Drivers of Lower Inpatient Hospital Costs and Greater Improvements in Health-Related Quality of Life for Patients Undergoing Total Shoulder and Ream-and-Run Arthroplasty.

BACKGROUND: With increasing emphasis on value-based care and the heavy demands on the nation's health care budget, surgeons must be cognizant of factors that drive cost and quality of patient care. Our objective was to determine patient-level drivers of lower costs and improved health-related quality of life (HRQoL) in two anatomic shoulder arthroplasty procedures - total shoulder arthroplasty (TSA) and ream-and-run arthroplasty.

METHODS: 222 TSAs and 211 ream-and-run arthroplasties were included. Simple Shoulder Test (SST) scores, Single Assessment Numeric Evaluation (SANE), and Short-Form 36 (SF-36) scores were collected preoperatively and 2 years postoperatively. Quality adjusted life years (QALYs) were calculated as a measure of HRQoL. Univariate and multivariate analyses determined factors significantly associated with decreased hospitalization costs and improved HRQoL.

RESULTS: In the TSA group, female sex, lower ASA score, diagnoses other than capsulorrhaphy arthropathy, lower pain scores, and higher SANE scores were associated with decreased total hospitalization costs, and female sex was an independent predictor of lower total costs. Insurance other than worker's compensation, diagnosis of chondrolysis, and higher optimism led to greater QALY gains, but diagnosis of capsulorrhaphy arthropathy was the only independent predictor of greater QALY gains. In the ream-and-run group, older age, lower BMI, lower ASA score, insurance other than Medicaid, diagnoses other than capsulorrhaphy arthropathy, no history of previous surgery, higher preoperative SST scores, and higher preoperative SF-36 physical component summary scores were associated with lower total costs, and lower BMI was an independent predictor of lower costs. Higher preoperative optimism was an independent predictor of greater QALY gains.

CONCLUSIONS: Identifying factors associated with decreased costs and increased quality are becoming increasingly important in value-based care. This study identified fixed (sex, diagnosis) and modifiable (BMI) factors that drive decreased hospitalization costs and increased HRQoL improvements in shoulder arthroplasty patients. Higher preoperative patient optimism is a consistent predictor of improved HRQoL for both TSA and ream-and-run patients, and further study on optimizing the influence of patient expectations and optimism may be warranted.