Original Article
Cost-Effectiveness Analysis of Primary Arthroscopic Stabilization Versus Nonoperative Treatment for First-Time Anterior Glenohumeral Dislocations

https://doi.org/10.1016/j.arthro.2012.05.885Get rights and content

Purpose

The purpose of this study was to compare the cost-effectiveness of initial observation versus surgery for first-time anterior shoulder dislocation.

Methods

The clinical scenario of first-time anterior glenohumeral dislocation was simulated using a Markov model (where variables change over time depending on previous states). Nonoperative outcomes include success (no recurrence) and recurrence; surgical outcomes include success, recurrence, and complications of infection or stiffness. Probabilities for outcomes were determined from published literature. Costs were tabulated from Medicare Current Procedural Terminology data, as well as hospital and office billing records. We performed microsimulation and probabilistic sensitivity analysis running 6 models for 1,000 patients over a period of 15 years. The 6 models tested were male versus female patients aged 15 years versus 25 years versus 35 years.

Results

Primary surgery was less costly and more effective for 15-year-old boys, 15-year-old girls, and 25-year-old men. For the remaining scenarios (25-year-old women and 35-year-old men and women), primary surgery was also more effective but was more costly. However, for these scenarios, primary surgery was still very cost-effective (cost per quality-adjusted life-year, <$25,000). After 1 recurrence, surgery was less costly and more effective for all scenarios.

Conclusions

Primary arthroscopic stabilization is a clinically effective and cost-effective treatment for first-time anterior shoulder dislocations in the cohorts studied. By use of a willingness-to-pay threshold of $25,000 per quality-adjusted life-year, surgery was more cost-effective than nonoperative treatment for the majority of patients studied in the model.

Level of Evidence

Level II, economic and decision analysis.

Section snippets

Construction of Model

The clinical scenario of first-time anterior glenohumeral dislocation was simulated using a Markov model (where variables change over time depending on previous states) to describe how patients with this pathology might be treated over time (Fig 1) (TreeAge Pro 2011; TreeAge Software, Williamstown, MA). The upfront costs of a first-time dislocation, such as evaluation in the emergency department and closed reduction, were not incorporated into the model because these costs are incurred before

Literature Search and Estimate of Probabilities, Utilities, and Costs

References from the retrieved articles did not produce any extra citations that were initially missed. The minimum follow-up was 17 months (mean, 49 months). Probabilities for events in the model were based on 11 studies for a total of 329 patients (Table 1). For short-term probability inputs, the 2-year study by Robinson et al.31 was used. The exponential formula used to estimate dislocation probability after multiple recurrences was set to closely match the published rates after 1 and 2

Discussion

When analyzed over a period of 15 years, primary surgery was less costly and more effective for 15-year-old boys, 15-year-old girls, and 25-year-old men. For the remaining scenarios (25-year-old women and 35-year-old men and women), primary surgery was also more effective but was more costly. Primary surgery was still very cost-effective for these scenarios, however (cost per QALY ranging from $14,394 to $22,101). As a comparison, knee arthroscopy and anterior cruciate ligament reconstruction

Conclusions

Primary arthroscopic stabilization is a clinically effective and cost-effective treatment for first-time anterior shoulder dislocation in the cohorts studied. By use of a WTP threshold of $25,000/QALY, surgery was more cost-effective than nonoperative treatment for the majority of patients studied in the model.

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    The authors report the following potential conflict of interest or source of funding in relation to this article: institutional support from Arthrex, Breg, and Smith & Nephew (T.S.C., D.G., J.H.L.).

    This paper was selected to receive the J. Whit Ewing Resident/Fellow Essay Award for 2012 by the Arthroscopy Association of North America.

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