Health Economic Outcomes of Subacromial Balloon Spacer Implantation Across Surgical Care Pathways: A Propensity-Matched Analysis of German Statutory Insurance Claims

Background Massive irreparable rotator cuff tears are managed along a surgical spectrum from arthroscopic debridement to reverse shoulder arthroplasty (RSA). The biodegradable subacromial balloon spacer is a minimally invasive option with limited real-world payer-perspective comparative evidence. Objectives To quantify postoperative complications, payer reimbursement, and care-pathway utilization for balloon spacer implantation vs four surgical alternatives in routine statutory health insurance (SHI) practice. Methods Retrospective propensity-score-matched cohort analysis of anonymized claims from a German SHI database (~4.5 million insured). Adults treated surgically for rotator cuff pathology (ICD-10-GM M75.1) between 2017 and 2020 were included. Balloon spacer patients (n = 99) were matched 1:2 on propensity scores against RSA, open repair, arthroscopic repair, and debridement. Primary outcomes were 12- and 24-month complication rates and index hospitalization costs; secondary outcomes were shoulder-related sick leave and time to first physiotherapy. Results Balloon spacer hospitalization costs (€3502) were 65% lower than RSA (€9969) and modestly lower than open repair (€3829); arthroscopic repair (€3245) and debridement (€2464) were less expensive. Twelve-month complications were lower than RSA (1.3% vs 12.2%) and comparable to other comparators. Physiotherapy began earlier after balloon spacer (11.4 days) than RSA (27.6), open repair (20.0), or arthroscopic repair (18.1). In a small exploratory subgroup aged 60 to 64 years (n = 15 to 19 balloon spacer patients per comparison), sick leave duration and indirect costs were directionally lower for the balloon spacer, but these estimates are hypothesis-generating only. The balloon spacer occupied a cost-efficient position in the surgical care pathway, and the cost gap vs RSA was robust in an inpatient-only sensitivity analysis. Residual confounding by indication cannot be excluded. Conclusions Within a large German SHI dataset, balloon spacer implantation was associated with substantially lower direct hospitalization costs than RSA, comparable safety to less invasive alternatives, and earlier physiotherapy initiation. A subgroup signal of reduced indirect costs in working-age patients rested on very small samples and should be regarded as hypothesis-generating rather than as input for payer policy modeling. These findings support the device as a de-escalation option for appropriately selected patients in payer systems facing rising arthroplasty utilization.