Arthroscopy: The Journal of Arthroscopic & Related Surgery
Original ArticleCost-Effectiveness Analysis of Primary Arthroscopic Stabilization Versus Nonoperative Treatment for First-Time Anterior Glenohumeral Dislocations
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.