“Value” in health care, as defined by Professor Michael Porter of Harvard Business School, is outcomes achieved per dollar spent [1]. Referencing this definition, emphasis is placed on the quantification and optimization of patient-centric outcome measures while minimizing costs. In the current economic and political climate, orthopedic surgeons can expect to come under increasing scrutiny to justify the value of therapeutic interventions, particularly new and/or expensive ones. Much of the pressure to justify interventions stems from the increasingly unsustainable burden of healthcare costs in the US. The health share of the GDP was 17.2 % in 2012 and is expected to grow to 19.8 % of the GDP by 2020 [2].

Therapeutic intervention of shoulder pathology constitutes a significant portion of these health expenditures, with 18.9 million Americans (8.2 % of the population) complaining of chronic shoulder pain in 2008 [3]. Further, shoulder pain constitutes 30.6 % of all chronic joint complaints and is a significant burden on society in terms of lost productivity, medical office visits, hospitalizations, and the cost of interventions. Given the prevalence of shoulder pathology and its impact on healthcare costs, an immediate opportunity exists for orthopedic surgeons to act as leaders in healthcare reform by critically demonstrating the value of shoulder procedures.

The reverse shoulder arthroplasty (RSA) is one intervention that provides orthopedic surgeons with the opportunity to apply value-driven principles to therapeutic care. Previously trending toward clinical irrelevance due to poor patient outcomes and high failure rates, the RSA was revolutionized in 1985 following introduction of the Grammont prosthesis [4]. By establishing a medialized and distalized prosthesis and reversing the anatomic ball and socket relationship, Grammont reintroduced the RSA as a viable clinical option for the rotator cuff-deficient arthritic shoulder.

Despite introduction in Europe during the 1980s, the modern iteration of the RSA did not receive US Food and Drug Administration (FDA) approval until 2003. Since that time, use and application of the RSA has dramatically expanded. Several studies have demonstrated clinical benefit not only in the cuff-deficient arthritic shoulder but also as treatment for proximal humerus fractures in the elderly, severe rotator cuff deficiency, and in revision surgery [5–10]. From 1993 to 2003, the number of shoulder arthroplasties increased by an average of 373 per year.  Kim et al. [11] demonstrated a sharp rise in the incidence of shoulder arthroplasties throughout the United States between 2003 and 2004. After 2004, that number increased to 2922 additional shoulder replacements per year. It is assumed that a large driver of this dramatic increase was the US approval of the RSA in late 2003 coupled with expanded indications [11]. By 2007, nearly 10,000 RSAs were performed in the USA annually [12] as the calculated growth rate of RSA exceeded that of hip and knee replacements [13]. Despite the decreasing rate of revision hip arthroplasty between 2001 and 2010, the population-based incidence of revision total shoulder replacements in the state of New York increased 288 % from 1993 to 2010 [14]. As the use and indications for RSA expand, it can be expected that a greater percentage of revision total shoulder replacements will involve RSA.

Despite the increasing rate RSA, orthopedic surgeons have just recently begun to critically analyze the value of this procedure. As noted by Kevin Bozic, current healthcare delivery and payment systems are “value-agnostic,” with physician incentives based on volume with scant financial motivation to improve outcomes or reduce costs [15]. There is little onus to focus on quality and patient-centric outcome measures. As a result, variation in rates, indications, and costs persist for many orthopedic procedures, including RSA.

At the Boston Shoulder Institute, we advocate a unique patient–focused method to shoulder care. Our approach is centered on three principles advanced by Porter and Teisberg [16, 17].

This approach, with an emphasis on patient value through the measurement of outcomes and the associated costs of care, requires a fundamental shift in how caregivers and organizations select treatment options. In the United States, RSA represents a relatively new technology and provides an opportunity to apply this patient-focused approach to a burgeoning area of orthopedic surgery.

Historically, economic evaluations have been poorly represented in orthopedic literature. Brauer et al. [18] found only 37 studies published between 1976 and 2001 that examined cost utility, with outcomes reported as costs per quality-adjusted life-years (QALY). Mathematically, the QALY is a product of life expectancy and the quality of remaining life-years. It is a valuation of health benefit and allows calculation of the relative economic worth of interventions, centered around impact on a patient’s quality of life. The Brauer study found significant variability across research methodologies, with only 5 of the 37 studies including four key criteria determined by the US Panel for cost-effectiveness in health and medicine as relevant to cost analysis. Only three of these studies were related to the upper extremity. Most of the studies also failed to breach the $50,000 threshold per QALY that is considered cost-effective [18]. In 2012, Kuye et al. [19] performed a MEDLINE search for “cost” or “economic” combined with terms for several shoulder disorders. His group found 32 economic evaluations, of which 53 % had been published between 2005 and 2010. Only 8 of these studies matched with all six principles developed by Udvarhelyi et al. [20] to evaluate the quality of economic evaluations.

Udvarhelyi et al’s six fundamental principles of cost-effectiveness analysis [20].

Given the paucity of research related to RSA costs specifically, recent studies have attempted to quantify the value afforded by this operation [21]. Although initial clearance was for rotator cuff arthropathy, the RSA has seen increasing off label use. Despite this, comprehensive data on variable use, underlying costs, and overall cost-effectiveness of the RSA remains limited.

Proper data collection and analysis of the RSA procedure will be the cornerstone for indications of various applications. High variability in the use of specific procedures between surgeons and institutions elicit concerns for appropriate indications, incentives, and cost structures. A critical view of application is an essential element of quality improvement. Patient-focused clinical outcomes coupled with cost data should drive utilization, yet the lack of arthroplasty registries and universal outcome measures limits the development of cost-effective protocols.

Scant data exists regarding the use of RSA in the Unites States. Through a retrospective supply chain analysis, Boguski et al. [22] looked at variation in RSA use across hospitals. They found amongst 100 hospitals, the total RSA cases in one year varied from 0 to 172. The percentage of RSA as a fraction of the total number of shoulder arthroplasties performed at each hospital ranged from 0 to 100 % with a mean of 42.3 % and a standard deviation of 27.8. Perhaps unsurprisingly, high-volume hospitals had lower variation in prosthesis selection.