies on adequate management strategies of acromegalic arthropathy are needed.

Temporal and Geographic Trends in Medicare Reimbursement of Primary and Revision Shoulder Arthroplasty: 2000 to 2020

INTRODUCTION

A comprehensive understanding of the trends for financial reimbursement of shoulder arthroplasty is important as progress is made toward achieving sustainable payment models in orthopaedics. This study analyzes Medicare reimbursement trends for shoulder arthroplasty. We hypothesize that Medicare reimbursement has decreased for shoulder arthroplasty procedures from 2000 to 2020 and that revision procedures have experienced greater decreases in reimbursement.

METHODS

The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each Current Procedural Terminology code used in shoulder arthroplasty, and physician reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars. Both the average annual and the total percentage change in surgeon reimbursement were calculated based on these adjusted trends for all included procedures. Mean percentage change in adjusted reimbursement among primary procedures in comparison to revision procedures was calculated. The mean reimbursement was assessed and visually represented by geographic state.

RESULTS

The average reimbursement for all shoulder arthroplasty procedures decreased by 35.5% from 2000 to 2020. Revision total shoulder arthroplasty (TSA) experienced the greatest mean decrease (-44.6%), whereas primary TSA (-23.9%) experienced the smallest mean decrease. The adjusted reimbursement rate for all included procedures decreased by an average of 1.8% each year. The mean reimbursement for revision procedures decreased more than the mean reimbursement for primary procedures (-41.1% for revision, -29.9% for primary; P < 0.001). The mean reimbursement for TSA in 2020, and the percent change in reimbursement from 2000 to 2020, varied by state.

DISCUSSION

Medicare reimbursement for shoulder arthroplasty procedures has decreased from 2000 to 2020, with revision procedures experiencing the greatest decrease. Increased awareness and consideration of these trends will be important as healthcare reform evolves, and reimbursements for large joint arthroplasty are routinely adjusted.

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.

Drivers of lower inpatient hospital costs and greater improvements in health-related quality of life for patients undergoing total shoulder and ream-and-run arthroplasty

BACKGROUND

With increasing emphasis on value-based care and the heavy demands on the US health care budget, surgeons must be cognizant of factors that drive cost and quality of patient care. Our objective was to determine patient-level drivers of lower costs and improved health-related quality of life (HRQoL) in 2 anatomic shoulder arthroplasty procedures: total shoulder arthroplasty (TSA) and ream-and-run arthroplasty.

METHODS

This study included 222 TSAs and 211 ream-and-run arthroplasties. Simple Shoulder Test, Single Assessment Numeric Evaluation, and Short Form 36 scores were collected preoperatively and 2 years postoperatively. Quality-adjusted life-years (QALYs) were calculated as a measure of HRQoL. Univariate and multivariate analyses determined factors significantly associated with decreased hospitalization costs and improved HRQoL.

RESULTS

In the TSA group, female sex, lower American Society of Anesthesiologists class, diagnosis other than capsulorrhaphy arthropathy, lower pain score, and higher Single Assessment Numeric Evaluation score were associated with decreased total hospitalization costs; in addition, female sex was an independent predictor of lower total costs. Insurance other than workers' compensation, a diagnosis of chondrolysis, and higher optimism led to greater QALY gains, but a diagnosis of capsulorrhaphy arthropathy was the only independent predictor of greater QALY gains. In the ream-and-run arthroplasty group, older age, lower body mass index (BMI), lower American Society of Anesthesiologists class, insurance other than Medicaid, diagnosis other than capsulorrhaphy arthropathy, no history of surgery, higher preoperative Simple Shoulder Test score, and higher preoperative Short Form 36 Physical Component Summary score were associated with lower total costs; moreover, lower BMI was an independent predictor of lower costs. Higher preoperative optimism was an independent predictor of greater QALY gains.

CONCLUSIONS

Identifying factors associated with decreased costs and increased quality is becoming increasingly important in value-based care. This study identified fixed (sex and diagnosis) and modifiable (BMI) factors that drive decreased hospitalization costs and increased HRQoL improvements in shoulder arthroplasty patients. Higher preoperative patient optimism is a consistent predictor of improved HRQoL for both TSA patients and ream-and-run arthroplasty patients, and further study on optimizing the influence of patient expectations and optimism may be warranted.