Background 

Shoulder arthroplasty is increasingly performed for patients with symptoms of glenohumeral arthritis. Advanced imaging may be used to assess the integrity of the rotator cuff preoperatively because a deficient rotator cuff may be an indication for reverse shoulder arthroplasty (RSA) rather than anatomic total shoulder arthroplasty (TSA). However, the cost-effectiveness of advanced imaging in this setting has not been analyzed.

Questions/purposes 

In this cost-effectiveness modeling study of TSA, all patients underwent history and physical examination, radiography, and CT, and we compared (1) no further advanced imaging, (2) selective MRI, (3) MRI for all, (4) selective ultrasound, and (5) ultrasound for all.

Methods 

A simple chain decision model was constructed with a base-case 65-year-old patient with a 7% probability of a large-to-massive rotator cuff tear and a follow-up of 5 years. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness to pay of both USD 50,000 and 100,000 per quality-adjusted life year (QALY) used, in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. Diagnostic test sensitivity and specificity were extracted from published systematic reviews and meta-analyses, and patient utilities were obtained using the Cost-Effectiveness Analysis Registry from the Center for the Evaluation of Value and Risk in Health. Final patient states were categorized as either inappropriate or appropriate based on the actual rotator cuff integrity and type of arthroplasty performed. Additionally, to evaluate the real-world impact of intraoperative determination of rotator cuff status, a secondary analysis was performed where all patients indicated for TSA underwent intraoperative rotator cuff examination to determine appropriate implant selection.

Results 

Selective MRI (ICER of USD 40,964) and MRI for all (ICER of USD 79,182/QALY) were the most cost-effective advanced imaging strategies at a willingness to pay (WTP) of USD 50,000/QALY gained and 100,000/QALY gained, respectively. Overall, quality-adjusted life years gained by advanced soft tissue imaging were minimal: 0.04 quality-adjusted life years gained for MRI for all. Secondary analysis accounting for the ability of the surgeon to alter the treatment plan based on intraoperative rotator cuff evaluation resulted in the no further advanced imaging strategy as the dominant strategy as it was the least costly (USD 23,038 ± 2259) and achieved the greatest health utility (0.99 ± 0.05). The sensitivity analysis found the original model was the most sensitive to the probability of a rotator cuff tear in the population, with the value of advanced imaging increasing as the prevalence increased (rotator cuff tear prevalence greater than 12% makes MRI for all cost-effective at a WTP of USD 50,000/QALY).

Conclusion 

In the case of diagnostic ambiguity based on physical exam, radiographs, and CT alone, having both TSA and RSA available in the operating room appears more cost-effective than obtaining advanced soft tissue imaging preoperatively. However, performing selective MRI to assess rotator cuff integrity to indicate RSA or TSA is cost-effective if surgical preparedness, patient expectations, and implant availability preclude the ability to switch implants intraoperatively.

Level of Evidence 

Level III, economic and decision analysis.

中文翻译：

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在肩关节置换术之前使用高级成像评估肩袖完整性是否具有成本效益？决策建模研究

背景 

肩关节置换术越来越多地用于患有盂肱关节炎症状的患者。先进的成像可用于术前评估肩袖的完整性，因为肩袖缺陷可能是反向肩关节置换术（RSA）而不是解剖性全肩关节置换术（TSA）的指征。然而，尚未分析这种情况下先进成像的成本效益。

问题/目的 

在这项 TSA 成本效益模型研究中，所有患者均接受了病史和体格检查、放射线检查和 CT，我们比较了 (1) 没有进一步的高级成像，(2) 选择性 MRI，(3) 所有人 MRI，(4)选择性超声，(5) 全民超声。

方法 

以一名 65 岁患者为基础案例构建了一个简单的链式决策模型，该患者发生大面积肩袖撕裂的可能性为 7%，并进行了 5 年的随访。根据第二届健康和医学成本效益专家组的规定，使用增量成本效益比 (ICER) 与愿意为每个质量调整生命年 (QALY) 支付 50,000 美元和 100,000 美元的策略进行比较。诊断测试的敏感性和特异性是从已发表的系统评价和荟萃分析中提取的，患者效用是使用健康价值和风险评估中心的成本效益分析注册表获得的。根据实际肩袖完整性和所进行的关节置换术类型，最终患者状态被分类为不适当或适当。此外，为了评估术中确定肩袖状态的实际影响，我们进行了二次分析，其中所有需要 TSA 的患者均接受了术中肩袖检查，以确定合适的植入物选择。

结果 

选择性 MRI（ICER 为 40,964 美元）和所有人 MRI（ICER 为 79,182 美元/QALY）是最具成本效益的先进成像策略，支付意愿 (WTP) 分别为 50,000 美元/QALY 和 100,000 美元/QALY 。总体而言，通过先进软组织成像获得的质量调整生命年是最小的：MRI 为所有人获得了 0.04 质量调整生命年。考虑到外科医生根据术中肩袖评估改变治疗计划的能力的二次分析导致不再将先进的成像策略作为主导策略，因为它成本最低（23,038 美元±2259 美元）并实现了最大的健康效用（0.99±0.05）。敏感性分析发现，原始模型对人群中肩袖撕裂的概率最敏感，随着患病率的增加，高级成像的价值也随之增加（肩袖撕裂患病率大于 12%，使得 MRI 对所有人来说都具有成本效益）支付意愿为 50,000 美元/QALY）。

结论 

如果仅根据体检、X 光片和 CT 诊断结果不明确，那么在手术室同时使用 TSA 和 RSA 似乎比术前获得先进的软组织成像更具成本效益。然而，如果手术准备、患者期望和植入物可用性妨碍了术中更换植入物的能力，则执行选择性 MRI 来评估肩袖完整性以指示 RSA 或 TSA 是具有成本效益的。

证据水平 

第三级，经济和决策分析。