Cost-Utility Analysis of Arthroscopic Rotator Cuff Repair: A Prospective Health Economic Study Using Real-World Data

Abstract

Purpose: To assess the change in quality of life (QOL) and costs for patients with rotator cuff tears after arthroscopic rotator cuff repair (aRCR) compared with continued nonoperative management, using real-world evidence.

Methods: Patients indicated for aRCR were included in a prospective study and followed up to 2 years after surgery (postop) for all measurements. QOL (EQ-5D-5L) and shoulder function (Constant Score, Oxford Shoulder Score, subjective shoulder value) were assessed. Sixteen major insurance companies provided all-diagnoses direct medical costs in Swiss francs (CHF; 1 CHF = 1.03 USD). Baseline data at recruitment and costs sustained over 1 year before surgery (preop) served as a proxy for nonoperative management. Total direct medical costs to gain 1 extra quality-adjusted life year (QALY) were calculated as the incremental cost-effectiveness ratio (ICER; mean of 2 years postop compared with 1 year preop) from a societal perspective. Subgroup analyses were separately performed for traumatic (trauma-OP) and degenerative (degen-OP) rotator cuff tear patients. Sensitivity analyses for aRCR patients included more intensive nonoperative treatment with corresponding QOL gain. The relationship between QOL and shoulder function was explored using regression analysis.

Results: For 153 aRCR patients (mean age 57 years; 63% male), the mean EQ-5D index improved from 0.71 (preop) to 0.94 (1 year postop) and 0.96 (2 years postop). Mean total costs increased from 5,499 CHF (preop) to 17,116 CHF (1 year postop), then decreased to 4,226 CHF (2 years postop). The ICER for all aRCR patients was 24,924 CHF/QALY (95% confidence interval [CI] 16,742 to 33,106) and 17,357 CHF/QALY (95% CI 10,951 to 23,763) and 36,474 CHF/QALY (95% CI 16,301 to 56,648) for the trauma-OP and degen-OP groups, respectively. QOL and shoulder function were significantly associated (P < .001).

Conclusions: For RC patients treated at a specialized Swiss orthopaedic clinic, aRCR is a cost-effective intervention associated with clinically relevant improvement in QOL up to 2 years after repair compared with prior nonoperative management.

Level of evidence: Economic Analyses - Developing an Economic Model, Level II.

Figure 1

Study flow. Patient recruitment and follow-up flowchart.

Figure 2

Utility index (EQ-5D-5L) over time. Quality of life (utility index) for arthroscopic rotator cuff repair patients as measured by the European Quality of Life 5 Dimensions 5 Level (EQ-5D-5L) questionnaire at each follow-up time point (range –0.66 to 1.0; minimal clinically important difference [MCID] = 0.074 points). The horizontal dashed line indicates the utility index for the health state we assumed patients would maintain throughout the entire follow-up period if they had not undergone surgery.

Figure 3

Shoulder function and quality of life over time. Outcome scores for arthroscopic rotator cuff repair patients are shown at each follow-up time point. Clinical examinations for the Constant Score (range 0 to 100; minimal clinically important difference [MCID] = 8.3 points) were performed up to the 6-month follow-up and patient-reported outcomes up to 2 years after surgery. The original scale of the Oxford Shoulder Score ranging from 0 to 48 was adapted to 0 to 100 for presentation purposes (MCID adapted for range 0 to 100 = 11.0 points). Subjective shoulder value: Subjective evaluation of shoulder function by the patient in relation to normal shoulder function (range 0% to 100%). EQ-VAS = EQ-5D General Health Visual Analogue Scale (range 0 to 100 points; MCID = 7.18 points).

Figure 4

Cost-effectiveness plot using direct medical costs. Incremental cost-effectiveness ratio (ICER) for patients with traumatic and degenerative rotator cuff tears (black and grey bold lines, respectively) and the 95% confidence interval (dashed lines). Incremental costs, direct medical costs; QALY, quality-adjusted life years

Figure 5

Return-to-work rates over time. Kaplan-Meier curve showing the percentage of patients returning to work after arthroscopic rotator cuff repair; m, months; y, years.

Figure 6

Productivity losses over time. Productivity losses of all arthroscopic rotator cuff repair patients (N = 97) until 2 years after surgery. The horizontal line between –4 and 0 weeks indicates the preoperative period.

Figure 7

Association between quality of life and shoulder function over time. Each data point represents 1 patient preoperatively or 2 years after surgery. Scatter plot showing the association between quality of life (indicated by the European Quality of Life 5 Dimensions 5 Level [EQ-5D-5L] utility index; range 0.0 to 1.0; minimal clinically important difference [MCID] = 0.074) and the Oxford Shoulder Score (OSS; range 0 to 48; MCID = 4.7 and 6.0 for shoulder pain and function, respectively) before and 2 years after surgery. The regression line indicates the association between quality of life and OSS at the preoperative time point.