Anatomic total shoulder arthroplasty is cost-effective in patients over 67 years of age with glenohumeral osteoarthritis and an intact rotator cuff: a decision-analytic Markov model-based cost-utility analysis

Abstract

BackgroundAnatomic total shoulder arthroplasty (aTSA) has historically been considered the gold-standard surgical strategy for patients with end-stage glenohumeral osteoarthritis (GHOA). However, reverse shoulder arthroplasty (RSA) is increasingly used for shoulders with GHOA with an intact rotator cuff due to concerns regarding late cuff failure, anatomic glenoid component loosening, and the impact of bone loss and severe soft-tissue balance in aTSA. With substantial differences in cost between aTSA and RSA, it remains unclear whether the increased risk of late rotator cuff dysfunction in older adults justifies the increased cost of RSA. Therefore, the objective of this study was to utilize a decision-analytic Markov model to 1) quantify the cost-effectiveness of aTSA vs. RSA in patients with GHOA and intact rotator cuff and 2) determine whether an age exists at which RSA is more cost-effective than aTSA. MethodsA Markov model was developed to determine accumulated costs and quality-adjusted life years (QALYs) over a lifetime horizon for patients with end-stage GHOA and an intact rotator cuff who undergo either aTSA or RSA. Costs, health utility values, and transition probabilities were derived from the published literature. Sensitivity analyses were performed to identify age cutoffs at which one treatment option is more cost-effective than the other. ResultsFor the baseline case of a 72-year-old patient, aTSA resulted in 9.43 QALYs and $29,077 in accumulated costs, while RSA produced 9.44 QALYs at a total cost of $31,199 (incremental cost-utility ratio (ICER) comparing rTSA to aTSA: $188,222.94/QALY). Because the ICER for rTSA fell above the $50,000 willingness-to-pay (WTP) threshold, aTSA was determined to be the most cost-effective strategy for patients of this age. Within the age-based sensitivity analysis, RSA was the most cost-effective option for those 67 years of age or younger, while aTSA was the dominant strategy at 77 years and older, resulting in both equal QALYs and lower costs for patients in this age group. ConclusionsBased on this analysis, aTSA is a cost-effective treatment strategy for GHOA with an intact rotator cuff in adults over 67 years of age. For patients between the ages of 67 and 77, RSA resulted in marginally higher QALYs, but this increase was not enough to offset the increased costs to be considered cost-effective. In this model, RSA was cost-effective for individuals 67 years of age or younger.