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The Societal and Economic Value of Rotator Cuff Repair
Richard C. Mather, III, MD1; Lane Koenig, PhD2; Daniel Acevedo, MD3; Timothy M. Dall, MS4; Paul Gallo, BS4; Anthony Romeo, MD5; John Tongue, MD6; Gerald Williams, Jr., MD3
1 Duke Orthopaedic Surgery, 4709 Creekstone Drive, Suite 200, Durham, NC 27710
2 KNG Health Consulting, 15245 Shady Grove Road, Suite 305, Rockville, MD 20850. E-mail address: lane.koenig@knghealth.com
3 The Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107
4 IHS Global Insight, 1150 Connecticut Avenue N.W., Washington, DC 20036
5 Midwest Orthopaedics at Rush, 1611 West Harrison Street, Suite 400, Chicago, IL 60612
6 Oregon Health and Science University, 6485 S.W. Borland Road, Tualatin, OR 97062
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  • Disclosure statement for author(s): PDF

A commentary by John-Erik Bell, MD, MS, is linked to the online version of this article at jbjs.org.

Investigation performed at KNG Health Consulting, Rockville, Maryland



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Nov 20;95(22):1993-2000. doi: 10.2106/JBJS.L.01495
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Abstract

Background: 

Although rotator cuff disease is a common musculoskeletal problem in the United States, the impact of this condition on earnings, missed workdays, and disability payments is largely unknown. This study examines the value of surgical treatment for full-thickness rotator cuff tears from a societal perspective.

Methods: 

A Markov decision model was constructed to estimate lifetime direct and indirect costs associated with surgical and continued nonoperative treatment for symptomatic full-thickness rotator cuff tears. All patients were assumed to have been unresponsive to one six-week trial of nonoperative treatment prior to entering the model. Model assumptions were obtained from the literature and data analysis. We obtained estimates of indirect costs using national survey data and patient-reported outcomes. Four indirect costs were modeled: probability of employment, household income, missed workdays, and disability payments. Direct cost estimates were based on average Medicare reimbursements with adjustments to an all-payer population. Effectiveness was expressed in quality-adjusted life years (QALYs).

Results: 

The age-weighted mean total societal savings from rotator cuff repair compared with nonoperative treatment was $13,771 over a patient’s lifetime. Savings ranged from $77,662 for patients who are thirty to thirty-nine years old to a net cost to society of $11,997 for those who are seventy to seventy-nine years old. In addition, surgical treatment results in an average improvement of 0.62 QALY. Societal savings were highly sensitive to age, with savings being positive at the age of sixty-one years and younger. The estimated lifetime societal savings of the approximately 250,000 rotator cuff repairs performed in the U.S. each year was $3.44 billion.

Conclusions: 

Rotator cuff repair for full-thickness tears produces net societal cost savings for patients under the age of sixty-one years and greater QALYs for all patients. Rotator cuff repair is cost-effective for all populations. The results of this study should not be interpreted as suggesting that all rotator cuff tears require surgery. Rather, the results show that rotator cuff repair has an important role in minimizing the societal burden of rotator cuff disease.

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    References

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    Richard Mather III MD, Lane Koenig, PhD, Daniel Acevedo MD, Tim Dall MS, Paul Gallo BS, Anthony Romeo MD, John Tongue MD, Gerald Williams Jr MD
    Posted on January 31, 2014
    Response to Rotator cuff repair may not be cost-effective - complex economic models require careful analysis
    Duke University Medical Center & KNG Health Consulting

    We appreciate your thoughtful response to our paper and value the critical review you provided. Complex analyses such as ours are often misinterpreted and we appreciate you positing your critiques so that we may clarify these points for you and other readers. We would respond first by disagreeing with your statement that the outcome probabilities were based on expert opinion. In fact, very few inputs were based on expert opinion and furthermore, sensitivity analysis revealed that these variables did not significantly influence the results from the model.

    Furthermore, your analysis of our inputs is incorrect. We assumed all patients had 6 weeks of nonoperative treatment including a corticosteroid injection and supervised PT prior to entering the model – this is in contrast to your interpretation of 6 weeks of symptoms before entering the model. As such, the assumption that 68% of patients would get better with continued nonoperative treatment is quite conservative in our opinion. We assume an annual retear rate of 2% for previously healed rotator cuff repairs. This is consistent with published prospective ultrasound studies. We did model a counterfactual scenario of allowing no nonoperative patients to crossover to surgery – we did this to measure the full impact of rotator cuff repair as well as to model a situation of decreased access to rotator cuff repair. You criticize the retear rate we used in our model – in fact you state that the healing rate in a level 1 study is 76%. This is a critique that is highly misplaced and incorrect. We used a healing rate of 75%, consistent with both your data and that of published systematic reviews. We would also note that your recent RCT was not representative of the entire cohort undergoing rotator cuff repair – in fact you only examined the oldest half. The younger patients are likely higher demand and would incur greater indirect costs through lost productivity from impaired shoulder function.

    In summary, we are excited to have this dialogue and would highlight that in the conclusion of our paper we do not recommend that every rotator cuff tear should be surgically repaired. However, we also guard against reflexively limiting access to a treatment just because it appears to be highly utilized. We must consider all relevant information – including the economic impact of indirect costs. Our analysis aims to provide decision makers with all relevant information so that the best decisions are made for our patients and for society as a whole. Surgical repair and nonoperative treatment both clearly have important and valuable roles, and getting the right treatment to the right patient at the right time should be our ultimate goal.

    Juha Kukkonen, MD, PhD (1), Antti Joukainen, MD, PhD (2), Janne Lehtinen, MD, PhD (3), Kimmo T. Mattila, MD, PhD (4), Esa K. J. Tuominen, MD, PhD(4), Tommi Kauko, BSc (5), Ville Äärimaa, MD, PhD (1)
    Posted on January 21, 2014
    Rotator cuff repair may not be cost-effective
    See below

    Although the topic of this article is of great interest, we found the conclusions potentially misleading and scientifically questionable. In the article the authors state that the economic burden of rotator cuff tears to society is substantial, and that after six weeks of symptoms a rotator cuff repair is a cost-effective treatment for all age-groups. We argue that the use of sophisticated statistical tools do not justify the presented conclusions, as the outcome probabilities were based so heavily on expert opinion and therefore this paper does not establish hard scientific evidence.

    Mather et al. make several forward assumptions eg.: 68% of conservatively treated patients would be initially satisfied but this number would annually decrease by 9%. The authors also assume that annually only 2% of the successfully operated patients would get a symptomatic retear. Their analysis model assumed that the patients stayed within the designated treatment arm forever, and failed conservative treatment could not be converted to further operative approach. As stated in the article, the threshold analysis showed that the most important factors influencing the conclusions by the authors were: initial success rates, initial cost of treatment, and durability of the repair.

    We have recently performed a randomized controlled trial regarding the treatment of symptomatic non-traumatic rotator cuff tears in patients over 55 years of age[1]. In our one-year follow-up we found only subtle and non-significant differences in Constant score outcomes between the operatively and conservatively treated groups. Furthermore in our cohort of patients rotator cuff repair seemed to postpone the recovery, and was significantly more expensive compared to non-operative treatment. We found out that 87% of the conservatively and 95% of the operatively treated patients were satisfied with the treatment outcome. In another level I randomized controlled trial with one-year follow-up by Moosmayer et al., the authors found 82% satisfaction in the conservatively treated patients[2]. In the Moosmayer trial also traumatic tears were included and they found a significant difference in Constant score outcome in favor of surgical intervention. However, they observed non-healed cuff tendons in 24% of the repaired group at control imaging. To our knowledge the above mentioned studies are the only level 1 comparative superiority trials investigating the effectiveness of rotator cuff repair.

    Rotator cuff tear is not a distinct entity with regard to optimal treatment, and the overall relationship between symptoms and morphology is obscure. In fact the pronounced prevalence of asymptomatic tears could be interpreted as a sign of nonsignificance of the tear itself to patients' symptoms[3]. The global degeneration of aging human tissues is also noteworthy. As people get older the prevalence of rotator cuff tears increase, and this problem may not be solved by surgical means. As a consequence a high proportion of retears after surgical treatment is reported by experienced shoulder surgeons (also depreciated by Mather et al.)[4].

    In a recent article by Judge et al. the authors report the upsurging number of shoulder surgeries in England[5]. This is a worldwide phenomenon with no scientific evidence behind it. It seems that we are rather driven by marketing and economy than medicine. In case of a patient with six weeks of symptoms and imaging study showing a rotator cuff tear, the treating physician should do many further queries to untangle the question of optimal treatment for the patient. We look forward to further analyses on cost-effectiveness of rotator cuff surgery in different patient groups.  Before making extensive conclusions one should have better evidence on the comparative outcomes following treatments. We find Mather et al. being too prompt in their conclusions. After all, we should keep in mind that we are practising medicine and not business.

    REFERENCES
    1. Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EKJ, Kauko T, Äärimaa V. Treatment of non-traumatic rotator cuff tears. A randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96(1):75-81.
    2. Moosmayer S, Lund G, Seljom U, Svege I, Hennig T, Tariq R, Smith HJ. Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A randomised controlled study of 103 patients with one-year follow-up. J Bone Joint Surg Br. 2010 Jan;92(1):83-91.
    3. Milgrom C, Schaffler M, Gilbert S, van Holsbeeck M. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br. 1995 Mar;77(2):296-8. 4. Vastamaki M, Lohman M, Borgmastars N. Rotator cuff integrity correlates with clinical and functional results at a minimum 16 years after open repair. Clin Orthop Relat Res. 2013 Feb;471(2):554-61.5. Judge A, Murphy RJ, Maxwell R, Arden NK, Carr AJ. Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England. Bone Joint J. 2014 Jan;96(1):70-4.

    AUTHOR AFFILIATIONS
    1) Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
    2) Department of Orthopaedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
    3) Department of Orthopaedics and Traumatology, Hatanpää Hospital, Tampere, Finland
    4) Medical Imaging Centre of Southwest Finland, Turku University Hospital and Department of Diagnostic Radiology, University of Turku, Turku, Finland
    5) Department of Biostatistics, University of Turku, Turku, Finland

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