Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty

Background: Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are two viable surgical treatment options for glenohumeral osteoarthritis. Recent systematic reviews and randomized trials suggest that TSA, while more costly initially, may have superior outcomes with regard to pain, function and quality of life with lower revision rates. This study compared the cost-effectiveness of TSA with HA.

Methods: A Markov decision model was constructed for a cost-utility analysis of TSA compared to HA in a cohort of 64-year-old patients. Outcome probabilities and effectiveness were derived from the literature. Costs were estimated from the societal perspective using the national average Medicare reimbursement for the procedures in 2008 US dollars. Effectiveness was expressed in quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, incremental effectiveness, incremental QALYs, and net health benefits.

Results: In the base case, HA resulted in a lower number of average QALYs gained at a higher average cost to society and was, therefore, dominated by the TSA strategy for the treatment of glenohumeral osteoarthritis. The cost effectiveness ratio for TSA and HA were $957/QALY and $1,194/QALY respectively. Sensitivity analysis revealed that if the utility of TSA is equal to, or revision rate lower than HA, TSA continues to be a dominant strategy.

Conclusion: Total shoulder arthroplasty with a cemented glenoid is a cost-effective procedure, resulting in greater utility for the patient at a lower overall cost to the payer. These findings suggest that TSA is the preferred treatment for certain populations from both a patient and payer perspective.