Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
The Dartmouth Institute for Health Policy and Clinical Practice Dartmouth College, Lebanon, NH, USA.
Iowa Orthop J. 2020;40(2):20-29.
Open reduction and internal fixation (ORIF) of proximal humerus fractures in elderly individuals (age >70) carries a relatively high short-term complication and reoperation rate but is generally durable once healed. Reverse total shoulder arthroplasty (RTSA) for fractures may be associated with superior short-term quality of life but carries the lifelong liabilities of joint replacement. The tradeoff between short and long-term risks, coupled with disparities in quality of life and cost, makes this clinical decision amenable to cost-effectiveness analysis.
A Markov state-transition model was constructed with a base case of a 75 year-old patient. Reoperation rates, quality of life values, mortality rates, and costs were based upon published literature. The model was run until all patients had died to simulate the accumulated costs and benefits.
RTSA was associated with greater quality of life (7.11 QALYs) than ORIF (6.22 QALYs). RTSA was cost-effective with an incremental cost-effectiveness ratio of $3,945/QALY and $27,299/ QALY from payor and hospital perspectives, respectively. RTSA was favored and cost-effective at any age above 65 and any Charlson Score. The model was sensitive to the utility of both procedures.
RTSA resulted in a higher quality of life and was cost-effective in comparison to ORIF for elderly patients..
老年（年龄>70 岁）肱骨近端骨折的切开复位内固定（ORIF）具有相对较高的短期并发症和再次手术率，但一旦愈合通常是持久的。对于骨折患者，反式全肩关节置换术（RTSA）可能与短期生活质量相关，但需要承担关节置换的终身责任。短期和长期风险之间的权衡，加上生活质量和成本的差异，使得这一临床决策适合进行成本效益分析。
建立了一个 Markov 状态转移模型，以 75 岁的患者作为基础病例。再手术率、生活质量值、死亡率和成本基于已发表的文献。该模型运行到所有患者死亡，以模拟累积成本和收益。
RTSA 与 ORIF 相比，具有更高的生活质量（7.11 QALYs）。从支付者和医院的角度来看，RTSA 的增量成本效益比分别为 3945 美元/QALY 和 27299 美元/QALY，具有成本效益。RTSA 在 65 岁以上的任何年龄和任何 Charlson 评分上都更有优势和成本效益。该模型对两种手术的效用都很敏感。
与 ORIF 相比，RTSA 为老年患者带来更高的生活质量，并具有成本效益。
