Commentary

The cost of healthcare in the United Kingdom and particularly in the United States is an important subject of discussion. Therefore, any study that provides information about the cost effectiveness of the treatments we provide has the potential to impact what we do. Nicholson, et al. specifically focus on the cost effectiveness of primary and revision reverse total shoulder arthroplasty (RTSA) to determine the cost per quality-adjusted life year (QALY). Their conclusions that primary and revision reverse total shoulder arthroplasty are cost-effective interventions with excellent patient outcomes is justified based upon the data presented. Their analysis assumed that all patients had an equivalent preoperative cost of imaging, physiotherapy and primary care physician visits. However, they did not factor in time loss from work or the potential cost to caregivers within the family unit as a result of the surgery. Admittedly, these are difficult costs to determine.

The cost effectiveness analysis was certainly benefitted by the fact that there were no revisions required in the group of 67 patients followed for two years. This is a credit to the surgeons performing the procedures. However, it is certainly not the experience reported by most who perform RTSA, particularly for revision surgery. The authors helped their analysis by excluding any patients who had “suspicion of infection.” The need for revision procedures and the development of infection would certainly have made the procedure more costly per QALY. The cost of the implants utilized was £3200 (equivalent to $4224 USD). This is much less expensive than the same implants utilized in the United States. I suspect that a similar analysis performed in the United States would show a greater cost per QALY than the authors reported because healthcare costs are greater in the United States.

The National Health Service indicates that an incremental cost effectiveness ratio of £20,000 per QALY is the upper limit above which a given treatment is not thought to be cost effective. The authors document a cost per QALY that is far less than this target for the first year and for two years. The cost per QALY decreases significantly when factoring in a life expectancy of 6.9 years, assuming that additional treatment is not necessary. It is also very encouraging that the cost per QALY over the life expectancy of the patients was comparable to total hip replacements (although greater) and coronary artery bypass surgery, which certainly places the procedure in good company.

Cost effectiveness studies like this are very important. The RTSA has become the most common shoulder arthroplasty procedure performed. It is more costly than hemiarthroplasty or anatomic total shoulder replacement. Therefore, it is essential that it withstand close scrutiny to determine cost effectiveness. How each country spends their healthcare dollars will only become increasingly important each year.