Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Am J Sports Med. 2024 Nov;52(13):3339-3348. doi: 10.1177/03635465241282342. Epub 2024 Oct 12.
Value-based decision-making regarding nonoperative management versus early surgical stabilization for first-time anterior shoulder instability (ASI) events remains understudied.
To perform (1) a systematic review of the current literature and (2) a Markov model-based cost-effectiveness analysis comparing an initial trial of nonoperative management to arthroscopic Bankart repair (ABR) for first-time ASI.
Economic and decision analysis; Level of evidence, 3.
A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 simulated patients (mean age, 20 years; range, 12-26 years) with first-time ASI undergoing nonoperative management versus ABR. Utility values, recurrence rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors' institution. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER).
The Markov model with Monte Carlo microsimulation demonstrated mean (± standard deviation) 10-year costs for nonoperative management and ABR of $38,649 ± $10,521 and $43,052 ± $9352, respectively. Total QALYs acquired over the 10-year time horizon were 7.67 ± 0.43 and 8.44 ± 0.46 for nonoperative management and ABR, respectively. The ICER comparing ABR with nonoperative management was found to be just $5725/QALY, which falls substantially below the $50,000 willingness-to-pay (WTP) threshold. The mean numbers of recurrences were 2.55 ± 0.31 and 1.17 ± 0.18 for patients initially assigned to the nonoperative and ABR treatment groups, respectively. Of 1000 samples run over 1000 trials, ABR was the optimal strategy in 98.7% of cases, with nonoperative management the optimal strategy in 1.3% of cases.
ABR reduces the risk for recurrent dislocations and is more cost-effective despite higher upfront costs when compared with nonoperative management for first-time ASI in the young patient. While all these factors are important to consider in surgical decision-making, ultimate treatment decisions should be made on an individual basis and occur through a shared decision-making process.
对于初次肩前不稳定（AS）事件，非手术治疗与早期手术固定的价值决策仍研究不足。
（1）对现有文献进行系统评价，（2）进行基于马尔可夫模型的成本效益分析，比较初次 AS 患者的非手术治疗与关节镜下 Bankart 修复术（ABR）的效果。
经济和决策分析；证据水平，3 级。
建立了马尔可夫链蒙特卡罗概率模型，以评估 1000 名初次 AS 患者（平均年龄 20 岁；范围 12-26 岁）接受非手术治疗与 ABR 的结果和成本。效用值、复发率和转移概率来自已发表的文献。根据作者机构中每位患者的典型治疗策略，确定成本。结果指标包括成本、质量调整生命年（QALY）和增量成本效益比（ICER）。
蒙特卡罗微模拟马尔可夫模型显示，非手术治疗和 ABR 的 10 年平均成本分别为 38649 美元±10521 美元和 43052 美元±9352 美元。10 年时间内获得的总 QALY 分别为非手术治疗组的 7.67±0.43 和 ABR 组的 8.44±0.46。ABR 与非手术治疗相比，ICER 为 5725 美元/QALY，远低于 50000 美元的支付意愿（WTP）阈值。最初分配到非手术和 ABR 治疗组的患者的平均复发次数分别为 2.55±0.31 和 1.17±0.18。在 1000 次试验中，1000 个样本中，ABR 为 98.7%的情况下是最佳策略，非手术治疗为 1.3%的情况下是最佳策略。
ABR 降低了年轻初次 AS 患者的复发性脱位风险，且与非手术治疗相比，具有更高的成本效益，尽管前期成本更高。虽然所有这些因素在手术决策中都很重要，但最终的治疗决策应基于个体情况，并通过共同决策过程做出。
