Reverse Total Shoulder Arthroplasty Is the Most Cost-effective Treatment Strategy for Proximal Humerus Fractures in Older Adults: A Cost-utility Analysis

Abstract

Background Proximal humerus fractures are the secondmost common fragility fracture in older adults. Although reverse total shoulder arthroplasty (RTSA) is a promising treatment strategy for proximal humerus fractures with favorable clinical and quality of life outcomes, it is associated with much higher, and possibly prohibitive, upfront costs relative to nonoperative treatment and other surgical alternatives.Questions/purposes (1) What is the cost-effectiveness of open reduction internal fixation (ORIF), hemiarthroplasty, and RTSA compared with the nonoperative treatment of complex proximal humerus fractures in adults older than 65 years from the perspective of a single-payer Canadian healthcare system? (2) Which factors, if any, affect the cost-effectiveness of ORIF, hemiarthroplasty, and RTSA compared with nonoperative treatment of proximal humerus fractures including quality of life outcomes, cost, and complication rates after each treatment? Methods This cost-utility analysis compared RTSA, hemiarthroplasty, and ORIF with the nonoperative management of complex proximal humerus fractures in adults older than 65 years over a lifetime time horizon from the perspective of a single-payer healthcare system. Short-term and intermediate-term complications in the 2-year postoperative period were modeled using a decision tree, with long-term outcomes estimated through a Markov model. The model was initiated with a cohort of 75-year-old patients who had a diagnosis of a comminuted (three-or four-part) proximal humerus fractures; 90% of the patients were women. The mean age and gender composition of the model's cohort was based on a systematic review conducted as part of this analysis. Patients were managed nonoperatively or surgically with either ORIF, hemiarthroplasty, or RTSA. The three initial surgical treatment options of ORIF, hemiarthroplasty, and RTSA resulted in uncomplicated healing or the development of a complication that would result in a subsequent surgical intervention. The model reflects the complications that result in repeat surgery and that are assumed to have the greatest impact on clinical outcomes and costs. Transition probabilities and health utilities were derived from published sources, with Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Ethical approval for this study was not sought.

CORR Insights®: Reverse Total Shoulder Arthroplasty Is the Most Cost-effective Treatment Strategy for Proximal Humerus Fractures in Older Adults: A Cost-utility Analysis

“…Because lifetime costs were estimated, higher revision rates would negatively affect the cost-effectiveness. In this study [7], the RTSA group had only an 1.8% revision rate. If that rate rose to 11%, however, then RTSA would no longer be more cost-effective than hemiarthroplasty, the next best option.…”

“…Finally, do we need more studies like this one [7]? Proximal humerus fractures are the third most common osteoporotic fracture [1].…”

“…In this article, the authors [7] evaluated the cost-effectiveness of four different treatment options for complex proximal humerus fractures from the perspective of the Canadian healthcare system. They examined the lifetime expected costs of RTSA, hemiarthroplasty, ORIF, and nonoperative treatment and compared them with quality-adjusted life years.…”

“…This analysis [7] was performed in a single-payer healthcare system. We need to ask how applicable the conclusions are to mixed healthcare systems, such as the United States, Singapore, France, Germany, and Spain, where implant costs may not be as predictable and controlled.…”

“…For this reason, it is helpful to know which options and surgeries truly work. Cost-effectiveness analysis, as seen in this article [7], is one more tool we can use to see which solutions are best for our patients and our healthcare systems at large.…”