CORR Insights®: Is Advanced Imaging to Assess Rotator Cuff Integrity Before Shoulder Arthroplasty Cost-effective? A Decision Modeling Study

Where Are We Now? The concept of value-based healthcare has been around for well over a decade [8], and the term is now ubiquitous. Many of us may cringe at hearing the term “value-based practice because too often the discussion evolves into simple cost-cutting measures, loss of frontline personnel, limitations to adopting novel technologies, or additional hurdles or preapprovals for medical orders such as advanced imaging. Putting cynicism aside, there is important work to be done that requires the active input of clinicians to truly advance the value agenda. Although the idea of value-based healthcare is simple—better outcomes at lower costs—measuring those inputs with adequate accuracy to inform practice changes has proven difficult. Surgeons are often insulated from the costs of the resources we use. Outside of bundled payment models or ownership interests in ambulatory surgical centers, few incentives exist for us to be truly thoughtful about the costs of the resources we choose to use. Our training, traditions of practice, forms of reimbursement, and perhaps our medicolegal landscape all work against a cost-effectiveness mindset. Practice patterns and technology are rapidly changing, research output has seen exponential growth, and keeping up with clinical best practices can be daunting. Layering cost considerations on top of this requires first questioning our typical clinical practices and then robust research designs to appropriately integrate the cost variable into our decision-making processes. The authors of the current study [6] grapple with these topics. They compared the cost-effectiveness of additional soft-tissue advanced imaging (MRI or ultrasound) for decision-making related to shoulder arthroplasty in patients who had already undergone standard radiography and CT assessments. The authors rely heavily, and appropriately, on prior systematic reviews for many of the assumptions of the model, and used a base-case 65-year-old patient with a low likelihood of rotator cuff tear. Interestingly, despite a complex model, one takeaway conclusion is quite simple: have both an anatomic and reverse total shoulder system available for use in the operating room and allow intraoperative decision-making to guide the final treatment selection [2, 7]. Without the need for additional preoperative soft tissue imaging, this approach is cost-effective. This was reassuring to me because I often not only ensure the equipment for both options is available, but also counsel patients accordingly regarding the risks and benefits of each type of arthroplasty. Some underlying assumptions may not be valid for some practicing orthopaedic surgeons. For example, Levin et al. [6] defined the use of reverse total shoulder arthroplasty in a patient with an intact rotator cuff as an inappropriate outcome in their model. Some would argue and even advocate for reverse total shoulder arthroplasty in patients of a certain age, regardless of the status of the rotator cuff [10, 12]. Because reverse total shoulder arthroplasty in patients with an intact rotator cuff is controversial, we need additional cost-effectiveness models to account for our varied practice patterns. Where Do We Need To Go? Because there are so many complex questions on what we consider to be the standard practice and how we even measure costs [5], studies like this one [6] are useful to stimulate discussion and consider traditional practices, ones we may have presumed to be best clinical practice but are not the most cost-effective. Here, we have another example of a practice pattern that is rapidly changing or controversial, highlighting the need for multiple cost-effectiveness models to account for our varied practice patterns. We must continue to investigate clinically with cost-effectiveness research, and be willing to challenge the status quo. For example, do we need any advanced imaging at all, including CT? Can well-performed radiography suffice in patients with a high likelihood of an intact rotator cuff? Can we establish an algorithm based on demographic factors and historical and physical examination details that can help determine which patients require any advanced imaging? Many low-value services that have been targeted by value initiatives relate to routine imaging for uncomplicated conditions; for example, imaging for low-back pain within 6 weeks of symptoms in uncomplicated situations [7]. And looking beyond imaging, do we need interscalene blocks for all of our patients undergoing shoulder arthroplasty? Could local field blocks delivered by surgeons as part of surgery provide value to the patient and efficiency to the delivery of care? Does everyone need physical therapy after shoulder arthroplasty? What percentage of total shoulder arthroplasty can be done in the ambulatory surgery environment? These interventions—advanced imaging, interscalene blocks, physical therapy, and inpatient admission—remain routine for many of us. We need to understand whether we can and should be more selective. How Do We Get There? We can march towards value-based healthcare by asking these important questions and challenging existing assumptions. This can be uncomfortable, and it may involve moving against current incentives. For example, eliminating interscalene nerve blocks pits surgeons against the financial interests of anesthesiologists and may limit learning opportunities to gain the skill when interscalene blocks are appropriate. We must continue to embrace the complex and messy nature of value-based work, encourage complex model building and testing as done by Levin et al. [6] and others [3, 11], and continue to challenge the underlying assumptions that feed the models. We need to continue to better measure and define costs, outcomes, and relevant timeframes for those outcomes [5]. For example, to understand whether only radiographs are sufficient in a subset of patients undergoing shoulder arthroplasty, we could compare the outcomes radiographically and clinically (patient-reported outcomes) of surgeons who practice in these two different ways. With that quality metric appropriately measured, we can then outline a cost-effectiveness model, like Levin et al. have done, to determine the cost-effectiveness of each imaging approach. An algorithm or calculator might be required to determine who needs additional imaging, and we might benefit from machine learning and large database or registry data [1]. Regarding new technologies, we should insist on data that demonstrate value before adopting them widely. We are already beginning to do this at the local and health system level with value-analysis committees that are demanding more data before granting a new approval. Without surgeon representation on these committees to represent the interests of our patients and balance questions about quality, costs alone will drive the decision-making process. When there is inadequate quality information, limited approvals may be appropriate and surgeon engagement is again required so innovation can continue, but in the most responsible way. Cost awareness can be a simple first step as well. Firsthand knowledge at the time of ordering a test, for example, can modulate physician behavior and reduce costs [4], although not always [9]. Ultimately, to make meaningful progress, we must have the courage to be the first to engage in this difficult and complex work by actively engaging with local and health system value analysis committees. Surgeons and their patients are best suited to make complex decisions about healthcare. We need the research and cost data to serve as the foundation for these decisions so we may be responsible stewards of our resources. As Levin et al. [6] demonstrated, simply reducing care or tests is not always cost-effective. Overuse and underuse can be a problem and are affected by the costs of the test (see the MRI cost-sensitivity analysis in Levin et al.’s study [6]). I congratulate the authors, not for a perfect study or decision model, but for driving the discussion forward. If surgeons lead the way, we can have a more nuanced and fruitful discussion of value.