Disclosures THE COST-EFFECTIVENESS OF SURGICAL TREATMENT FOR None - - PowerPoint PPT Presentation

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Disclosures THE COST-EFFECTIVENESS OF SURGICAL TREATMENT FOR None - - PowerPoint PPT Presentation

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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

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THE COST-EFFECTIVENESS OF SURGICAL TREATMENT FOR COMPLEX PROXIMAL HUMERUS FRACTURES

David Shearer MD, MPH, Ehsan Tabaraee MD, Paul Toogood MD, Kevin Bozic MD, MBA, Brian Feeley MD

Disclosures

  • None

Background

  • Common Injury
  • 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

Purpose/Question

  • What is the most cost-effective treatment for complex (3-

and 4- part) proximal humerus fractures?

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Study Design

  • Markov model in Treeage 2012 (Williamstown, MA)
  • Four interventions
  • Nonoperative treatment2 health states
  • ORIF with locking plate6 health states
  • Hemiarthroplasty
  • Reverse total shoulder arthroplasty
  • One-year cycle length
  • Cost and Quality-of-life accumulated over time
  • 3% discount rate
  • Lifetime time horizon

4 health states

Model structures

Successful ORIF Failed ORIF Successful revision ORIF Convert to athro Infected Arthro Revision Arthro

ORIF Arthro

Well- functioning Arthro Death All health states

Key assumptions

  • No reoperations for ORIF after the first year (Hirschmann, 2011)
  • Constant annual failure rate for all arthroplasties (primary, revision)
  • Rehabilitation costs, indirect costs (missed work of patient/family,

travel time, etc.) are equivalent among groups (Fjalestad, Injury 2010)

  • Cost and benefit of revision ORIF and revision arthroplasty

assumed to be constant

  • Nonoperatively treated patients do not later elect to undergo

surgery (Fjalestad, Injury 2010)

  • No impact on mortality

Model Inputs

Cost Utility Prob. Failure Nonoperative treatment 1000 0.62

  • ORIF

10000 0.70 13% Hemiarthroplasty 11500 0.65 1% annual Reverse TSA 22000 0.68 1% annual

  • 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)
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Results

$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 1 2 3 4 5 6 7 8 9 10 Nonoperative Treatment ORIF Hemiarthroplasty Reverse TSA QALYs Cost

Cost QALYs ICER ($/QALY) Nonoperative Treatment $1,000 8.64 ‘- ORIF $11,510 9.39 $13,974 Hemiarthroplasty $15,761 9.04 $37,038 Reverse TSA $24,514 9.23 $39,652

Sensitivity Analysis: Reoperation after ORIF

  • rTSA > ORIF if reoperation> 19%, hemi preferred > 26%
  • Lifetime risk reoperation after hemi or rTSA = 18%

Sensitivity analysis: Age + Reoperation

WTP = $50,000/QALY

Sensitivity analysis: Age + Reoperation

WTP = $100,000/QALY

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Limitations

  • “Garbage in, garbage out”
  • Few comparison studies, poor follow up, high heterogeneity
  • Difficult to include all patient and fracture variables into a

model

  • Sensitivity analysis
  • Identify meaningful clinical thresholds
  • Cost data not true societal perspective (rehab, outpatient

pain prescriptions, missed work for family)

Conclusions

  • Poor functional outcome, long-term risk reoperation

associated with shoulder replacement make ORIF preferred in most cases

  • In high-risk cases (head-split, fracture-dislocation) or

elderly, reverse TSA may be preferred over hemiarthroplasty

  • Caution should be taken in interpreting short-term studies

comparing ORIF with arthroplasty

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