Conversion to Arthroscopic Surgery for Anterior Shoulder Instability Does Not Significantly Increase Patient Out-of-Pocket Costs, But Both Conversion and Initial Arthroscopic Management Are Twice as Costly as Isolated Nonoperative Management

Abstract

Purpose: To elucidate patient out-of-pocket costs associated with arthroscopic and nonoperative treatment of anterior shoulder instability, with a secondary aim to examine the costs of conversion from nonoperative to arthroscopic treatment within 12 months after initial shoulder instability diagnosis.

Methods: The MarketScan Commercial Claims and Encounters database was used to identify patients aged 18 to 40 years with anterior shoulder instability via diagnosis codes from 2014 to 2017. Three cohorts were created: an operative cohort, a nonoperative cohort, and an operative conversion cohort. The operative cohort was initially treated with primary arthroscopic shoulder surgery. The nonoperative cohort was treated with physical therapy. The conversion cohort was initially treated nonoperatively and then converted to operative management. Eighty-one patients with failed arthroscopic treatment were excluded. Open stabilization procedures were excluded as well. Patient out-of-pocket costs were calculated for each cohort and compared.

Results: In total, 713 operative, 1,144 nonoperative, and 79 conversion cohort patients were identified. Initial nonoperative treatment failed in approximately 6% of patients (79 of 1,223). Patients in the operative cohort were more likely to be men (percentage of male patients, 78% vs 69%; P < .001) and to be younger (median age, 21 years vs 26 years; P < .001) than those in the nonoperative cohort. Nonoperative treatment had the lowest patient out-of-pocket cost ($998 for nonoperative vs $1,961 for operative, P < .001), and conversion to operative treatment had the highest patient cost ($2,230). The additional cost of physical therapy, when nonoperative treatment fails, played a significant role in this difference.

Conclusions: Among patients presenting for evaluation of anterior shoulder instability, converting from nonoperative to arthroscopic treatment does not significantly increase patient costs compared with initial arthroscopic intervention. However, both treatment pathways are roughly 2 times more costly to the patient than isolated nonoperative management.

Clinical relevance: This study shows that nonoperative management of anterior shoulder instability is associated with the lowest patient out-of-pocket costs whereas conversion from nonoperative to arthroscopic treatment results in the highest costs. These findings highlight the financial implications of treatment selection and the potential cost burden for patients in whom initial conservative management fails.