Healthcare Resource Utilization in the Two Years Prior to Total Shoulder Arthroplasty

Background: Reverse (RTSA) and anatomic total shoulder arthroplasty (ATSA) are the gold standard surgical treatments for symptomatic glenohumeral osteoarthritis (OA). Typically, these procedures are pursued after exhausting medical management and non-arthroplasty procedures. There is little reliable evidence focused on non-arthroplasty treatments for glenohumeral OA, although their use is widespread. To understand the treatment patterns and healthcare spending associated with degenerative shoulder pathologies, we sought to determine the costs and utilization rates of non-arthroplasty treatment modalities in the two years prior to shoulder reconstruction. We then compared these patterns between patients who went on to RTSA and ATSA.

Methods: We retrospectively analyzed a nationwide private insurance payer database looking at patients who had either RTSA or ATSA from 2018-2020. Of these patients, we looked at the percentage who had injections, non-arthroplasty surgical procedures, and physical therapy in the two years prior to arthroplasty and compared the utilization of procedures and costs prior to RTSA and ATSA. We also looked at the demographics of these populations.

Results: In total 9,756 patients underwent primary TSA, with 4292 (44%) receiving RTSA and 5464 (56%) ATSA. In comparison to RTSA, the ATSA patients were younger (59 vs. 62 years old, p<0.001), more likely to be male (64% vs. 51%, p<0.001), and had lower co-morbidity scores (2.25 vs. 2.90, p < 0.001). Patients who had ATSA were more likely to have an injection beforehand (65% vs. 59%, p < 0.001). In contrast, patients who had a RTSA were more likely to undergo a procedure (14% vs. 6%, p<0.001) and more likely to undergo physical therapy (41% vs. 36%, p < 0.001). There were no significant differences between groups in terms of imaging in the 2 years prior to shoulder replacement. The per patient cost for the treatment of these shoulders in the 2 years prior to reconstruction were lower for ATSA in comparison to RTSA ($5,748 vs. $15,233, p < 0.001).

Conclusion: These data provide a baseline for understanding current trends regarding the non-arthroplasty treatment of shoulder pathology prior to shoulder replacement. As the utilization of RTSA continues to grow, the difference in non-arthroplasty interventions used and costs prior to RTSA in comparison to ATSA is notable with nearly 3-times higher per patient spending prior to RTSA. The cost data highlights the significant amount of resources being devoted to these treatments, and further research is needed to determine the efficacy and optimal utilization of non-arthroplasty treatments prior to shoulder replacement.