JAAOS - 2026-08-12 - Journal Article
Patient-Level Value Analysis in Anatomic Total Shoulder Arthroplasty: Evaluating a One-Year Episode of Care.
Banfield NF, Puckett HD, Kleinsmith RM, Doxey SA, Dixon DT, Throckmorton TW, Brolin TJ, Cunningham BP
Topics
Key Takeaway
In 139 aTSA patients, implants accounted for 49% of total episode-of-care cost ($13,301 mean), and ASC setting reduced cost by $2,847 without a corresponding improvement in 1-year ASES scores.
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Summary
This study applied patient-level value analysis (PLVA) using time-driven activity-based costing (TDABC) to 139 primary aTSA patients at a single institution to quantify value as ASES improvement per cost unit. Mean 1-year ASES improvement was 32.1 points at a mean EOC cost of $13,301; implants alone comprised 49% of total cost. ASC setting predicted $2,847 lower cost, while inpatient stay and SNF discharge drove costs higher, with no corresponding outcome benefit from higher-cost pathways.
Key Limitation
Single-institution retrospective design with exclusion of complicated cases limits generalizability and underestimates true cost variance across practice settings and patient risk profiles.
Original Abstract
BACKGROUND
As the cost of anatomic total shoulder arthroplasty (aTSA) continues to rise, there is increasing pressure to optimize value through cost-effective care strategies. Patient-level value analysis (PLVA) is an emerging method that quantifies value as the change in patient-reported outcomes (PROs) relative to total cost. Although PLVA has been applied to other orthopaedic procedures, it has not been used to evaluate aTSA. This study aimed to assess 1-year value delivery in aTSA and identify characteristics that influence cost and outcomes.
METHODS
A retrospective cohort study was conducted using prospectively collected patient-reported outcome registries at one healthcare institution. Patients undergoing primary unilateral aTSA for osteoarthritis between 2018 and 2022 were included. Patients were excluded if they lacked preoperative or 1-year American Shoulder and Elbow Surgeons (ASES) scores or experienced complications or revisions. Episode-of-care (EOC) costs were calculated using time-driven activity-based costing (TDABC), including direct and indirect care costs. The value quotient (Vq) was defined as the change in ASES score divided by total EOC cost, multiplied by 100. Multivariate regression was used to assess predictors of cost, outcome, and value.
RESULTS
A total of 139 patients met inclusion criteria. The mean age was 67.8 years, and 54.4% were female. The average 1-year ASES improvement was 32.1 ± 24.9, and the mean EOC cost was $13,301±$3,137. Implants accounted for 49% of the total EOC cost. Surgeries in the ASC setting predicted lower cost (β = -$2,847; P < 0.001), whereas inpatient stay and SNF discharge were associated with higher costs. The average value quotient was 0.23 ± 0.19 for each patient.
CONCLUSION
Cost variability in aTSA is driven by surgical setting, implant selection, and discharge disposition. Higher costs do not correspond to better outcomes, highlighting opportunities to improve value by targeting modifiable cost drivers, particularly implant prices and use of postacute care facilities.