Costs of shoulder and elbow procedures are significantly reduced in ambulatory surgery centers compared to hospital outpatient departments.

BACKGROUND: Recent literature has shown the advantages of outpatient surgery for many shoulder and elbow procedures, including cost savings with equivalent safety in appropriately selected patients. Two common settings for outpatient surgeries are ambulatory surgery centers (ASCs), which function as independent financial and administrative entities, or hospital outpatient departments (HOPDs), which are owned and operated by hospital systems. The purpose of this study was to compare shoulder and elbow surgery costs between ASCs and HOPDs. METHODS: Publicly available data from 2022 provided by the Centers for Medicare & Medicaid Services (CMS) was accessed via the Medicare Procedure Price Lookup Tool. Current Procedural Terminology (CPT) codes were used to identify shoulder and elbow procedures approved for the outpatient setting by CMS. Procedures were grouped into arthroscopy, fracture, or miscellaneous. Total costs, facility fees, Medicare payments, patient payment (costs not covered by Medicare), and surgeon's fees were extracted. Descriptive statistics were used to calculate means and standard deviations. Cost differences were analyzed using Mann-Whitney U tests. RESULTS: Fifty-seven CPT codes were identified. Arthroscopy procedures (n = 16) at ASCs had significantly lower total costs ($2667 ± $989 vs. $4899 ± $1917; P = .009), facility fees ($1974 ± $819 vs. $4206 ± $1753; P = .008), Medicare payments ($2133 ± $791 vs. $3919 ± $1534; P = .009), and patient payments ($533 ± $198 vs. $979 ± $383; P = .009) compared with HOPDs. Fracture procedures (n = 10) at ASCs had lower total costs ($7680 ± $3123 vs. $11,335 ± $3830; P = .049), facility fees ($6851 ± $3033 vs. $10,507 ± $3733; P = .047), and Medicare payments ($6143 ± $2499 vs. $9724 ± $3676; P = .049) compared with HOPDs, although patient payments were not significantly different ($1535 ± $625 vs. $1610 ± $160; P = .449). Miscellaneous procedures (n = 31) at ASCs had lower total costs ($4202 ± $2234 vs. $6985 ± $2917; P < .001), facility fees ($3348 ± $2059 vs. $6132 ± $2736; P < .001), Medicare payments ($3361 ± $1787 vs. $5675 ± $2635; P < .001), and patient payments ($840 ± $447 vs. $1309 ± $350; P < .001) compared with HOPDs. The combined cohort (n = 57) at ASCs had lower total costs ($4381 ± $2703 vs. $7163 ± $3534; P < .001), facility fees ($3577 ± $2570 vs. $6539.1 ± $3391; P < .001), Medicare payments ($3504 ± $2162 vs. $5892 ± $3206; P < .001), and patient payments ($875 ± $540 vs. $1269 ± $393; P < .001) compared with HOPDs. CONCLUSION: Shoulder and elbow procedures performed at HOPDs for Medicare recipients were found to have average total cost increase of 164% compared with those performed at ASCs (184% savings for arthroscopy, 148% for fracture, and 166% for miscellaneous). ASC use conferred lower facility fees, patient payments, and Medicare payments. Policy efforts to incentivize migration of surgeries to ASCs may translate into substantial health care cost savings.

Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures: A Cost-effectiveness Analysis.

To date, the optimal management of displaced midshaft clavicle fractures remains unknown. Operatively, plate or nail fixation may be used. Nonoperatively, the options are sling or harness. Given the equivocal effectiveness between approaches, the costs to the health care system and the patient become critical considerations. A decision tree model was constructed to study plate and sling management of displaced midshaft clavicle fractures. Primary analysis used 6 randomized controlled trials that directly compared open reduction and internal fixation with a plate to sling. Secondary analysis included 18 studies that studied either plate, sling, or both. Incremental cost-effectiveness ratios (ICERs) were calculated using quality-adjusted life-years (QALYs). Second-order Monte Carlo probabilistic sensitivity analysis (PSA) was subsequently conducted. In primary analysis, at a willingness-to-pay (WTP) threshold of $100,000, operative management was found to be less cost-effective relative to nonoperative management, with an ICER of $606,957/QALY (0.03 additional QALYs gained for an additional $16,120). In PSA, sling management was cost-effective across all WTP ranges. In secondary analysis, the ICER decreased to $75,230/QALY. Primary analysis shows that plate management is not a cost-effective option. In secondary analysis, the incremental effectiveness of plate management increased enough that the calculated ICER is below the WTP threshold of $100,000; however, the strength of evidence in secondary analysis is lower than in primary analysis. Thus, because neither option is dominant in this model, both plate and sling remain viable approaches, although the cost-conscious decision will be to treat these fractures with a sling until future data suggest otherwise. [Orthopedics. 2022;45(5):e243-e251.].

Defining Clinically Significant Outcomes Following Superior Capsular Reconstruction With Acellular Dermal Allograft.

PURPOSE: To define clinically significant outcomes (CSO) thresholds for minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptomatic state (PASS) in patients undergoing superior capsular reconstruction (SCR) with an acellular dermal allograft. We also evaluated patient-specific variables predictive of achieving CSO thresholds. METHODS: The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant-Murley (Constant) scores were collected preoperatively and at the most recent follow up for patients undergoing SCR from 2010 to 2019. A distribution-based approach was used to calculate MCID, and an anchor-based approach was used to calculate SCB and PASS. Logistic regression was used to determine factors associated with CSO achievement. RESULTS: Fifty-eight patients were identified (n = 39 males; n = 19 females) with a mean age of 53.4 ± 14.1 years at surgery and an average follow-up of 23 months. The MCID, SCB, and PASS were 11.2, 18.02, and 68.82 for ASES, 14.5, 23.13, and 69.9 for SANE, and 3.6, 10, and 18 for Constant, respectively. Subscapularis tear, female sex, and workers compensation (WC) status reduced odds of achieving MCID. Reduced odds of achieving Constant SCB were associated with older age, female sex, and WC status, while concomitant distal clavicle excision during SCR and lower preoperative ASES increased odds of achieving ASES SCB. Reduced odds for achieving ASES PASS were associated with female sex and WC status, while reduced odds for achieving SANE PASS were associated with subscapularis tearing preoperatively. CONCLUSION: On the basis of calculated values for MCID, SCB, and PASS, subscapularis tearing, WC status, age, and sex are associated with failure to achieve clinically significant outcomes following SCR. Concomitant distal clavicle excision during SCR and lower preoperative ASES was predictive for achievement of MCID and SCB. By defining the thresholds and variables predictive of achieving CSOs following SCR, surgeons may better counsel patients prior to SCR. LEVEL OF EVIDENCE: Level IV, case series.

Short stay after shoulder arthroplasty does not increase 90-day readmissions in Medicare patients compared with privately insured patients.

BACKGROUND: As of January 1, 2021, total shoulder arthroplasty was removed from the Medicare inpatient-only list, reflecting a growing belief in the potential merits of same-day discharge regardless of insurance type. It is yet unknown whether Medicare populations, which frequently have more severe comorbidity burdens, would experience higher complication rates relative to privately insured patients, who are often younger with fewer comorbidities. Given the limited number of true outpatient cohorts available to study, discharge at least by postoperative day 1 may serve as a useful proxy for true same-day discharge, and we hypothesized that these Medicare patients would have increased 90-day readmission rates compared with their privately insured counterparts. METHODS: Data on 4723 total shoulder arthroplasties (anatomic in 2459 and reverse in 2264) from 2 large, geographically diverse health systems in patients having either Medicare or private insurance were collected. The unplanned 90-day readmission rate was the primary outcome, and patients were stratified into those who were discharged at least by postoperative day 1 (short inpatient stay) and those who were not. Patients with private insurance (n = 1845) were directly compared with those with Medicare (n = 2878), whereas cohorts of workers' compensation (n = 198) and Medicaid (n = 58) patients were analyzed separately. Forty preoperative variables were examined to compare overall health burden, with the χ2 and Wilcoxon rank sum tests used to test for statistical significance. RESULTS: Medicare patients undergoing short-stay shoulder arthroplasty were not significantly more likely than those with private insurance to experience an unplanned 90-day readmission (3.6% vs. 2.5%, P = .14). This similarity existed despite a substantially worse comorbidity burden in the Medicare population (P < .05 for 26 of 40 factors). Furthermore, a short inpatient stay did not result in an increased 90-day readmission rate in either Medicare patients (3.6% vs. 3.4%, P = .77) or their privately insured counterparts (2.5% vs. 2.4%, P = .92). Notably, when the analysis was restricted to a single insurance type, readmission rates were significantly higher for reverse shoulder arthroplasty compared with total shoulder arthroplasty (P < .001 for both), but when the analysis was restricted to a single procedure (anatomic or reverse), readmission rates were similar between Medicare and privately insured patients, whether undergoing a short or extended length of stay. CONCLUSIONS: Despite a substantially more severe comorbidity profile, Medicare patients undergoing short-stay shoulder arthroplasty did not experience a significantly higher rate of unplanned 90-day readmission relative to privately insured patients. A higher incidence of reverse shoulder arthroplasty in Medicare patients does increase their overall readmission rate, but a similar increase also appears in privately-insured patients undergoing a reverse indicating that Medicare populations may be similarly appropriate for accelerated-care pathways.

The Relationship of Staged, Bilateral Arthroscopic Primary Rotator Cuff Repair Timing and Postoperative Complications.

BACKGROUND: Although previous studies have reported acceptable clinical outcomes after simultaneous, single-stage bilateral and staged bilateral rotator cuff repair (RCR), few studies have been adequately powered to compare postoperative complication rates at various time intervals between procedures. PURPOSE: To examine the relationship between the timing of bilateral arthroscopic RCR and complications. STUDY DESIGN: Descriptive epidemiology study. METHODS: Patients from the Medicare data set within the PearlDiver database who underwent bilateral RCR between 2005 and 2014 were identified. These patients were then stratified by time between surgeries into cohorts: (1) single stage, (2) <3 months, (3) 3 to 6 months, (4) 6 to 9 months, (5) 9 months to 1 year, and (6) 1 to 2 years. Surgical and medical complications of these cohorts were compared with those of a control cohort of patients who underwent bilateral RCR >2 years apart using a regression analysis. RESULTS: A total of 11,079 patients who underwent bilateral RCR were identified. Patients who underwent single-stage bilateral arthroscopic RCR experienced higher rates of revision RCR (odds ratio [OR], 2.1; P < .0001), reverse total shoulder arthroplasty (RTSA) (OR, 2.47; P < .0001), and postoperative infection (OR, 2.18; P = .007) in addition to higher rates of venous thromboembolism (VTE) (OR, 1.78; P = .031) and emergency department visits (OR, 1.51; P = .002) compared with the control group. Patients who underwent bilateral RCR with a <3-month interval had higher rates of revision surgery (OR, 1.56; P = .003), RTSA (OR, 1.89; P = .002), and lysis of adhesions (OR, 2.31; P < .0001) in addition to increased rates of VTE (OR, 1.92; P = .015) and emergency department visits (OR, 1.62; P < .0001) compared with the control group. There were no differences in any surgical or medical complications when surgeries were staged by ≥3 months compared with controls. CONCLUSION: Patients with Medicare undergoing single-stage and staged bilateral RCR who had the second repair within 3 months had significantly higher rates of multiple medical and surgical complications compared with patients waiting >2 years between procedures.

Establishing clinically significant outcome thresholds for the Single Assessment Numeric Evaluation 2 years following total shoulder arthroplasty.

BACKGROUND: Single Assessment Numerical Evaluation (SANE) is a simple, time-efficient patient-reported outcome measure (PROM) used to assess postoperative shoulder function. Clinically significant outcome values and ability to correlate with longer legacy PROM scores at 2 years following shoulder arthroplasty are unknown. METHODS: A retrospective analysis was performed using SANE, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores that were collected at a minimum 2-year follow-up. A total of 153 patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) were included. A distribution-based method was used to determine the minimal clinically important difference (MCID). An anchor-based method was used to determine substantial clinical benefit (SCB). The following anchor question was collected alongside the PROMs and graded on a 15-point Likert-type scale to establish the SCB: "Since your surgery, has there been any change in the pain in your shoulder?" Linear regression was used to assess correlations between PROMs. RESULTS: SANE showed moderate correlation with ASES (R2 = 0.493) and Constant (R2 = 0.586) scores (P < .001). The MCID value was 14.9, and the SCB absolute value was 80.4 (area under the curve = 0.663) for SANE. Multivariate logistic regression demonstrated that patients undergoing RTSA were less likely to achieve SCB on all 3 outcome measures (P < .02). CONCLUSIONS: This study establishes concurrent construct validity for SANE and suggests that it is a valid metric to assess the MCID and SCB at 2 years following anatomic TSA and RTSA. SANE demonstrated moderate correlations with ASES and Constant scores. Patients undergoing RTSA demonstrated a lower propensity to achieve SCB at 2 years postoperatively compared with anatomic TSA.

Use and Cost of Reverse Shoulder Arthroplasty Versus Hemiarthroplasty for Acute Proximal Humerus Fractures.

Although reverse total shoulder arthroplasty (RTSA) may outperform hemiarthroplasty (HSA) for acute proximal humerus fractures (PHF), both the RTSA implant and the procedure are more expensive. The goal of this study was to compare the use and longitudinal cost of care for RTSA vs HSA for the treatment of PHF. Patients were selected from a private payer database with a surgical date between 2010 and 2015. The International Classification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM), codes were used to identify patients who underwent RTSA and HSA for PHF. The 1-year cost follow-up was guaranteed. During the study period, a total of 1038 patients underwent RTSA and 1046 patients underwent HSA for the treatment of PHF. A total of 601 patients who underwent RTSA and 431 patients who underwent HSA with at least 1 year of follow-up were matched by age and sex. The average Charlson Comorbidity Index for the RTSA and HSA groups was 4, indicating similar health status. From 2010 to 2015, the use of RTSA increased linearly (R2=0.986), whereas the use of HSA decreased linearly (R2=0.796). The average index admission cost was higher for RTSA than for HSA ($15,263 vs $14,356, respectively; mean difference [MD], $907; 95% confidence interval [CI], $58-$1760; P=.04). At 1 year postoperatively, however, no statistically significant difference was noted in cost (P=.535). The 1-year physical and occupational therapy cost per patient was higher after HSA than after RTSA (MD, $723; CI, $718-$728; P<.001), but no difference was noted in discharge disposition or 1-year revision or readmission rates. The results of this study suggest that despite the higher initial cost of RTSA, the total cost of care in the year after RTSA and HSA is similar. Therefore, RTSA should be considered in the appropriate clinical setting. [Orthopedics. 2020;43(2):119-125.].

2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions.

Musculoskeletal infections (MSKI) remain the bane of orthopedic surgery, and result in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis, and treatment has remained largely unchanged over the last 50 years, a 2nd International Consensus Meeting on Musculoskeletal Infection (ICM 2018, https://icmphilly.com) was completed. Questions pertaining to all areas of MSKI were extensively researched to prepare recommendations, which were discussed and voted on by the delegates using the Delphi methodology. The questions, including the General Assembly (GA) results, have been published (GA questions). However, as critical outcomes include: (i) incidence and cost data that substantiate the problems, and (ii) establishment of research priorities; an ICM 2018 research workgroup (RW) was assembled to accomplish these tasks. Here, we present the result of the RW consensus on the current and projected incidence of infection, and the costs per patient, for all orthopedic subspecialties, which range from 0.1% to 30%, and $17,000 to $150,000. The RW also identified the most important research questions. The Delphi methodology was utilized to initially derive four objective criteria to define a subset of the 164 GA questions that are high priority for future research. Thirty-eight questions (23% of all GA questions) achieved the requisite > 70% agreement vote, and are highlighted in this Consensus article within six thematic categories: acute versus chronic infection, host immunity, antibiotics, diagnosis, research caveats, and modifiable factors. Finally, the RW emphasizes that without appropriate funding to address these high priority research questions, a 3rd ICM on MSKI to address similar issues at greater cost is inevitable.

Cost-effectiveness analysis of total elbow arthroplasty versus open reduction-internal fixation for distal humeral fractures.

BACKGROUND: Total elbow arthroplasty (TEA) and open reduction-internal fixation (ORIF) are 2 viable surgical treatment options for acute, intra-articular distal humeral fractures in elderly patients. Whereas recent systematic reviews and randomized trials have suggested that TEA and ORIF result in similar functional outcome scores, no previous study has assessed the comparative cost-effectiveness between TEA and distal humeral ORIF in this specific demographic. METHODS: A Markov model was created with the highest-level data available from the literature depicting transitioning health states based on treatment strategies. To populate the quality-of-life data points in the model lacking in the literature, a survey was conducted of patients at 2 referral institutions who underwent TEA or ORIF for acute, intra-articular distal humeral fractures via the European Quality of Life, 5 Domains (EQ-5D) questionnaire at least 2 years postoperatively. Cost data from 2016 for each strategy were used to calculate the comparative cost-effectiveness of TEA versus ORIF. RESULTS: For patients aged 65 years, the total cost of TEA was $19,407 compared with $20,669 for ORIF. The effectiveness of TEA and ORIF was 8.17 and 7.72, respectively. Overall, the incremental cost-effectiveness ratio of TEA ($2375.76/quality-adjusted life-year) was favored more than ORIF ($2677.26/quality-adjusted life-year). CONCLUSION: These findings suggest TEA is a slightly more cost-effective procedure than ORIF for most elderly patients who sustain acute, intra-articular distal humeral fractures. Still, the unique limitations, complications, and revision rates for each strategy must be carefully weighed for each patient when making a decision.

In Vivo Assessment of Exercise-Induced Glenohumeral Cartilage Strain.

BACKGROUND: The human shoulder joint is the most mobile joint in the body. While in vivo shoulder kinematics under minimally loaded conditions have been studied, it is unclear how glenohumeral cartilage responds to high-demand loaded exercise. HYPOTHESIS: A high-demand upper extremity exercise, push-ups, will induce compressive strain in the glenohumeral articular cartilage, which can be measured with validated magnetic resonance imaging (MRI)-based techniques. STUDY DESIGN: Descriptive laboratory study. METHODS: High-resolution MRI was used to measure in vivo glenohumeral cartilage thickness before and after exercise among 8 study participants with no history of upper extremity injury or disease. Manual MRI segmentation and 3-dimensional modeling techniques were used to generate pre- and postexercise thickness maps of the humeral head and glenoid cartilage. Strain was calculated as the difference between pre- and postexercise cartilage thickness, normalized to the pre-exercise cartilage thickness. RESULTS: Significant compressive cartilage strains of 17% ± 6% and 15% ± 7% (mean ± 95% CI) were detected in the humeral head and glenoid cartilage, respectively. The anterior region of the glenoid cartilage experienced a significantly higher mean strain (19% ± 6%) than the posterior region of the glenoid cartilage (12% ± 8%). No significant regional differences in postexercise humeral head cartilage strain were observed. CONCLUSION: Push-ups induce compressive strain on the glenohumeral joint articular cartilage, particularly at the anterior glenoid. This MRI-based methodology can be applied to further the understanding of chondral changes in the shoulder under high-demand loading conditions. CLINICAL RELEVANCE: These results improve the understanding of healthy glenohumeral cartilage mechanics in response to loaded upper extremity exercise. In the future, these methods can be applied to identify which activities induce high glenohumeral cartilage strains and deviations from normal shoulder function.

Survey finds few orthopedic surgeons know the costs of the devices they implant.

Orthopedic procedures represent a large expense to the Medicare program, and costs of implantable medical devices account for a large proportion of those procedures' costs. Physicians have been encouraged to consider cost in the selection of devices, but several factors make acquiring cost information difficult. To assess physicians' levels of knowledge about costs, we asked orthopedic attending physicians and residents at seven academic medical centers to estimate the costs of thirteen commonly used orthopedic devices between December 2012 and March 2013. The actual cost of each device was determined at each institution; estimates within 20 percent of the actual cost were considered correct. Among the 503 physicians who completed our survey, attending physicians correctly estimated the cost of the device 21 percent of the time, and residents did so 17 percent of the time. Thirty-six percent of physicians and 75 percent of residents rated their knowledge of device costs "below average" or "poor." However, more than 80 percent of all respondents indicated that cost should be "moderately," "very," or "extremely" important in the device selection process. Surgeons need increased access to information on the relative prices of devices and should be incentivized to participate in cost containment efforts.