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Patient-Level Value Analysis in Anatomic Total Shoulder Arthroplasty: Evaluating a One-Year Episode of Care
Nicholas F Banfield1, Haley D Puckett, Rebekah M Kleinsmith
1From the Department Orthopaedic Surgery (Banfield), University of Minnesota, Minneapolis, MN, the Department of Orthopaedic Surgery (Puckett, Doxey, Cunningham), TRIA Orthopedic Center, Bloomington, MN, the Department of Orthopaedic Surgery (Kleinsmith, Throckmorton, Dr. Brolin), Campbell Clinic, Germantown, TN, the Department of Orthopaedic Surgery (Dixon), Campbell Foundation, Germantown, TN, the Department of Orthopaedic Surgery, Des Moines University (Throckmorton), West Des Moines, IA, and the Department of Orthopaedic Surgery (Cunningham), Park Nicollet-Methodist Hospital, St. Louis Park, MN.
Background:
As the cost of anatomic total shoulder arthroplasty (aTSA) continues to rise, there is increasing pressure to optimize value through cost-effective care strategies. Patient-level value analysis (PLVA) is an emerging method that quantifies value as the change in patient-reported outcomes (PROs) relative to total cost. Although PLVA has been applied to other orthopaedic procedures, it has not been used to evaluate aTSA. This study aimed to assess 1-year value delivery in aTSA and identify characteristics that influence cost and outcomes.
Methods:
A retrospective cohort study was conducted using prospectively collected patient-reported outcome registries at one healthcare institution. Patients undergoing primary unilateral aTSA for osteoarthritis between 2018 and 2022 were included. Patients were excluded if they lacked preoperative or 1-year American Shoulder and Elbow Surgeons (ASES) scores or experienced complications or revisions. Episode-of-care (EOC) costs were calculated using time-driven activity-based costing (TDABC), including direct and indirect care costs. The value quotient (Vq) was defined as the change in ASES score divided by total EOC cost, multiplied by 100. Multivariate regression was used to assess predictors of cost, outcome, and value.
Results:
A total of 139 patients met inclusion criteria. The mean age was 67.8 years, and 54.4% were female. The average 1-year ASES improvement was 32.1 ± 24.9, and the mean EOC cost was $13,301±$3,137. Implants accounted for 49% of the total EOC cost. Surgeries in the ASC setting predicted lower cost (β = -$2,847; P < 0.001), whereas inpatient stay and SNF discharge were associated with higher costs. The average value quotient was 0.23 ± 0.19 for each patient.
Conclusion:
Cost variability in aTSA is driven by surgical setting, implant selection, and discharge disposition. Higher costs do not correspond to better outcomes, highlighting opportunities to improve value by targeting modifiable cost drivers, particularly implant prices and use of postacute care facilities.
