Regarding "Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Arthroscopic Rotator Cuff Repair for Symptomatic Large and Massive Rotator Cuff Tears".

We read with great interest the article “Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Arthroscopic Rotator Cuff Repair for Symptomatic Large and Massive Rotator Cuff Tears” by Makhni et al.1Makhni E.C. Swart E. Steinhaus M.E. et al.Cost-effectiveness of reverse total shoulder arthroplasty versus arthroscopic rotator cuff repair for symptomatic large and massive rotator cuff tears.Arthroscopy. 2016; 32: 1771-1780Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar The treatment of massive rotator cuff tears is still debated. These lesions are usually associated with pain, disability, and, more uncommonly (unless a traumatic event occurs), pseudoparalysis. Biologic treatment such as arthroscopic complete or partial repair with tenotomy tenodesis is an attractive option. It is less invasive than replacement surgery and ensures the possibility of a further shoulder prosthesis in case of failure. Unfortunately, massive tears are more susceptible to re-rupture in this cohort of patients.2Zhao J. Luo M. Pan J. et al.Risk factors affecting rotator cuff retear after arthroscopic repair: A meta-analysis and systematic review.J Shoulder Elbow Surg. 2021; 30: 2660-2670Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Replacement surgery with both anatomic and reverse implants is gaining popularity since it ensures more reliable and longstanding outcomes.3Kääb M.J. Kohut G. Irlenbusch U. Joudet T. Reuther F. Reverse total shoulder arthroplasty in massive rotator cuff tears: Does the Hamada classification predict clinical outcomes?.Arch Orthop Trauma Surg. 2022; 142: 1405-1411Crossref PubMed Scopus (4) Google Scholar However, the economic implications are strong, especially in those countries in which the reimbursement of surgeries is provided by a national health system. In some European countries (for example, Italy), the public health system is based on a fixed reimbursement system called diagnosis-related group (DRG), which accounts for hospitalization, implantable devices, and physicians’ fees. This is a simple organization based on the patient’s pathologies and consequent surgical procedures. However, the system is highly biased by the different reimbursement provided for arthroscopic surgeries and open replacements. In the Italian DRG-based health system, the diagnosis of a cuff tear (small, medium, or massive) is 72761 and impingement syndrome is 72610. The surgical code for a rotator cuff repair procedure is 8363, which leads to DRG 224 with reimbursement of 4,303€ (data from Grouper DRG simulation). The diagnosis code, DRG, and reimbursement are set for an open rotator cuff repair procedure. When the procedure is performed arthroscopically, the code 8021 (arthroscopy) must be added to 8363, leading to a DRG 232 with an expected reimbursement for the whole operation of 1,333€. The reimbursement does not change according to the number of anchors implanted. Interestingly, when the rotator cuff repair is associated with an acromioplasty (code 8183), the DRG changes from 232 to 223, with a reimbursement increasing from 1,333€ to 3,041€. Therefore, the reimbursement of a massive rotator cuff repair in the population of the study by Makhni et al. would vary from 1,333€ to 3,041€. The DRG of an arthroscopic rotator cuff repair covers 2 nights of hospitalization (as decided by the health system) (600€), tools (480€ for burr and shaver, 290€ for an arthroscopic cautery device, and 44€ for 1 cannula), occupation of the operating room (300€ for 60 minutes), and “various” (100€ which include drugs, irrigation bags, sutures, surgical drapes, etc.). The number and type of anchors to be implanted depends on the tear pattern and repair technique; however, the cost of one of the most common double-loaded metallic anchors is 497€, whereas the cost of an absorbable double-loaded anchor is 540€ and the cost of a knotless anchor (for a double row repair) is 515€ (data from Mitek Italy). According to the tear pattern, the price for implanted materials may vary from 497€ (single metallic anchor) to 2,110€ for a double- row repair with 2 medial absorbable anchors and 2 lateral knotless anchors. The overall cost varies from 1,911€ to 3,524€. The reimbursement for such a procedure does not cover the costs, since it varies from 1,333€ (isolated repair) to 3,041€ (associated acromioplasty). The situation is completely different when a replacement procedure is performed in this cohort of patients. Although the initial diagnosis DRG code is the same: 72761 for cuff tear (small, medium, or massive) and 72610 for impingement syndrome, the surgical code is completely different. The code of the partial replacement (hemiarthroplasty) is 81.81 whereas the total replacement (anatomic or reverse) code is 81.80. Both codes lead to DRG 491, which reimburses 8,565€. The DRG 491 covers the hospitalization (2-3 nights) (600-900€), occupation of the operating room (300€ for 60 minutes), the implant (2,000€ for an hemiarthoplasty, 2,300€ for a total shoulder arthroplasty and 2,700€ for a reverse prosthesis) (data from Lima Italy) and “various” (2,000€, which include drugs, sutures, surgical drapes, sterile drapes, etc.), with an overall cost of 5,900€. Therefore, the overall cost of the arthroscopic repair varies from 1,911€ to 3,524€, and the reimbursement for such a procedure varies from 1,333€ (isolated repair) to 3,041€ (associated acromioplasty). The reimbursement just covers the expenses. When the fee for the surgeon and assistants is considered (9%-20% of the initial DRG of 1,911€ to 3,524€), it is evident that this procedure is not cost-effective for the hospital. In contrast, the overall costs of a shoulder replacement are 5,900€ (3 nights of hospitalization and reverse implant) with reimbursement of 8,565€. Even when the fee for the surgeon and assistants is considered (9%-20% of the initial DRG of 8,565€), it is evident that this procedure is much more cost effective for the hospital. It is evident that in a DRG-based public health system, the choice of the appropriate surgical treatment may be strongly affected by the administration of the hospitals, which have relevant interests in their economic convenience. Surgeons’ choices, which should primarily consider the individual patient’s benefits and outcomes with secondary consideration of social costs and economic reimbursement, are clearly influenced in this kind of system, with the risk of inappropriate treatments. Download .pdf (.51 MB) Help with pdf files ICMJE author disclosure forms