The Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Open Reduction Internal Fixation for Proximal Humerus Fractures in the Elderly

Abstract

Background: Open reduction and internal fixation (ORIF) of proximal humerus fractures in elderly individuals (age >70) carries a relatively high short-term complication and reoperation rate but is generally durable once healed. Reverse total shoulder arthroplasty (RTSA) for fractures may be associated with superior short-term quality of life but carries the lifelong liabilities of joint replacement. The tradeoff between short and long-term risks, coupled with disparities in quality of life and cost, makes this clinical decision amenable to cost-effectiveness analysis.

Methods: A Markov state-transition model was constructed with a base case of a 75 year-old patient. Reoperation rates, quality of life values, mortality rates, and costs were based upon published literature. The model was run until all patients had died to simulate the accumulated costs and benefits.

Results: RTSA was associated with greater quality of life (7.11 QALYs) than ORIF (6.22 QALYs). RTSA was cost-effective with an incremental cost-effectiveness ratio of $3,945/QALY and $27,299/ QALY from payor and hospital perspectives, respectively. RTSA was favored and cost-effective at any age above 65 and any Charlson Score. The model was sensitive to the utility of both procedures.

Conclusion: RTSA resulted in a higher quality of life and was cost-effective in comparison to ORIF for elderly patients.Level of Evidence: III.

Keywords: cost-effectiveness; open reduction and internal fixation; proximal humerus fracture; reverse total shoulder arthroplasty.

Figure 1

Reverse total shoulder arthroplasty portion of the Markov Model. Curved arrows indicate health states where patients remain indefinitely until a revision event or death. *Annual RTSA revision rate doubled after 5 years (1.48%) and tripled after 10 years (2.22%).

Figure 2

Open Reduction and Internal Fixation portion of the Markov Model. Curved arrows indicate health states where patients remain indefinitely until death. *Indicates instantaneous chance nodes used to distribute patients based upon probabilities; these do not have a cost or quality of life value associated with them.

Figure 3

Two-way sensitivity analysis of the quality of life associated with the two procedures. The conclusions of the model varied based upon the utility values assigned to each procedure.

Figure 4

Two-way sensitivity analysis of the costs associated with the two procedures from the standpoint of the hospital. The conclusions of the model varied based upon the costs assigned to each procedure.