Sudah Suleiman Y, Faccone Robert D, Imam Nareena, Patankar Aneesh, Manzi Joseph E, Menendez Mariano E, Nicholson Allen
Department of Orthopedics, Monmouth Medical Center, Long Branch, NJ, USA.
Department of Research, Alabama College of Osteopathic Medicine, Dothan, AL, USA.
J Shoulder Elbow Surg. 2023 Nov;32(11):2222-2231. doi: 10.1016/j.jse.2023.04.014. Epub 2023 May 27.
The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty.
Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management.
A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n = 70; 59.3%) followed by review or expert opinion articles (n = 35; 29.7%). Most references were of level IV evidence (n = 60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty.
The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.
在过去十年中，肩关节置换术的发生率持续上升。作为回应，商业医保机构已实施策略来控制这些手术的医疗需求，试图遏制不断增长的成本。例如，大多数医保机构要求对那些原本可能是手术候选人的患者，在进行肩关节置换术前进行长期的保守治疗试验。然而，对于支持这些适应症的证据知之甚少。本研究的目的是分析商业医保机构用于证实其肩关节置换术覆盖政策的参考文献。
确定了十家主要的全肩关节置换术商业医保机构。在互联网上搜索公开可用的覆盖政策，或通过电子邮件或电话直接向医保机构索取。两位作者独立审查引用的参考文献，以确定文献类型、证据水平以及对保守治疗疗效的提及情况。
共获得5份覆盖政策，包含118篇参考文献。最常见的参考文献类型是初级期刊文章（n = 70；59.3%），其次是综述或专家意见文章（n = 35；29.7%）。大多数参考文献为IV级证据（n = 60；52.2%），只有6篇（5.2%）为I级或II级证据。只有4篇（3.5%）参考文献提到了保守治疗对可能适合肩关节置换术患者的疗效。
美国主要商业医保机构用于证实肩关节置换术覆盖政策的大多数参考文献科学证据水平较低，且未能证明所需非手术干预策略的成功性。我们的研究强调需要开展高质量的对比试验，以评估终末期盂肱关节骨关节炎患者保守治疗与肩关节置换术的疗效，从而确定最具成本效益的治疗方案。
