Economic advantage of outpatient shoulder arthroplasty: a Markov model analysis

Outpatient total shoulder arthroplasty (TSA) has become increasingly common due to advances in perioperative care and policy changes. While prior studies have demonstrated lower short-term costs associated with outpatient TSA, its long-term economic value compared with inpatient TSA remains unclear.

A Markov cost-utility model compared outpatient and inpatient TSA from a U.S. payer perspective over a 20-year horizon. Costs and quality-adjusted life-years (QALYs) were discounted at 3%. Cost-effectiveness was evaluated at a willingness-to-pay threshold of $100,000 per QALY, with probabilistic sensitivity analyses varying readmission and revision risks.

In the base case analysis, outpatient TSA was the dominant strategy. Mean discounted lifetime costs were lower for outpatient TSA compared with inpatient TSA ($23,375 vs. $28,402), resulting in a cost savings of $5,027 per patient. Outpatient TSA was associated with a modest increase in effectiveness, generating 10.436 QALYs compared with 10.427 QALYs for inpatient TSA (incremental gain, 0.009 QALYs). In probabilistic sensitivity analysis, outpatient TSA demonstrated a mean incremental cost of -$5,142 (95% uncertainty interval, -$13,642 to $3,109) and a mean incremental effectiveness of 0.009 QALYs (95% uncertainty interval, -0.034 to 0.057). At a willingness-to-pay threshold of $100,000 per QALY, outpatient TSA was cost-effective in 89.0% of simulations and economically dominant in 61.1% of simulations.

Outpatient TSA is a cost-effective and economically dominant strategy compared with inpatient TSA, driven primarily by lower initial procedural costs. Sensitivity analyses demonstrated that outpatient TSA remained cost-effective even when differences in perioperative complication and revision rates were substantially reduced.