Longitudinal analysis of shoulder arthroplasty utilization, clinical outcomes, and value: a comparative assessment of changes in improvement over 15 years with a single platform shoulder prosthesis

Abstract

Background: The goal of this longitudinal analysis of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) utilization from 2007 to 2021 is to quantify changes in clinical outcomes, cost, and value, resulting from the introduction and adoption of new shoulder arthroplasty (SA) technologies.

Methods: We analyzed an international database of a single SA prosthesis (Equinoxe; Exactech, Inc.; Gainesville, FL, USA) for all clinical sites that have continuously enrolled cases from 2007 to 2021 to compare changes in primary aTSA and primary rTSA utilization and outcomes across 3, 5-year cohorts based upon the date of implantation. A value analysis was conducted across the 5-year implantation cohorts, with value measured by the ratio of each postoperative outcome measure at 24-36 months and 36-60 months after surgery, and the average implant selling price each year for the U.S. sites in constant 2007 U.S. dollars. These measures of value were compared between cohorts to quantify the impact of new technology introduced over the study period.

Results: A dramatic increase in rTSA utilization was observed across the 6 sites over the 15-year study period, along with a rapid adoption of new aTSA and rTSA technologies. The average patient receiving primary aTSA and primary rTSA changed over the 15-year study period, with significant shifts in diagnosis, comorbidities, and preoperative functional status. A comparison of postoperative results demonstrated that both aTSA and rTSA clinical and radiographic outcomes showed improvement relative to 2007-2011. Over this 15-year study period, the average aTSA implant selling price has been relatively stable while the average rTSA implant selling price has significantly declined. As a result, the value associated with the Equinoxe rTSA significantly increased for nearly every outcome measure at 24-36 months and 36-60 months after surgery, while value associated with the Equinoxe aTSA stayed relatively constant from 2007 to 2021.

Conclusion: Our 6042-patient longitudinal analysis quantified numerous changes in utilization, outcomes, and value across 6 clinical sites over the 15-year study period. Rapid adoption of new aTSA and rTSA technologies was observed and clinical and radiographic outcomes improved relative to 2007-2011. These clinical improvements, in combination with steady aTSA and declining rTSA implant prices, have driven rTSA value to continuously increase while aTSA value has been maintained at a high-level over the 15-year study period with this particular SA system, even when considering the cost and adoption of new technologies.

Keywords: Longitudinal outcomes analysis; cost analysis; shoulder arthroplasty outcomes; technology adoption; utilization analysis; value assessment.