Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
Clin Orthop Relat Res. 2022 Jun 1;480(6):1129-1139. doi: 10.1097/CORR.0000000000002110. Epub 2022 Jan 11.
Shoulder arthroplasty is increasingly performed for patients with symptoms of glenohumeral arthritis. Advanced imaging may be used to assess the integrity of the rotator cuff preoperatively because a deficient rotator cuff may be an indication for reverse shoulder arthroplasty (RSA) rather than anatomic total shoulder arthroplasty (TSA). However, the cost-effectiveness of advanced imaging in this setting has not been analyzed.
QUESTIONS/PURPOSES: In this cost-effectiveness modeling study of TSA, all patients underwent history and physical examination, radiography, and CT, and we compared (1) no further advanced imaging, (2) selective MRI, (3) MRI for all, (4) selective ultrasound, and (5) ultrasound for all.
A simple chain decision model was constructed with a base-case 65-year-old patient with a 7% probability of a large-to-massive rotator cuff tear and a follow-up of 5 years. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness to pay of both USD 50,000 and 100,000 per quality-adjusted life year (QALY) used, in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. Diagnostic test sensitivity and specificity were extracted from published systematic reviews and meta-analyses, and patient utilities were obtained using the Cost-Effectiveness Analysis Registry from the Center for the Evaluation of Value and Risk in Health. Final patient states were categorized as either inappropriate or appropriate based on the actual rotator cuff integrity and type of arthroplasty performed. Additionally, to evaluate the real-world impact of intraoperative determination of rotator cuff status, a secondary analysis was performed where all patients indicated for TSA underwent intraoperative rotator cuff examination to determine appropriate implant selection.
Selective MRI (ICER of USD 40,964) and MRI for all (ICER of USD 79,182/QALY) were the most cost-effective advanced imaging strategies at a willingness to pay (WTP) of USD 50,000/QALY gained and 100,000/QALY gained, respectively. Overall, quality-adjusted life years gained by advanced soft tissue imaging were minimal: 0.04 quality-adjusted life years gained for MRI for all. Secondary analysis accounting for the ability of the surgeon to alter the treatment plan based on intraoperative rotator cuff evaluation resulted in the no further advanced imaging strategy as the dominant strategy as it was the least costly (USD 23,038 ± 2259) and achieved the greatest health utility (0.99 ± 0.05). The sensitivity analysis found the original model was the most sensitive to the probability of a rotator cuff tear in the population, with the value of advanced imaging increasing as the prevalence increased (rotator cuff tear prevalence greater than 12% makes MRI for all cost-effective at a WTP of USD 50,000/QALY).
In the case of diagnostic ambiguity based on physical exam, radiographs, and CT alone, having both TSA and RSA available in the operating room appears more cost-effective than obtaining advanced soft tissue imaging preoperatively. However, performing selective MRI to assess rotator cuff integrity to indicate RSA or TSA is cost-effective if surgical preparedness, patient expectations, and implant availability preclude the ability to switch implants intraoperatively.
Level III, economic and decision analysis.
肩关节置换术越来越多地用于治疗肩关节炎患者。术前可能会使用先进的影像学方法来评估肩袖的完整性，因为肩袖缺损可能是行反式肩关节置换术（RSA）而不是解剖型全肩关节置换术（TSA）的指征。然而，这种情况下先进影像学的成本效益尚未进行分析。
问题/目的：在这项 TSA 的成本效益建模研究中，所有患者均接受了病史和体格检查、影像学检查和 CT 检查，我们比较了（1）不进行进一步的先进影像学检查，（2）选择性 MRI，（3）所有患者进行 MRI，（4）选择性超声，和（5）所有患者进行超声。
使用基础情况为 65 岁、7%概率存在大到巨大肩袖撕裂且随访 5 年的患者建立简单链式决策模型。使用增量成本效益比（ICER）比较策略，采用 5 万美元和 10 万美元/QALY 两种意愿支付水平，符合第二健康和医学成本效益小组。诊断测试的敏感性和特异性从已发表的系统评价和荟萃分析中提取，患者效用通过来自健康价值和风险评估中心的成本效益分析登记处获得。最终患者状态根据实际肩袖完整性和所进行的关节置换类型分类为适当或不适当。此外，为了评估术中确定肩袖状态的实际影响，进行了二次分析，所有指征为 TSA 的患者均接受术中肩袖检查以确定适当的植入物选择。
选择性 MRI（ICER 为 40964 美元）和所有患者进行 MRI（ICER 为 79182 美元/QALY）在意愿支付（WTP）5 万美元/QALY 和 10 万美元/QALY 时是最具成本效益的先进影像学策略。总体而言，先进软组织成像带来的质量调整生命年获益很小：所有患者进行 MRI 获益 0.04 个质量调整生命年。考虑到外科医生根据术中肩袖评估改变治疗计划的能力的二次分析结果显示，不进行进一步的先进影像学检查是主导策略，因为它的成本最低（23038 美元±2259 美元），并且获得的健康效用最大（0.99±0.05）。敏感性分析发现，原始模型对人群中肩袖撕裂的概率最为敏感，随着患病率的增加，先进影像学的价值也随之增加（肩袖撕裂患病率超过 12%时，所有患者进行 MRI 在 5 万美元/QALY 的意愿支付水平下具有成本效益）。
在仅基于体格检查、影像学和 CT 存在诊断模棱两可的情况下，在手术室同时提供 TSA 和 RSA 似乎比术前获得先进的软组织影像学更具成本效益。然而，如果手术准备、患者期望和植入物可用性排除了术中更换植入物的能力，那么进行选择性 MRI 评估肩袖完整性以指示 RSA 或 TSA 是具有成本效益的。
III 级，经济和决策分析。
