Gerald R. Williams, MD

Transcription

1 Reverse Arthroplasty: Is Overutilization a Problem? Gerald R. Williams, MD John M. Fenlin, Jr, MD Professor of Shoulder and Elbow Surgery The Rothman Institute Jefferson Medical College

2 Royalties Conflict of Interest Slide Depuy: shoulder arthroplasty Lippincott, Williams, and Wilkins: shoulder texts IMDS/Cleveland Clinic: arthroplasty Research: Tornier, Depuy, Synthasome Stock Ownership: In-vivo therapeutics, ForMD, CrossCurrent Business Analytics, LLC, OBERD, LLC, Force Therapeutics

3 Constrained Implants Early experience s Miserable experience with multiple imlants Post, Fenlin, Neer and Averil, etc. 50 % infection rate Frequent and early failure Loosening Fracture Dislocation

4 Modern Day Reverse Paul Grammont 1985 Dijon, France

5 Delta III (Grammont 1987) How is it Different? Large sphere, no neck Medialized center Valgus neck-shaft angle (155 degrees)

6 Results

7 Complications Higher than anatomic implants, lower than previous constrained implants Complications Dislocation Infection Notching Acromial stress fracture Humeral/glenoid fracture Components unscrewing Loosening (survivorship)

8 Werner, Gerber, et.al Total complication rate 50% Reoperation rate 33% Primary cases 18% Revisions 39% Hematoma most common complication

9 Early Experience Reverse arthroplasty is a salvage procedure for severe shoulder dysfunction caused by an irreparable rotator cuff tear associated with other glenohumeral lesions. --Werner CM, Steinmann PA, Gilbart M, Gerber C. J Bone Joint Surg Am 2005;87: Reverse arthroplasty should be used exclusively in patients over seventy years old with low functional demands. Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. J Bone Joint Surg Am 2006;88:

10 American Experience Relatively few published series Generally lower complication rate Benefit of European learning curve Still high relative to anatomic implant

11 Expanding Indications Revision CTA Malunion/nonunion RA Tumor Osteoarthritis with cuff tear Osteoarthritis with intact cuff and bone deformity Post-traumatic arthritis Cuff tear without arthritis

12 Market Impact Kim SH, Wise BL, Zhang Y, Szabo RM. J Bone Joint Surg Am 2011;93:

13 Utilization Of Reverse Total Shoulder Arthroplasty In The Medicare Population Judd S Day E. Scott Paxton, MD Edmund Lau Victoria A Gordon, BA Joseph A. Abboud, MD Gerald R. Williams Jr, MD

14 Medicare Database 40 million persons aged >65 yo Largest single insurer for the elderly Claims data previously used to examine THA, TKA and TSA utilization 2011 Medicare Part A claims data allows for the examination of the utilization of TSA, shoulder hemiarthroplasty (SHA) and RSA in United States separate code added for RSA in 2010

15 Purpose and Hypothesis Purpose: Examine/compare utilization of RSA to TSA and SHA in Medicare population in USA provide data on potential impact of cost Hypothesis: RSA accounts for a substantial percentage of shoulder arthroplasties performed in Medicare population RSAs are implanted for a variety of diagnoses, in addition to cuff tear arthropathy

16 Methods 100% sample of Medicare claims (Part A) for patients > 65 yo from 1/1/ /31/2010 evaluated Patient demographics, diagnoses, provider information, reimbursement & length of stay data were also extracted Diagnoses categorized into one of 9 categories: Osteoarthritis, Inflammatory Arthritis, Traumatic Arthropathy/Non- Rheumatoid Arthropathy, Rotator Cuff Tear, Fracture/Dislocation, Late Fracture Sequelae, Aseptic Necrosis, Mechanical Complication, Other Patients evaluated for 1 o diagnosis and any 2 o diagnoses Provider data analyzed for procedure volume Medicare procedure counts also compared to those reported by the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS)

17 Comparative Demographic Data from the National Inpatient Survey Procedure RSA TSA SHA Total Age Group Sex Payer y.o y.o y.o. 85+ y.o. Male Female Medicare Medicaid Private Uninsured Other Discharges St Error Discharges St Error Discharges St Error 21,916 (100.00%) 83 (0.38%) 3,948 (18.02%) 16,141 (73.65%) 1,713 (7.81%) 7,868 (35.90%) 14,002 (63.89%) 17,215 (78.55%) 314 (1.43%) 3,291 (15.02%) 128 (0.58%) 878 (4.00%) 1,589 29,414 (100.00%) (1.95%) 430 9,923 (33.74%) 1,132 18,024 (61.28%) (2.89%) ,483 (49.24%) ,855 (50.50%) 1,209 18,468 (62.79%) (1.77%) 335 9,152 (31.11%) (0.34%) 108 1,028 (3.49%) The NIS database demonstrated that 79% of all RSAs, 63% of TSAs, and 60% of SHAs were performed in patients who were older than 65 Our Medicare sample included those patients who were >65 yo AND with Medicare Part A (not Part C Medicare Advantage) 1,665 15,860 (100.00%) (5.69%) 647 5,507 (34.72%) 1,007 8,126 (51.23%) 82 1,271 (8.02%) 903 5,890 (37.14%) 813 9,902 (62.44%) 1,031 9,570 (60.34%) (4.39%) 657 4,483 (28.27%) (1.69%) (4.96%)

18 Volume All Surgeons 10 per yr > 10 per yr TSA RSA SHA Total

19 Procedural Volumes Surgeon Volume RSA TSA SHA All (RSA+TSA+SHA) Proportion Count Proportion Count Proportion Count Proportion Count % 4,016 45% 5,982 88% 5,613 32% 9, % 2,519 20% 2,627 9% % 5, % 2,472 18% 2,432 2% % 5,796 >20 22% 2,473 16% 2,111 0% 0 31% 9,497 70% RSAs are implanted by surgeons who perform more RSAs than THAs + SHAs 30% of RSAs are implanted by surgeons who perform 3x as many RSAs as THAs + SHAs 57% of all RSAs done by surgeons who do 10 or less a year

20 Analysis of Diagnosis Codes RSA TSA SHA Primary Dx Any Dx Primary Dx Any Dx Primary Dx Any Dx Osteoarthritis 45.3% 58.8% 91.2% 93.1% 37.2% 46.0% Inflammatory Arthritis 0.7% 7.2% 0.7% 5.3% 0.6% 5.7% Arthropathy/Traumatic Arthropathy - non RA 14.7% 20.2% 3.5% 4.1% 3.2% 4.5% RTC tear 20.7% 52.8% 1.0% 11.4% 2.9% 15.6% Fracture/ Dislocation 11.4% 12.9% 1.4% 2.1% 44.5% 48.0% Fracture Sequlae 2.3% 3.9% 0.3% 0.7% 2.9% 4.1% Aseptic Necrosis 0.6% 1.8% 1.0% 1.9% 2.1% 3.6% Mechanical Failure 1.8% 2.2% 0.2% 0.3% 1.3% 1.9% Other 2.5% 0.8% 5.5% 27% of RSA are implanted for osteoarthritis with an intact rotator cuff

21 Medicare population demographic and admission related data Procedure RSA TSA SHA n 11,480 13,152 6,370 Gender Male Female Age Average St Dev Admission Type Emergency Urgent Elective Other Length of Stay Average St Dev Payment Average St Dev 34% 66% % 6% 90% 1% $12,625 $4,619 Reported average sales price is approximately $10,000 for reverse total shoulder implants, and ranges from $4000 to $9000 for anatomic shoulder implants ONN: A 2011 Extremity Update. Orthopedic Network News, 22(1): 9-12, % 58% % 4% 94% 1% $11,989 $4,416 27% 73% % 10% 69% 1% $12,958 $5,906

22 Conclusions RSA is performed with similar frequency to TSA and almost twice as much as SHA in the Medicare population Lower volume surgeons perform most reverse total shoulders A substantial number of surgeons perform more reverses than anatomic and hemi shoulder arthroplasties combined (overutilization?) 22% of RSA with intact cuff (overutilization?) Cost/reimbursement ratio not sustainable

23 THANK YOU.