Failure after proximal humeral fracture osteosynthesis: a one year analysis of hospital-related healthcare cost.

PURPOSE: The issue of rising healthcare costs and limited resources is a topic of worldwide discussion over the last several decades. We hypothesized that failure of proximal humeral fracture osteosynthesis is presumed to be an important determinant in healthcare resources and related costs. The aim of this study was to calculate the total hospital-related healthcare cost of proximal humeral fracture osteosynthesis over one  year focusing on failure. METHODS: A total of 121 patients with a proximal humeral fracture treated by angular stable osteosynthesis were included in this retrospective study. All hospital-related healthcare costs were investigated. Five main hospital-related cost categories were defined: hospitalization cost, honoraria, day care admission, materials, and pharmaceuticals. RESULTS: A total healthcare cost of € 1,139,448 was calculated for the whole patient group. Twelve patients needed revision surgery due to complications or fixation-related failure. This failure rate alone costed € 190,809 of the healthcare resources. In other words, failure after proximal humeral fracture osteosynthesis costed 17% of the total healthcare expenditure inone year. CONCLUSION: This study demonstrates that a high amount of hospital-related healthcare resources is spent because of failure after proximal humeral fracture osteosynthesis. Further research is necessary and should investigate on how to prevent failure. This is not only in the patient's interest, but it is also of great importance for maintaining a healthy healthcare system.

Current diagnosis-related group-based bundling for upper-extremity arthroplasty: a case of insufficient risk adjustment and misaligned incentives.

BACKGROUND: The current Centers for Medicare & Medicaid Services diagnosis-related group (DRG) bundled-payment model for upper-extremity arthroplasty does not differentiate between the type of arthroplasty (anatomic total shoulder arthroplasty [ATSA] vs. reverse total shoulder arthroplasty vs. total elbow arthroplasty [TEA] vs. total wrist arthroplasty) or the diagnosis and indication for surgery (fracture vs. degenerative osteoarthritis vs. inflammatory arthritis). METHODS: The 2011-2014 Medicare 5% Standard Analytical Files (SAF5) database was queried to identify patients undergoing upper-extremity arthroplasty under DRG-483 and -484. Multivariate linear regression modeling was used to assess the marginal cost impact of patient-, procedure-, diagnosis-, and state-level factors on 90-day reimbursements. RESULTS: Of 6101 patients undergoing upper-extremity arthroplasty, 3851 (63.1%) fell under DRG-484 and 2250 (36.9%) were classified under DRG-483. The 90-day risk-adjusted cost of an ATSA for degenerative osteoarthritis was $14,704 ± $655. Patient-level factors associated with higher 90-day reimbursements were male sex (+$777), age 75-79 years (+$740), age 80-84 years (+$1140), and age 85 years or older (+$984). Undergoing a TEA (+$2175) was associated with higher reimbursements, whereas undergoing a shoulder hemiarthroplasty (-$1000) was associated with lower reimbursements. Surgery for a fracture (+$2354) had higher 90-day reimbursements. Malnutrition (+$10,673), alcohol use or dependence (+$6273), Parkinson disease (+$4892), cerebrovascular accident or stroke (+$4637), and hyper-coagulopathy (+$4463) had the highest reimbursements. In general, states in the South and Midwest had lower 90-day reimbursements associated with upper-extremity arthroplasty. CONCLUSIONS: Under the DRG-based model piloted by the Centers for Medicare & Medicaid Services, providers and hospitals would be reimbursed the same amount regardless of the type of surgery (ATSA vs. hemiarthroplasty vs. TEA), patient comorbidity burden, and diagnosis and indication for surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Lack of risk adjustment for fracture indications leads to strong financial disincentives within this model.

Impact of Increasing Comorbidity Burden on Resource Utilization in Patients With Proximal Humerus Fractures.

INTRODUCTION: Proximal humerus fractures (PHF) are a common upper extremity fracture in the elderly cohort. An aging and more comorbid cohort, along with recent trends of increased operative intervention, suggests that there could be an increase in resource utilization caring for these patients. We sought to quantify these trends and quantify the impact that comorbidity burden has on resource utilization. METHODS: Data on 83,975 patients with PHFs were included from the Premier Healthcare Claims database (2006 to 2016) and stratified by Deyo-Charlson index. Multivariable models assessed associations between Deyo-Charlson comorbidities and resource utilization (length and cost of hospitalization, and opioid utilization in oral morphine equivalents [OME]) for five treatment modalities: (1) open reduction internal fixation (ORIF), (2) closed reduction internal fixation (CRIF), (3) hemiarthroplasty, (4) reverse total shoulder arthroplasty, and (5) nonsurgical treatment (NST). We report a percentage change in resource utilization associated with an increasing comorbidity burden. RESULTS: Overall distribution of treatment modalities was (proportion in percent/median length of stay/cost/opioid utilization): ORIF (19.1%/2 days/$11,183/210 OME), CRIF (1.1%/4 days/$11,139/220 OME), hemiarthroplasty (10.7%/3 days/$17,255/275 OME), reverse total shoulder arthroplasty (6.4%/3 days/$21,486/230 OME), and NST (62.7%/0 days/$1,269/30 OME). Patients with an increased comorbidity burden showed a pattern of (1) more pronounced relative increases in length of stay among those treated operatively (65.0% for patients with a Deyo-Charlson index >2), whereas (2) increases in cost of hospitalization (60.1%) and opioid utilization (37.0%) were more pronounced in the NST group. DISCUSSION: In patients with PHFs, increased comorbidity burden coincides with substantial increases in resource utilization in patients receiving surgical and NSTs. Combined with known increases in operative intervention, trends in increased comorbidity burden may have profound effects on the cohort level and resource utilization for those with PHFs, especially because the use of bundled payment strategies for fractures increases. LEVEL OF EVIDENCE: Level III.

Shoulder Arthroplasty for a Fracture Is Not the Same as Shoulder Arthroplasty for Osteoarthritis: Implications for a Bundled Payment Model.

INTRODUCTION: The Center for Medicare Services currently bundles all shoulder arthroplasties, total shoulder arthroplasty and reverse total shoulder arthroplasty, into one Diagnosis-Related Group on which bundled reimbursements are then further characterized. An arthroplasty performed for traumatic indications, such as fractures, may have a different postoperative course of care compared with the one being done for degenerative arthritis/osteoarthritis (OA), despite having the same Current Procedural Terminology (CPT) and Diagnosis-related Group code. METHODS: The 2012 to 2016 American College of Surgeons-National Surgical Quality Improvement Program databases were queried using CPT-23472 to retrieve records of patients undergoing total shoulder arthroplasty/reverse total shoulder arthroplasty for degenerative arthritis/OA or proximal humerus fracture. RESULTS: A total of 8,283 (92.5%) and 667 (7.5%) patients underwent a shoulder arthroplasty for OA and proximal humeral fracture, respectively. After adjustment, the fracture group was associated with a higher risk for a longer length of stay of >2 days (P < 0.001), 30-day surgical complications (P = 0.005), revision surgeries within 30 days (P = 0.008), 30-day medical complications (P < 0.001), pulmonary embolism (P = 0.013), postoperative transfusions (P < 0.001), non-home discharge (P < 0.001), and 30-day readmissions (P < 0.001). DISCUSSION: Shoulder arthroplasty is associated with higher resource utilization when this procedure is performed for a fracture. As we move toward the era of bundled payment models, an appropriate risk adjustment based on the indication of surgery should be promoted to maintain the quality of care for all patients.

Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice.

OBJECTIVES: The objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for proximal, diaphyseal or distal fractures of the humerus in elderly patients. Secondary objectives were to evaluate the intervention costs per treatment of proximal humerus fractures (PHF) and to investigate treatment traditions of PHF in Sweden. METHODS AND FINDINGS: The assessment contains a systematic review of clinical and health economic studies comparing treatment options for humerus fractures in elderly patients. The results regarding the effectiveness of treatments are summarized in meta-analyses. The assessment also includes a cost analysis for treatment options and an analysis of registry data of PHF. For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced PHF at one-year follow-up regarding patient rated outcomes, (standardized mean difference [SMD]) -0.17 (95% CI: -0.56; 0.23). The intervention cost for HA was at least USD 5500 higher than non-surgical treatment. The trend in Sweden is that surgical treatment of PHF is increasing. When functional outcome of percutaneous fixation/plate fixation/prosthesis surgery and non-surgical treatment was compared for PHF there were no clinically relevant differences, SMD -0.05 (95% CI: -0.26; 0.15). There was not enough data for interpretation of quality of life or complications. Evidence was scarce regarding comparisons of different surgical options for humerus fracture treatment. The cost of plate fixation of a PHF was at least USD 3900 higher than non-surgical treatment, costs for complications excluded. In Sweden the incidence of plate fixation of PHF increased between 2005 and 2011. CONCLUSIONS: There is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options. Further research of humerus fractures is likely to have an important impact.

Cost of Treatment for Proximal Humerus Fractures: An Acute and 90-Day Cost Evaluation.

The purpose of this study was to examine the 90-day costs of three common surgical treatments for proximal humerus fractures and compare the costs associated with the initial day and subsequent 89 days of care. This was conducted through a retrospective review of a national database examining patients who suffered proximal humerus fractures. Patients were stratified by type of surgical procedure performed, hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), and open reduction and internal fixation (ORIF). RSA was the most costly procedure for the same-day and 90-day costs (p < 0.001). Mean initial day reimbursement costs were significantly different among treatment groups, with the highest costs seen with RSA ($16,151), followed by HA ($9,348), and ORIF ($6,745). Subsequent 89-day reimbursement costs were not significantly different for RSA, HA, and ORIF (p = 0.112). The 90-day costs for the surgical treatment of proximal humerus fractures are driven by the initial day costs. RSA was associated with the highest cost, followed by HA and ORIF.

Increasing Use of Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures in Elderly Patients.

This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was $24,154, which was significantly higher than that for ORIF ($16,269) or hemiarthroplasty ($19,175) (P<.001). In a multivariable model, patients undergoing reverse TSA were less likely than those undergoing hemiarthroplasty to be discharged to a skilled nursing facility (odds ratio, 0.75; P=.027). The national rate of reverse TSA nearly doubled from 2011 to 2013. As of 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures for patients 65 years and older. Patients undergoing reverse TSA were more likely than those undergoing hemiarthroplasty to be discharged home. [Orthopedics. 2017; 40(6):e982-e989.].

A Cost-Effectiveness Analysis of Reverse Total Shoulder Arthroplasty versus Hemiarthroplasty for the Management of Complex Proximal Humeral Fractures in the Elderly.

BACKGROUND: There is ongoing debate regarding the optimal surgical treatment of complex proximal humeral fractures in elderly patients. OBJECTIVES: To evaluate the cost-effectiveness of reverse total shoulder arthroplasty (RTSA) compared with hemiarthroplasty (HA) in the management of complex proximal humeral fractures, using a cost-utility analysis. METHODS: On the basis of data from published literature, a cost-utility analysis was conducted using decision tree and Markov modeling. A single-payer perspective, with a willingness-to-pay (WTP) threshold of Can$50,000 (Canadian dollars), and a lifetime time horizon were used. The incremental cost-effectiveness ratio (ICER) was used as the study's primary outcome measure. RESULTS: In comparison with HA, the incremental cost per quality-adjusted life-year gained for RTSA was Can$13,679. One-way sensitivity analysis revealed the model to be sensitive to the RTSA implant cost and the RTSA procedural cost. The ICER of Can$13,679 is well below the WTP threshold of Can$50,000, and probabilistic sensitivity analysis demonstrated that 92.6% of model simulations favored RTSA. CONCLUSIONS: Our economic analysis found that RTSA for the treatment of complex proximal humeral fractures in the elderly is the preferred economic strategy when compared with HA. The ICER of RTSA is well below standard WTP thresholds, and its estimate of cost-effectiveness is similar to other highly successful orthopedic strategies such as total hip arthroplasty for the treatment of hip arthritis.

National trends in proximal humerus fracture treatment patterns.

BACKGROUND: The treatment of proximal humerus fractures (PHF) is largely surgeon dependent with no clear guidelines for selecting the optimal method of treatment. AIMS: The aim of this study was to evaluate trends and variations in treatment methods of PHF in the United States from 2004 to 2012 and to determine the regional differences in treatment. METHODS: The National Inpatient Sample was used to identify all patient discharges with diagnosis codes for PHF and the data were classified based on ICD-9 procedure codes. Patient and hospital demographics were also analyzed. Simple linear regression analyses were performed for each treatment modality to evaluate current treatment trends and to extrapolate the future trends of PHF treatment over the next 20 years. RESULTS: A national estimate of 550,116 PHF discharges was identified over the time period. Significant correlations between change over time and treatment modality were found for reverse shoulder arthroplasty (RSA) (r = 0.903, p < 0.001), open reduction internal fixation (r = 0.876, p = 0.002), and closed reduction internal fixation (r = -0.922, p < 0.001). The RSA regression model showed that by the year 2032, PHF treated with RSA will increase 100% from 2012. DISCUSSION: There were significant changes in treatment modalities for PHF from 2004 to 2012; The projected number of RSA used to treat PHF will be about 9115 in 2032, compared to 340 in 2004. CONCLUSION: Overall, there was a growth in proximal humerus fractures treated in an inpatient setting in the United States. RSA had the greatest proportional increase over time, but only accounted for less than 2% of total interventions.

Cost effectiveness of surgical versus non-surgical treatment of adults with displaced fractures of the proximal humerus: economic evaluation alongside the PROFHER trial.

AIMS: A pragmatic multicentre randomised controlled trial (PROFHER) was conducted in United Kingdom National Health Service (NHS) hospitals to evaluate the clinical effectiveness and cost effectiveness of surgery compared with non-surgical treatment for displaced fractures of the proximal humerus involving the surgical neck in adults. METHODS: A cost utility analysis from the NHS perspective was performed. Differences between surgical and non-surgical treatment groups in costs and quality adjusted life years (QALYs) at two years were used to derive an estimate of the cost effectiveness of surgery using regression methods. RESULTS: Patients randomised to receive surgical intervention accumulated mean greater costs and marginally lower QALYs than patients randomised to non-surgery. The surgical intervention cost a mean of £1758 more per patient (95% confidence intervals (CI) £1126 to £2389). Total QALYs for the surgical group were smaller than those for non-surgery -0.0101 (95% CI -0.13 to 0.11). The probability of surgery being cost effective was less than 10% given the current NICE willingness to pay at a threshold of £20 000 for an additional QALY. The results were robust to sensitivity analyses. DISCUSSION: The results suggest that current surgical treatment is not cost effective for the majority of displaced fractures of the proximal humerus involving the surgical neck in the United Kingdom's NHS. TAKE HOME MESSAGE: The results of this trial do not support the trend of increased surgical treatment for patients with displaced fractures of the proximal humerus involving the surgical neck within the United Kingdom NHS.

Cost analysis of the surgical treatment of fractures of the proximal humerus: an evaluation of the determinants of cost and comparison of the institutional cost of treatment with the national tariff.

AIMS: The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost. METHODS: A detailed inpatient treatment pathway was constructed using semi-structured interviews with 32 members of hospital staff. Its content validity was established through a Delphi panel evaluation. Costs were calculated using time-driven activity-based costing (TDABC) and sensitivity analysis was performed to evaluate the determinants of cost RESULTS: The mean cost of the different surgical treatments was estimated to be £3282. Although this represented a profit of £1138 against the national tariff, hemiarthroplasty as a treatment choice resulted in a net loss of £952. Choice of implant and theatre staffing were the largest cost drivers. Operating theatre delays of more than one hour resulted in a loss of income DISCUSSION: Our findings indicate that the national tariff does not accurately represent the cost of treatment for this condition. Effective use of the operating theatre and implant discounting are likely to be more effective cost containment approaches than control of bed-day costs. TAKE HOME MESSAGE: This cost analysis of fractures of the proximal humerus reinforces the limitations of the national tariff within the English National Health Service, and underlines the importance of effective use of the operating theatre, as well as appropriate implant procurement where controlling costs of treatment is concerned.

Total shoulder arthroplasty for proximal humerus fracture is associated with increased hospital charges despite a shorter length of stay.

BACKGROUND: Operation choice is a complex decision in the surgical management of proximal humerus fractures. Recently, there has been an increase in the use of total shoulder arthroplasty (TSA) for complex fracture patterns. HYPOTHESIS: Patients with proximal humerus fractures who receive TSA are more likely to have higher hospital charges and a prolonged length of stay relative to patients receiving hemiarthroplasty (HA), open reduction with internal fixation (ORIF) or closed reduction with internal fixation (CRIF). MATERIALS AND METHODS: A statewide electronic database was used to identify 13,316 hospital admissions from 2000-2011 were a proximal humerus fracture was surgically managed in an effort to determine the effect of operation choice on cost and length of stay. A univariate analysis was preformed to examine overall trends in surgical management. Additionally, a periodic, multivariate logistic regression analysis was used to determine how operation choice affected the odds of a high cost hospital stay or a prolonged length of stay after controlling for age, comorbidity burden, gender, and insurance type. RESULTS: After controlling for confounding factors, patients receiving total shoulder arthroplasty (TSA) were 2.25 times more likely to have high total hospital charges than patients receiving HA and 3.21 times more likely than patients receiving ORIF. Additionally, TSA was found to be a significant negative predictor of prolonged length of stay (pLOS). HA, ORIF and CRIF did not significantly predict pLOS. DISCUSSION: The use of TSA for acute proximal humerus fractures is associated with increased hospital costs despite a shorter length of stay when compared to other operative choices. As reverse total shoulder arthroplasty becomes more popular for treatment of this injury, it is important that functional outcomes be interpreted in the context of relative cost trade-offs. LEVEL OF EVIDENCE: Level IV.

Cost Drivers After Surgical Management of Proximal Humerus Fractures in Medicare Patients.

OBJECTIVES: This comparative effectiveness study sought to determine the impact of complications, readmission, and procedure choice on in-hospital and total 90-day costs for surgical management of proximal humerus fractures. METHODS: Medicare claims data from the Upstate New York area (2008-2009) were evaluated. The study included all patients treated with open reduction and internal fixation (ORIF) or hemiarthroplasty for proximal humerus fracture identified by ICD-9 codes. The primary end points included in-hospital costs and total health care costs within 90 days after the index operation. Multivariable generalized linear models with negative binomial distributions and log link function were used for cost analysis. RESULTS: ORIF was performed in 52 cases and hemiarthroplasty in 57 cases, total n = 109. On univariate analysis, readmission increased in-hospital cost by $54,345 and total 90-day costs by $63,104, whereas complications increased in-hospital cost by $23,300 and total 90-day costs by $30,237. On multivariable analysis, ORIF was associated with 29% lower in-hospital cost compared with hemiarthroplasty [Odds Ratio 0.71; 95% Confidence Interval (CI), 0.54-0.92; P = 0.01], and readmission was associated with a 5.68-fold in-hospital cost increase (Odds Ratio 5.68; CI, 3.57-9.03; P < 0.0001). CONCLUSIONS: Complications and hospital readmission continue to drive cost upward underscoring the need for best practice. The acute inpatient period costs may be decreased with ORIF in appropriately selected patients with proximal humerus fractures in comparison with hemiarthroplasty. This study provides real world cost estimates with the cost implications of complications, readmissions, and procedure choice. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Economic and social impact of upper extremity fragility fractures in elderly patients.

BACKGROUND: Fragility fractures of the proximal humerus and distal radius can have a significant impact on the elderly population, both economically and physically. Limited data are available to demonstrate the functional and economic impact of upper extremity fragility fractures. AIMS: To investigate the economic and social impact that proximal humerus fragility fractures may have on an older population. METHODS: A retrospective chart review for patients ≥50 years old treated as an inpatient at a local hospital between 2006 and 2012 for a proximal humerus or a distal radius fracture was done. Patients were divided into two groups to show age impact; Group 1 = 50-79 years old and Group 2 = 80 years and older. Eighty-six charts were reviewed, 38 for Group 1 and 48 for Group 2. Demographic, admission, inpatient, and discharge data were compared between groups. RESULTS: A third of patients in each group had a previous fragility fracture. Inpatient length of stay was comparable between groups. Surgical treatment was used at a higher rate in the younger cohort (p = 0.06). Approximate average hospital charges for an inpatient surgical treatment were about twice those of the non-surgically treated patients. DISCUSSION: Our results illustrate the significant burden of upper extremity fractures in terms of loss of independence, inpatient hospitalizations and prolonged nursing home or rehabilitation needs, which account for considerable health care costs. CONCLUSION: Fractures of the humerus, forearm and wrist account for one-third of the total incidence of fractures and can be a significant burden to individuals and the community.

Burden of proximal humerus fractures in the French National Hospital Database.

OBJECTIVE: To describe the characteristics of patients hospitalized for osteoporotic proximal humerus fracture in 2009 in France, in-patient mortality, and further hospitalizations for hip fracture. METHODS: Data were extracted from the French Hospital National Database. We selected patients aged 40 years and over hospitalized for proximal humerus fracture in 2009, without cancer. Based on their unique identification number, we described the next hospitalizations occurring in 2009-2011 whatever the causes. Incidence, in-patient mortality, and hospital costs were calculated. RESULTS: We numbered 10,874 patients (77% of women, mean age 72.5 years). The incidence per million was 477 and 163 in women and men, respectively. This incidence increased with age and was higher in women (i.e. 1374 and 320 in women and men aged over 74 years, respectively). Surgical treatment was applied in 56% of patients; median hospital stay was 5 days. Rehabilitation unit was necessary in 26% of cases. In-patient mortality was 1.1%. The overall hospital costs was €34 millions. Rehospitalizations occurred for 61% of the patients and had more co-morbidities than others. Near 8% of the rehospitalized patients were for hip fractures occurring in a median of 353 days after hospitalization for proximal humerus fracture. The hospital costs for these rehospitalizations was €52 millions. CONCLUSION: Proximal humerus fractures incidence increases with aging, especially in women. These fractures are associated with a significant in-patient mortality and health care resources utilization. Patients with such fracture must receive high priority for optimal post fracture treatment.

Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty.

BACKGROUND: Significant controversy surrounds optimal treatment of displaced 4-part proximal humeral fractures. Reverse total shoulder arthroplasty (RTSA) has recently been proposed as an alternative to hemiarthroplasty (HA) and open reduction-internal fixation (ORIF). Several authors have questioned the additional implant cost for RTSA. The purpose of this study was to compare outcomes and cost of RTSA, HA, and ORIF. MATERIALS AND METHODS: We prospectively evaluated patients who underwent RTSA for displaced 3- and 4-part proximal humeral fractures and then retrospectively developed age- and sex-matched control groups with 3- and 4-part proximal humeral fractures who underwent HA and ORIF. Range of motion including active forward elevation and external rotation and time to achieve active forward elevation >90° were recorded. American Shoulder and Elbow Surgeons (ASES), Short-Form 12-item (SF-12), and Simple Shoulder Test (SST) scores were recorded. In addition, treatment cost was assessed by Medicare data and implant list prices. RESULTS: This study enrolled 27 patients; 9 underwent RTSA, 9 HA, and 9 ORIF. Minimum follow-up was 1 year. No significant differences were seen in SST, ASES, or SF-12 scores. Significantly more patients achieved >90° of active forward elevation after RTSA (P = .012). RTSA provided significant cost savings to Medicare compared with HA and ORIF (P = .002.) CONCLUSION: In this case-control study, RTSA appears to provide superior range of motion earlier and more predictably than HA and ORIF, with significant cost savings to Medicare.

Surgeon volume is associated with cost and variation in surgical treatment of proximal humeral fractures.

BACKGROUND: The issue of rising costs will likely dominate the healthcare debate in the forthcoming years. QUESTIONS/PURPOSES: We assessed factors including surgeon volume that were associated with lower hospital costs and variations in surgical treatment for proximal humeral fractures. METHODS: We used national databases for 2001 to 2008 to extract information on 25,731 patients undergoing surgery for proximal humeral fractures. We calculated hospital cost by converting hospital charges based on the hospital accounting reports collected by the Centers for Medicare & Medicaid Services. RESULTS: In a multivariate linear regression analysis, higher surgeon volume, open reduction and internal fixation (versus hemiarthroplasty), and lower burden of comorbidities were associated with lower hospital cost. Higher surgeon volume was linearly associated with lower hospital costs such that, on average, adjusting for all other factors, a surgeon performing 20 shoulder arthroplasties per year saves a hospital approximately US $1800 per surgery. Factors associated with higher utilization of hemiarthroplasty included high surgeon volume (odds ratio [OR] = 1.46; 95% CI = 1.43, 1.97; as compared with low surgeon volume) and earlier years of our study period (OR = 0.61; 95% CI = 0.56, 0.66; for hemiarthroplasty in 2007-2008 versus 2001-2002). CONCLUSIONS: Higher surgeon volume was associated with lower hospital costs for proximal humeral fractures. Therefore, policies on minimum volume requirements by hospitals may result in substantial cost savings. There is provider-based practice variation in the surgical treatment of proximal humeral fractures and evidence-based guidelines in this area are needed. LEVEL OF EVIDENCE: Level III, economic analysis. See Instructions for Authors for a complete description of levels of evidence.

Economic evaluations in shoulder pathologies: a systematic review of the literature.

BACKGROUND: Economic evaluations provide decision makers with a tool for reducing health care costs because they assess both the costs and consequences of health care interventions. This study reviewed the quality of published economic evaluations for shoulder pathologies. MATERIALS AND METHOD: A MEDLINE search was conducted to identify articles published from 1980 to 2010 that contained "cost" or "economic" combined with terms for several shoulder disorders and treatments. We selected studies that fit the definition of 1 of the 4 routinely performed economic evaluations: cost-minimization, cost-effectiveness, cost-utility, and cost-benefit analyses. Study quality was determined by measuring adherence to 6 established health economic principles, as described in the literature. RESULTS: The search retrieved 942 studies. Of these, 32 were determined to be economic evaluations, and 53% of the economic evaluations were published from 2005 to 2010. Only 8 of the 32 studies (25%) adhered to all 6 health economic principles. Publication in a nonsurgical journal (P < .05) or in more recent years (P < .01) was significantly associated with higher quality. CONCLUSION: Future health care resource allocation will likely be based on the economic feasibility of treatments. Although the number and quality of economic evaluations of shoulder disorders have risen in recent years, the current state of the literature is poor. Given that availability of such data may factor in private and public reimbursement decisions, there is a clear demand for more rigorous economic evaluations.

Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients.

OBJECTIVE: This study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures. DESIGN: This study is a randomised controlled trial. PARTICIPANTS: This study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture. INTERVENTIONS: The patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients). MAIN OUTCOME MEASURE: The outcomes measured included quality-adjusted life years (QALYs) and societal costs. RESULTS: At 12 months' follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI)=-0.025, 0.078) while the mean difference in total health-care costs was 597 euro in favour of surgery (95% CI=-5291, 3777). CONCLUSION: There was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.

Protocol for the ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial: a pragmatic multi-centre randomised controlled trial of surgical versus non-surgical treatment for proximal fracture of the humerus in adults.

BACKGROUND: Proximal humeral fractures, which occur mainly in older adults, account for approximately 4 to 5% of all fractures. Approximately 40% of these fractures are displaced fractures involving the surgical neck. Management of this group of fractures is often challenging and the outcome is frequently unsatisfactory. In particular it is not clear whether surgery gives better outcomes than non-surgical management. Currently there is much variation in the use of surgery and a lack of good quality evidence to inform this decision. METHODS/DESIGN: We aim to undertake a pragmatic UK-based multi-centre randomised controlled trial evaluating the effectiveness and cost-effectiveness of surgical versus standard non-surgical treatment for adults with an acute closed displaced fracture of the proximal humerus with involvement of the surgical neck. The choice of surgical intervention is left to the surgeon, who must use techniques that they are fully experienced with. This will avoid 'learning curve' problems. We will promote good standards of non-surgical care, similarly insisting on care-provider competence, and emphasize the need for comparable provision of rehabilitation for both groups of patients.We aim to recruit 250 patients from a minimum of 18 NHS trauma centres throughout the UK. These patients will be followed-up for 2 years. The primary outcome is the Oxford Shoulder Score, which will be collected via questionnaires completed by the trial participants at 6, 12 and 24 months. This is a 12-item condition-specific questionnaire providing a total score based on the person's subjective assessment of pain and activities of daily living impairment. We will also collect data for other outcomes, including general health measures and complications, and for an economic evaluation. Additionally, we plan a systematic collection of reasons for non-inclusion of eligible patients who were not recruited into the trial, and their baseline characteristics, treatment preferences and intended treatment. DISCUSSION: This article presents the protocol for a multi-centre randomised controlled trial. It gives extensive details of, and the basis for, the chosen methods, and describes the key measures taken to avoid bias and to ensure validity. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50850043.