5/11/2013 Disclosures THE COST-EFFECTIVENESS OF SURGICAL TREATMENT FOR • None COMPLEX PROXIMAL HUMERUS FRACTURES David Shearer MD, MPH, Ehsan Tabaraee MD, Paul Toogood MD, Kevin Bozic MD, MBA, Brian Feeley MD Background Purpose/Question • Common Injury • What is the most cost-effective treatment for complex (3- and 4- part) proximal humerus fractures? • 5% of all fractures (Baron et al., Bone, 1996) • Aging population = increasing incidence • Many treatments, no consensus • Nonoperative • Fix (CRPP, ORIF) • Replace (Hemiarthroplasty, rTSA) • 20-30 fold geographic variation in rate of surgery (Bell, JBJS 2011) • 30% increase in ORIF, 20% increase in hemiarthroplasty from 1998 to 2006 1
5/11/2013 Study Design Model structures • Markov model in Treeage 2012 (Williamstown, MA) Well- Successful • Four interventions functioning ORIF Arthro • Nonoperative treatment � 2 health states • ORIF with locking plate � 6 health states • Hemiarthroplasty Failed Convert to Revision 4 health states ORIF Arthro • Reverse total shoulder arthroplasty ORIF athro Arthro • One-year cycle length • Cost and Quality-of-life accumulated over time Successful Infected revision • 3% discount rate Arthro ORIF • Lifetime time horizon Death All health states Key assumptions Model Inputs Prob. • No reoperations for ORIF after the first year (Hirschmann, 2011) Cost Utility Failure • Constant annual failure rate for all arthroplasties (primary, revision) • Rehabilitation costs, indirect costs (missed work of patient/family, Nonoperative treatment 1000 0.62 - travel time, etc.) are equivalent among groups (Fjalestad, Injury 2010) ORIF 10000 0.70 13% • Cost and benefit of revision ORIF and revision arthroplasty assumed to be constant Hemiarthroplasty 11500 0.65 1% annual • Nonoperatively treated patients do not later elect to undergo surgery (Fjalestad, Injury 2010) Reverse TSA 22000 0.68 1% annual • No impact on mortality • Costs obtained from HCUP.net, supplemented by literature (Coe et al. JSES 2012) • Utilities derived from linear interpolation of Constant scores from multiple systematic reviews (Kantakis, Injury 2008; Sproul et al. Injury 2011) based on EQ-5D scores (Olerud, JSES 2011) • Failure rates based on literature (Multiple studies) 2
5/11/2013 Sensitivity Analysis: Reoperation after Results ORIF 10 $30,000 9 $25,000 8 7 $20,000 6 QALYs 5 $15,000 Cost 4 $10,000 3 2 $5,000 1 0 $0 Nonoperative Treatment ORIF Hemiarthroplasty Reverse TSA Cost QALYs ICER ($/QALY) Nonoperative Treatment $1,000 8.64 ‘- ORIF $11,510 9.39 $13,974 • rTSA > ORIF if reoperation> 19%, hemi preferred > 26% Hemiarthroplasty $15,761 9.04 $37,038 Reverse TSA $24,514 9.23 $39,652 • Lifetime risk reoperation after hemi or rTSA = 18% Sensitivity analysis: Age + Reoperation Sensitivity analysis: Age + Reoperation WTP = $50,000/QALY WTP = $100,000/QALY 3
5/11/2013 Limitations Conclusions • “Garbage in, garbage out” • Poor functional outcome, long-term risk reoperation associated with shoulder replacement make ORIF • Few comparison studies, poor follow up, high heterogeneity preferred in most cases • Difficult to include all patient and fracture variables into a model • In high-risk cases (head-split, fracture-dislocation) or elderly, reverse TSA may be preferred over • Sensitivity analysis hemiarthroplasty • Identify meaningful clinical thresholds • Cost data not true societal perspective (rehab, outpatient • Caution should be taken in interpreting short-term studies pain prescriptions, missed work for family) comparing ORIF with arthroplasty References Thank you Baron JA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone. 1996: 18: 209S-213S. PMID: 8777090. • Chu SP, Kelsey JL, Keegan TH, Sternfeld B, Prill M, Quesenberry CP, Sidney S. Risk factors for proximal humerus fractures. Am J • Epidemiol. 2004; 160: 360-7. PMID: 15286021. Hallberg I, Rosenqvist AM, Kartous L, Lofrnan O, Wahlstrom O, Toss G. Health related quality of life after osteoporotic fractures. • Osteoporos Int. 2004; 15:834-41. PMID: 15045468. Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative • treatment. J Bone Joint Surg Br. 2002; 84:504-8. PMID: 12043768. Court-Brown CM, Caesar B. The Epidemiology of Adult Fractures: A review. Injury. Aug 2006; 37 (8): 691-7 PMID: 16814787 • Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006 Jan; • 442:87-92. PMID: 16394745. • Ricchetti ET, Warrender WJ, Abboud JA. Use of Locking Plates in the Treatment of Proximal Humerus Fractures. J Shoulder and Elbow Surg. 2010; 19: 66-75. PMID: 20188270. • Duralde XA, Leddy LR. The Results of ORIF of Displaced Unstable Proximal Humeral Fractures Using a Locking Plate. J Shoulder and Elbow Surg. 2010; 19: 480-488. PMID: 19963400. • Philippe C, Philippe A, Bevort A, Bonnomet F, Kempf JF. Pitfalls and complications with locking plate for Proximal Humerus Fractures. J Shoulder and Elbow Surg. 2010; 19: 489-494. PMID: 19995683. • Shulte LM, Matteini LE, Neviaser RJ. Proximal periarticular locking plates in proximal humeral fractures: functional outcomes. J Shoulder and Elbow Surg. 2011; 21: 1-6 PMID: 21420322 • Robinson CM, Page RS, Hill RMF, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone and Joint Surg, Am. 2003; July 85-A: 1215-1223. PMID 12851345. • Voos JE, Dines JS, Dines DM. Arthroplasty for fractures of the proximal part of the humerus. Instr Course Lect. 2011; 60:105-12. PMID: 21553766. • Sirveaux F, Roche O, Mole D. Shoulder Arthropalsty for Acute Proximal Humerus Fracture. Orthopaedics and Traumatology: Surgery and Research. 2010; 96: 683-694. PMID: 20692881. Noyes MP, Kleinhenz B, Markert RJ, Crosby LA. Functional and radiographic long-term outcomes of hemiarthroplasty for proximal humeral • fractures. J Shoulder Elbow Surg. 2011; 20, 372-377. PMID: 20926312. Handoll HH, Gibson JN, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2003; 4: • CD000434. PMID: 21154345. Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein JD, Goodman DC, Tosteson A. Trends and Variation in Incidence, Surgical Treatment, • and Repeat Surgery of Proximal Humeral Fractures in the Elderly. 2011; 93-A, 121-131. PMID: 21248210. Bernstein J. Decision Analysis. J Bone Joint Surg Am. 1997; 19: 1404-1414. PMID: 9314406. • Pauker SG, Kassirer JP. Decision Analysis. N Engl J Med. 1987; 316: 250-258. PMID: 3540670. • 4
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