TheSocietalandEconomicValue of Rotator Cuff Repair

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1 1993 COPYRIGHT Ó 2013 BY THE JOURAL OF BOE AD JOIT SURGERY, ICORPORATED TheSocietalanEconomicValue of Rotator Cuff Repair Richar C. Mather III, MD, Lane Koenig, PhD, Daniel Aceveo, MD, Timothy M. Dall, MS, Paul Gallo, BS, Anthony Romeo, MD, John Tongue, MD, an Geral Williams Jr., MD Investigation performe at KG Health Consulting, Rockville, Marylan Backgroun: Although rotator cuff isease is a common musculoskeletal problem in the Unite States, the impact of this conition on earnings, misse workays, an isability payments is largely unknown. This stuy examines the value of surgical treatment for full-thickness rotator cuff tears from a societal perspective. Methos: A Markov ecision moel was constructe to estimate lifetime irect an inirect costs associate with surgical an continue nonoperative treatment for symptomatic full-thickness rotator cuff tears. All patients were assume to have been unresponsive to one six-week trial of nonoperative treatment prior to entering the moel. Moel assumptions were obtaine from the literature an ata analysis. We obtaine estimates of inirect costs using national survey ata an patient-reporte outcomes. Four inirect costs were moele: probability of employment, househol income, misse workays, an isability payments. Direct cost estimates were base on average Meicare reimbursements with ajustments to an all-payer population. Effectiveness was expresse in quality-ajuste life years (QALYs). Results: The age-weighte mean total societal savings from rotator cuff repair compare with nonoperative treatment was $13,771 over a patient s lifetime. Savings range from $77,662 for patients who are thirty to thirty-nine years ol to a net cost to society of $11,997 for those who are seventy to seventy-nine years ol. In aition, surgical treatment results in an average improvement of 0.62 QALY. Societal savings were highly sensitive to age, with savings being positive at the age of sixty-one years an younger. The estimate lifetime societal savings of the approximately 250,000 rotator cuff repairs performe in the U.S. each year was $3.44 billion. Conclusions: Rotator cuff repair for full-thickness tears prouces net societal cost savings for patients uner the age of sixty-one years an greater QALYs for all patients. Rotator cuff repair is cost-effective for all populations. The results of this stuy shoul not be interprete as suggesting that all rotator cuff tears require surgery. Rather, the results show that rotator cuff repair has an important role in minimizing the societal buren of rotator cuff isease. Approximately 4.5 million patient visits relate to shouler pain occur each year in the Unite States 1. Disorers of the rotator cuff range from painful rotator cuff synromes to full-thickness tears of varying sizes an functional limitations 2. Outcomes for rotator cuff tears improve with both surgical an nonsurgical treatment 3. Disclosure: One or more of the authors receive payments or services, either irectly or inirectly (i.e., via his or her institution), from a thir party in support of an aspect of this work. In aition, one or more of the authors, or his or her institution, has ha a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. Also, one or more of the authors has ha another relationship, or has engage in another activity, that coul be perceive to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitte by authors are always provie with the online version of the article. With the aging of the U.S. population an increase labor force participation of the elerly, the buren of rotator cuff tears in the U.S. is an important issue. Using outpatient ata from Colorao, Floria, Marylan, ew Jersey, ew York, an Wisconsin in the State Ambulatory Surgery Databases, Healthcare Cost an Utilization Project, Agency for Healthcare Research A commentary by John-Erik Bell, MD, MS, is linke to the online version of this article at jbjs.org. J Bone Joint Surg Am. 2013;95:

2 1994 Fig. 1 Moel schematic iagram of rotator cuff repair treatment pathways. While not inicate irectly in the iagram, patients are assume to ie on the basis of all-cause mortality, at which time they exit the moel an enter a health state of eath that is assigne no aitional cost or utility. TxT = treatment. an Quality, we fin that more than two-thirs of patients treate with rotator cuff repair are of working age 4. In aition, the prevalence of rotator cuff tears increases with age 5.Despite these factors, few stuies have examine the buren of rotator cuff tears an the economic impact of treatment is largely unknown. Societal costs of a meical conition inclue irect an inirect costs. Direct costs are those associate with iagnosis an treatment, while inirect costs inclue lost income ue to inability to work or lower wages, misse workays, an isability payments. The purpose of this stuy was to etermine the value of operative treatment for rotator cuff tears, with value etermine by reuctions in costs to society from rotator cuff repair compare with nonoperative treatment. Markov moels are commonly use in cost-effectiveness analysis. In assessing the value of rotator cuff

3 1995 repair, these moels are useful because long-term clinical stuies o not exist an the risk of an outcome is continuous over time. By taking a societal perspective, we estimate the costs an benefits of rotator cuff repair to patients, employers, an payers. Materials an Methos General Moel Overview We investigate the cost-effectiveness of rotator cuff repair compare with nonoperative treatment for symptomatic full-thickness rotator cuff tears using the Markov ecision moel presente in Figure 1. Cost-effectiveness is estimate from the societal perspective for the cohort in the U.S. unergoing rotator cuff repair. Outcome an state transition probabilities (i.e., treatment success rates, revision rates, an complications) were obtaine from the literature or estimate on the basis of the expert opinion of five orthopaeic surgeons when ata were not available. The cycle length was one year, an the moel cycle until patient eath. The primary effectiveness outcome was expresse in qualityajuste life years (QALYs), an costs were estimate in 2013 U.S. ollars. Both costs an utilities were iscounte at 3% to reflect their present value, as is stanar practice in cost-effectiveness research 6. The moel an analysis were performe in accorance with the consensus-base recommenations for the conuct of cost-effectiveness analysis avocate by the Panel on Cost- Effectiveness in Health an Meicine of the U.S. Public Health Service an using a general ecision analysis software package (TreeAge Pro Suite 2011; TreeAge Software, Williamstown, Massachusetts). Moel Structure an Assumptions Our ecision tree consists of two primary treatment arms (Fig. 1). Patients with a symptomatic full-thickness rotator cuff tear unerwent either open or arthroscopic rotator cuff repair or continue to receive nonoperative treatment. Patients in both treatment arms were assume to have unergone an average of six weeks of nonoperative treatment prior to this initial ecision point. After initial treatment, the moel assumes that iniviuals remaine in a postproceure state for one year, which accounts for the costs an limitations of treatment an recovery as well as any complications. Postoperative complications after rotator cuff repair inclue infection, ahesive capsulitis, an retear or nonheale rotator cuff repair. After one year, the moel transitions all rotator cuff repairs into one of four health states: (1) heale rotator cuff repair (symptomatic an asymptomatic), (2) asymptomatic retear, (3) symptomatic retear, or (4) eath. Patients in the nonoperative treatment arm entere one of three health states: (1) symptomatic tear, (2) asymptomatic tear, or (3) eath. Patients in the rotator cuff repair arm who ha not heale in the first year, or who experience a late retear, coul choose to unergo revision surgery consisting of ebriement only or reconstruction. Patients who experience a heale rotator cuff repair coul have a retear at rates consistent with the general population 5. In the nonoperative treatment arm, patients who initially respone to treatment may have experience a recurrence of symptoms an coul unergo another six-week course of nonoperative treatment, succeeing with this treatment at the base rate outline below. Patients who ha failure of nonoperative treatment i not unergo repeat treatment an remaine symptomatic for the remainer of the moel. Because the focus of the stuy was on the value of receiving surgical treatment for rotator cuff tears, patients in the nonoperative treatment arm were not allowe to cross over to the surgical arm. Moel assumptions are provie in Table I. Population an Mortality Rates The moel was run with several populations, ranging from thirty to eighty years ol. A population representative of the annual incience of rotator cuff repair in the U.S. was use for the base case. All-cause mortality was from the Centers for Disease Control an Prevention life tables. o surgical mortality was moele. Utilities Utilities, which represent an iniviual s preferences for specific health outcomes, are erive from the Short Form-12 (SF-12) with the SF-6D (a preference-base TABLE I Moel Assumptions for Rotator Cuff Repair Base Case Health state utility* (QALY) Heale RCR 0.74 (0.13) Symptomatic RCT 0.66 (0.12) Asymptomatic RCT 0.74 (0.13) Transition probabilities Healing rate with RCR 75% Success of nonoperative 68% treatment Initial rate of symptom 5% evelopment after retear Long-term retear rate 2% Rate of symptom evelopment 8.8% in RCT Rate of stiffness after RCR 2.5% Rate of infection 0.1% Rate of irreparable rotator 10% cuff at revision Death Life tables Cost onoperative treatment $1802 RCR $15,063 Infection $12,131 Stiffness $11,323 Disutility* (QALY) RCR 0.02 Infection 0.05 Stiffness 0.10 Miscellaneous Discount rate 3% Age istribution (mean an 56 ± 13.5 stan. ev.) (yr) *The values are given as the mean quality-ajuste life years (QALYs), with the stanar eviation in parentheses. RCR = rotator cuff repair, an RCT = rotator cuff tear. Annual rate. All-cause mortality was from the Centers for Disease Control an Prevention life tables. The values are given as the cost per episoe. six-imensional health state classification) 7. Preoperative SF-12 values were prospectively measure from a cohort of ninety-five patients (mean age, 55.4 years [range, thirty-one to seventy-eight years]; 61% male) who receive a primary rotator cuff repair performe by an experience, shouler an elbow fellowship-traine orthopaeic surgeon at a major acaemic meical center. Minimum follow-up was one year, with the last value carrie forwar for patients whose last follow-up was at six months. The ifference between the mean utility (an stanar eviation) at the preoperative (0.66 ± 0.11 QALY) an postoperative evaluation (0.74 ± 0.13 QALY) was 0.08 QALY, which was above the minimum clinically important ifference of 0.03 QALY 8.Patientswitharotatorcufftearresponing to nonoperative treatment were assume to have the same utility as operatively treate patients; however, operatively treate patients experience a isutility of surgery of 0.02 QALY because of postoperative pain an inconvenience of recovery. Asymptomatic retears were also assume to have the utility of a heale

4 1996 TABLE II Results of the Base Case: Mean Societal Impact of Rotator Cuff Repair* Age Group et Societal Savings (A) QALY (B) Incremental Cost-Effectiveness Ratio (A/B) U.S. population $13, Dominant yr $77, Dominant yr $49, Dominant yr $18, Dominant yr $ $12,024/QALY yr $11, $36,576/QALY *et societal savings represent the ifference in total lifetime costs (the irect costs of treatment an inirect costs, such as lost wages) between the rotator cuff repair an nonoperative treatment. Positive numbers represent economic savings, an negative numbers represent economic losses. A strategy is terme ominant when it is both less costly an more effective. All savings are expresse in 2013 U.S. ollars. QALY = quality-ajuste life year. rotator cuff. Utility was expresse as QALYs. More etail on utility can be foun in the Appenix. Rotator Cuff Healing Rates an Complications For the spectrum of full-thickness rotator cuff tears, a systematic review of thirteen stuies by Slabaugh et al. showe that healing rates range from 55% to 88%, with an average of 79% 9. This average rate is similar to the 75% rate reporte by ho et al. on a prospective cohort of rotator repairs examine at two years with ultrasoun 10,11. Because the latter stuy allowe greater etail for subsequent analysis, 75% was chosen as the base case value, an rigorous sensitivity analyses were performe aroun this input. Because no literature exists on the percentage of retorn rotator cuff repairs becoming symptomatic, it was estimate by expert opinion. Of the rotator cuff repairs that ha a retear, 5% were assume to become substantially symptomatic annually an were assigne a utility of 0.66 QALY (symptomatic rotator cuff tear). Long-term retear rates of heale rotator cuff repairs are not well establishe in the literature. Expert opinion suggeste that they occur at rates consistent with rotator cuff tears in the general population. As such, long-term retear rates were base on age an were taken from the population stuy reporte by Yamamoto et al. 5. For complications, we assume rates for stiffness (2.5%) an infection (0.1%) following rotator cuff repair on the basis of the available literature 12,13. Outcomes with onoperative Treatment There are few high-quality stuies on outcomes of nonoperative treatment for rotator cuff tears. Most stuies from the literature review ha sample sizes of <100 an were prospective or retrospective cohort stuies. These prouce a range of satisfaction rates, from 15% to 90% A 2004 literature review by Gomoll et al. 17 note that pain relief an restoration of function ha been observe in 62% to 74% of patients with symptomatic rotator cuff tears confirme through magnetic resonance imaging (MRI) or other imaging stuies 14,17,18. Our stuy assume 68%, the mipoint of the 62% to 74% range reporte, as the rate of satisfactory outcome for nonoperative treatment. Long-Term Outcomes There are a limite number of stuies on the long-term outcomes of rotator cuff isease. Yamaguchi et al. reporte that 40% of patients with asymptomatic tears ha progression of tear size at an average of 5.5 years 19,whereasMamanetal. reporte that 52% of previously symptomatic full-thickness tears increase in size an 24% evelope atrophy of the rotator cuff musculature at a mean follow-up of twenty months 20. In a separate stuy, Yamaguchi et al. foun that 51% of previously asymptomatic patients with full-thickness rotator cuff tears evelope symptoms over a mean of 2.8 years with follow-up at five years 21. On the basis of this stuy, we annualize the rate of evelopment of symptoms in asymptomatic rotator cuff tears to 8.8% (51% per 5.6 years). Insufficient ata exist to accurately moel the progression to arthropathy, an this clinical outcome was not represente in the moel. Direct Meical Costs Since this moel is performe from the societal perspective, as is recommene by the Panel on Cost-Effectiveness in Health an Meicine 22-24, the moele costs are those that are accrue to society rather than to a hospital or orthopaeic practice. The costs for nonoperative treatment an surgery for both rotator cuff repair as well as revision proceures were base on the national average Meicare reimbursements for the proceures in 2013 U.S. ollars, ajuste to reflect reimbursement for various payers, incluing private insurance an Workers Compensation (see Appenix). Inirect Costs Four inirect costs were moele: probability of employment, househol income, misse workays, an isability payments. We applie an approach to infer inirect costs associate with rotator cuff tears on the basis of the methos an ata reporte by Dall et al. 25. They linke functional limitations an economic outcomes using ata from the ational Health Interview Survey (HIS), a feerally sponsore national survey 26. To estimate the effects of rotator cuff tears an treatment, we applie patient outcome ata to the finings from Dall et al. to preict inirect costs with an without surgery for patients unergoing rotator cuff surgery. Patient outcome ata were obtaine from a sample of seventy-three patients who unerwent surgery for a rotator cuff tear (a separate cohort from the patients use to etermine utility). The sample was erive from surgical patients at a large orthopaeic surgery group. Each patient reporte his or her functional outcomes at the time of the survey (between one an two years after surgery) an, on the basis of patient recall, in the weeks prior to the rotator cuff repair. We assume that functional outcomes for symptomatic patients after treatment (whether receiving surgery or not) woul be the same as those reporte at baseline prior to surgery. We assume that workers lost an average of twenty-eight aitional ays as a result of rotator cuff repair compare with those unergoing nonoperative treatments 27. Aitional etails can be foun in the Appenix. Cost-Effectiveness Analysis The principal outcome calculate was the incremental cost-effectiveness ratio (ICER), which is the ratio between the ifference in costs an QALY of each strategy. Incremental cost-effectiveness ratios of <$50,000 per QALY gaine were consiere to be cost-effective 28. In this cost-effectiveness analysis, the preferre treatment strategy was the most effective strategy with an incremental costeffectiveness ratio that was less than the willingness of the health-care system to pay. A strategy is terme ominant when it is both less costly an more effective. One, two, an three-way sensitivity analyses were performe on all variables in the moel.

5 1997 TABLE III Results of Probabilistic Sensitivity Analysis Treatment Strategy* Mean Stan. Dev. 95% CI for the Mean Meian Min. Max. Cost (2012 US$) RCR 19, ,312-19,419 20,266 12,231 22,275 onoperative 40,457 32,493 39,820-41,093 34, ,451 Effectiveness (QALY) RCR onoperative *RCR = rotator cuff repair, an QALY = quality-ajuste life year. CI = confience interval. Variables eeme sensitive are those that, when varie across a reasonable range, change the preferre strategy. If the preferre strategy oes not change, then the variable is terme robust. Monte Carlo analysis was use to evaluate (1) the impact of uncertainty in the moel assumptions using probabilistic sensitivity analysis an (2) the impact of iniviual patient variability using microsimulation. These two were combine to generate 95% confience intervals for cost an QALYs. Source of Funing This stuy was fune by the American Acaemy of Orthopaeic Surgeons (AAOS), ational Institutes of Health, an the ational Cancer Institute through grant number KM1CA Results Cost-Effectiveness Analysis The lifetime age-weighte mean total societal savings per patient from rotator cuff repair compare with nonoperative treatment is $13,771. The mean ifference in QALYs between rotator cuff repair an nonoperative treatment was The mean savings range from a positive $77,662 for the youngest cohort of patients (thirty to thirty-nine years ol) to a loss of $11,997 for the olest (seventy to seventy-nine years ol) (Table II). The lifetime QALYs were consistently higher for those who receive surgical treatment in all age groups. The age-weighte average ifference in QALYs between the surgical an nonsurgical groups range from 0.97 QALY gaine in the youngest cohort to 0.33 QALY gaine in the olest. Detaile cost an effectiveness statistics for a cohort representative of the annual incience of rotator cuff repair in the U.S. is foun in Table III. Effect of Age For patients uner the age of sixty-one years, rotator cuff repair is a ominant treatment strategy compare with nonoperative treatment. The lifetime societal irect an inirect costs across the age range of thirty to eighty years is shown in Figure 2, with the area between nonoperative costs an operative costs representing Fig. 2 Sensitivity analysis on the age at nonoperative treatment of rotator cuff tear or rotator cuff repair an total societal savings.

6 1998 TABLE IV Results of the Threshol Analyses* Base Case RCR Cost Threshol RCR Cost-Effectiveness Threshol Transition probabilities Healing rate with RCR 75% Robust Robust Recurrence of symptomatic RCT 8.8% Robust Robust Success of nonoperative treatment 68% 88% Robust Durability of the outcome of RCR Lifetime 3.51 yr Robust umber of full workays misse recovering from RCR Robust Rate of symptomatic nonheale RCR 5% 97% Robust Cost onoperative treatment $1802 Robust Robust RCR $15,063 $23,630 $46,810 Inirect costs of a symptomatic RCT $6638 $1250 Robust Utility (QALY) Heale rotator cuff or 0.74 A 0.62 asymptomatic tear Symptomatic RCT 0.66 A 0.77 Age (yr) Robust *A variable is terme robust if the preferre strategy oes not change across the range of values teste. RCR = rotator cuff repair, RCT = rotator cuff tear, an QALY = quality-ajuste life year. A = not applicable. After a heale RCR, patients return to retear rates consistent with population rates for primary RCTs. The values are given as the cost per episoe. societal savings for patients who are sixty-one years ol or younger. For patients over the age of sixty-one years, societal costs for surgery excee those for nonoperative treatment, inicating negative societal savings. The incremental cost-effectiveness ratio, however, remaine well below the health-care system s willingness-to-pay threshols for those over sixty-one years ol. Therefore, rotator cuff repair prouces societal cost savings for patients uner the age of sixty-one years an is cost-effective for all patients. Probabilistic Sensitivity Analysis Rotator cuff repair was the preferre cost-effective strategy in 72.2% of the samples (70% with cost only as the outcome). Microsimulation, with a cohort representative of the annual U.S. incience of rotator cuff repair, emonstrate that rotator cuff repair was the preferre cost-effective strategy in 48% of trials (44% with cost only as the outcome). This value suggests that, for 52% of patients, likely those who improve with nonoperative treatment or experience symptomatic retears, nonoperative treatment is preferre. However, the cost savings to society for patients for whom surgery is the preferre strategy far excees the savings from those patients when nonoperative treatment is the preferre strategy, which causes the mean cost of rotator cuff repair for everyone uner the age of sixty-one years to be less than that of nonoperative treatment. Threshol Analysis Results from threshol analyses emonstrate that our estimates of the cost-effectiveness of rotator cuff repair are relatively robust to any one of the unerlying moel assumptions. The most influential variable on cost-effectiveness appears to be the response to nonoperative treatment. The break-even point for operative treatment of full-thickness rotator cuff tears in terms of societal savings is at 88% effectiveness of nonsurgical treatment, which is outsie the range of values reporte in the literature. Greater etail on the sensitivity analyses of specific variables appears in the Appenix. Discussion The moel employe in this stuy estimate a lifetime societal savings (net present value in 2013 U.S. ollars) of approximately $3.44 billion from the approximately 250,000 rotator cuff repairs ($13,771 per patient) performe annually in the U.S. The reuce inirect costs resulting from the operative treatment of rotator cuff isease more than offset the aitional irect costs of treatment in patients uner the age of sixty-one years. Furthermore, for all ages, rotator cuff repair generates increase utility compare with nonoperative treatment an is cost-effective. The finings provie a rationale for payer coverage of rotator cuff repair after an initial trial of nonoperative treatment. This stuy is the first, to our knowlege, to comprehensively examine the societal impact of rotator cuff isease an its treatments. Our cost-effectiveness results are lower than those reporte previously in the literature. Vitale et al., for example, foun that rotator cuff repair yiele cost-effectiveness ratios ranging from $13,093 to $3092 per QALY 29. These values were base on the other two major inirect measures of utility,

7 1999 the Health Utilities Inex (0.85 QALY for post-rotator cuff repair an 0.80 QALY for the preoperative state) an the Euro- QoL inex (0.75 QALY for post-rotator cuff repair an 0.55 QALY for the preoperative state). The ifference between these numbers an those in our stuy is ue to the lifetime perspective of our moel an the inclusion of inirect costs. The sensitivity analyses are revealing an must be consiere with regar to societal cost an cost-effectiveness. First, our analysis emonstrates that the cost-effectiveness of rotator cuff repair is robust (Table IV). Secon, even if inirect costs are completely exclue, rotator cuff repair is still cost-effective although not cost-saving. Only one variable is sensitive within a reasonable range: the success rate of nonoperative treatment. This rate must be >90% for the nonoperative treatment strategy to be preferre. The robustness of rotator cuff repair to cost-effectiveness was also supporte using probabilistic sensitivity analysis. When total societal cost is consiere, several variables are highly sensitive, incluing success rates of nonoperative treatment an primary rotator cuff repair, initial costs of nonoperative treatment an primary rotator cuff repair, age, an urability of the benefit of rotator cuff repair. The rate of symptom recurrence with either strategy is robust (Table IV). These finings suggest that, when total societal cost only is consiere, patient characteristics an treatment characteristics as well as the perspective of the particular stakeholers are highly influential in etermining the preferre strategy. There are a number of limitations of this stuy to consier. First, patients in the nonoperative treatment arm of the Markov moel were not allowe to cross over to the rotator cuff repair arm, even if they respone poorly to nonoperative treatment. While this is an unlikely treatment pattern, the moel assumption is appropriate, given that we were concerne with the costs an benefits of surgical care an examine what woul have happene to surgical patients without access to operative treatment. Secon, evience to support some of the moel assumptions is limite. Very few ranomize controlle trials are esigne to test the effectiveness of operative treatment of rotator cuff tears. The utility values use, while being generate by a valiate outcome measure, were obtaine from the experience of one surgeon at an acaemic meical center an may not represent the national mean, although sensitivity analysis on utility i not change the preferre treatment strategy. In aition, little is known about the longer-term outcomes regaring relapse, response to repeate rouns of nonoperative treatment, an progression to rotator cuff arthropathy. Further, while ata exist on the rate of symptom evelopment in rotator cuff isease, the mean uration of follow-up is less than five years, making extrapolation to an entire lifetime less certain. These weaknesses are important, but sensitivity analyses on these factors i not materially alter our finings. Thir, estimates of inirect costs associate with rotator cuff tears o not exist in the literature. We inferre these costs by linking estimates of the relationship between rotator cuff tears an functional limitations to estimates of the relationship between functional limitations an inirect cost factors. While the stuy contributes to our unerstaning of the full societal effects of rotator cuff tears, aitional research is neee to confirm the stuy finings an caution shoul be taken in using the results to guie the treatment of iniviual patients. Although rotator cuff repair is cost-saving across all patients, nonoperative treatment is the preferre strategy for a large number of patients. The challenge to maximize the value of treatment for rotator cuff isease overall is to better istinguish between the patients who woul benefit more from nonoperative treatment an those who woul benefit more from operative treatment. Furthermore, ifferences in the type an quality of both operative an nonoperative treatment coul lea to further iniviual variation. Because the stuy focuse on the cohort of patients receiving surgery, the results of this stuy shoul not be interprete as suggesting that all rotator cuff tears require surgery. Rather, the results show that rotator cuff repair has an important role in minimizing the societal buren of rotator cuff isease. In summary, the economic buren to society of rotator cufftearsissubstantialanrotatorcuffrepairmayplayanimportant role in reucing that buren. We estimate that the surgical proceures for this conition performe each year in the U.S. will generate lifetime societal savings of approximately $3.44 billion. Rotator cuff repair is both cost-saving for society in younger patients an cost-effective for all patient age groups. Appenix A etaile escription of the technical aspects of the analyses an tables showing annual isability payments as well as the Current Proceural Terminology (CPT) coes, rate of occurrence of concomitant proceures, an 2013 average Meicare reimbursements are available with the online version of this article as a ata supplement at jbjs.org. n OTE: The authors thank the members of the AAOS Value Project Team for their valuable comments on earlier rafts of the paper. The authors also thank the Rothman Institute for proviing patient outcome ata, a panel of clinical experts who provie aitional review an input, an Josh Saavoss an Sheila Sankaran for their eitorial assistance. Richar C. Mather III, MD Duke Orthopaeic Surgery, 4709 Creekstone Drive, Suite 200, Durham, C Lane Koenig, PhD KG Health Consulting, Shay Grove Roa, Suite 305, Rockville, MD aress: lane.koenig@knghealth.com Daniel Aceveo, MD Geral Williams Jr., MD The Rothman Institute, 925 Chestnut Street, Philaelphia, PA Timothy M. Dall, MS Paul Gallo, BS IHS Global Insight, 1150 Connecticut Avenue.W., Washington, DC 20036

8 2000 Anthony Romeo, MD Miwest Orthopaeics at Rush, 1611 West Harrison Street, Suite 400, Chicago, IL John Tongue, MD Oregon Health an Science University, 6485 S.W. Borlan Roa, Tualatin, OR References 1. Oh LS, Wolf BR, Hall MP, Levy BA, Marx RG. Inications for rotator cuff repair: a systematic review. Clin Orthop Relat Res Feb;455: Praemer A, Furner S, Rice DP. Musculoskeletal conitions in the Unite States. 2n e. Rosemont, IL: American Acaemy of Orthopaeic Surgeons; Seia JC, LeBlanc C, Schouten JR, Mousavi SS, Hartling L, Vanermeer B, Tjosvol L, Sheps DM. Systematic review: nonoperative an operative treatments for rotator cuff tears. Ann Intern Me Aug 17;153(4): Epub 2010 Jul HCUP State Ambulatory Surgery Databases. Healthcare Cost an Utilization Project (HCUP) Agency for Healthcare Research an Quality, Rockville, MD Yamamoto A, Takagishi K, Osawa T, Yanagawa T, akajima D, Shitara H, Kobayashi T. Prevalence an risk factors of a rotator cuff tear in the general population. J Shouler Elbow Surg Jan;19(1): Smith DH, Gravelle H. The practice of iscounting in economic evaluations of healthcare interventions. Int J Technol Assess Health Care Spring;17(2): Brazier J, Roberts J, Deverill M. The estimation of a preference-base measure of health from the SF-36. J Health Econ Mar;21(2): Walters SJ, Brazier JE. What is the relationship between the minimally important ifference an health state utility values? The case of the SF-6D. Health Qual Life Outcomes. 2003;1:4. Epub 2003 Apr Slabaugh MA, ho SJ, Grumet RC, Wilson JB, Seroyer ST, Frank RM, Romeo AA, Provencher MT, Verma. Does the literature confirm superior clinical results in raiographically heale rotator cuffs after rotator cuff repair? Arthroscopy Mar;26(3): ho SJ, Brown BS, Lyman S, Aler RS, Altchek DW, MacGillivray JD. Prospective analysis of arthroscopic rotator cuff repair: prognostic factors affecting clinical an ultrasoun outcome. J Shouler Elbow Surg Jan-Feb;18(1): ho SJ, Shinle MK, Aler RS, Warren RF, Altchek DW, MacGillivray JD. Prospective analysis of arthroscopic rotator cuff repair: subgroup analysis. J Shouler Elbow Surg Sep-Oct;18(5): Epub 2009 Mar Huberty DP, Schoolfiel JD, Bray PC, Vaala AP, Arrigoni P, Burkhart SS. Incience an treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy Aug;25(8): Ranelli P, Spennacchio P, Ragone V, Arrigoni P, Casella A, Cabitza P. Complications associate with arthroscopic rotator cuff repair: a literature review. Musculoskelet Surg Jun;96(1): Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickenantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop Relat Res Sep;(294): Golberg BA, owinski RJ, Matsen FA 3r. Outcome of nonoperative management of full-thickness rotator cuff tears. Clin Orthop Relat Res Jan;(382): Hawkins RH, Dunlop R. onoperative treatment of rotator cuff tears. Clin Orthop Relat Res Dec;(321): Gomoll AH, Katz J, Warner JJ, Millett PJ. Rotator cuff isorers: recognition an management among patients with shouler pain. Arthritis Rheum Dec;50(12): Wirth MA, Basamania C, Rockwoo CA Jr. onoperative management of fullthickness tears of the rotator cuff. Orthop Clin orth Am Jan;28(1): Yamaguchi K, Ditsios K, Mileton WD, Hilebolt CF, Galatz LM, Teefey SA. The emographic an morphological features of rotator cuff isease. A comparison of asymptomatic an symptomatic shoulers. J Bone Joint Surg Am Aug;88(8): Maman E, Harris C, White L, Tomlinson G, Shashank M, Boynton E. Outcome of nonoperative treatment of symptomatic rotator cuff tears monitore by magnetic resonance imaging. J Bone Joint Surg Am Aug;91(8): Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Mileton WD. atural history of asymptomatic rotator cuff tears: a longituinal analysis of asymptomatic tears etecte sonographically. J Shouler Elbow Surg May-Jun;10(3): Siegel JE, Weinstein MC, Russell LB, Gol MR; Panel on Cost-Effectiveness in Health an Meicine. Recommenations for reporting cost-effectiveness analyses. JAMA Oct 23-30;276(16): Weinstein MC, Siegel JE, Gol MR, Kamlet MS, Russell LB. Recommenations of the Panel on Cost-effectiveness in Health an Meicine. JAMA Oct 16;276(15): Russell LB, Gol MR, Siegel JE, Daniels, Weinstein MC; Panel on Cost- Effectiveness in Health an Meicine. The role of cost-effectiveness analysis in health an meicine. JAMA Oct 9;276(14): Dall TM, Gallo P, Koenig L, Gu Q, Ruiz D. Moeling the inirect economic implications of musculoskeletal isorers an treatment. Cost Eff Resour Alloc. 2013;11(1):5. Epub 2013 Mar Centers for Disease Control an Prevention, U.S. Department of Health an Human Services national health interview survey. Hyattsville, MD: ational Center for Health Statistics; June Accesse 2013 Aug Work Loss Data Institute. Official isability guielines: special eition top 200 conitions. 17th e. Encinitas, CA: Work Loss Data Institute; Grosse SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshol. Expert Rev Pharmacoecon Outcomes Res Apr;8(2): Vitale MA, Vitale MG, Zivin JG, Braman JP, Bigliani LU, Flatow EL. Rotator cuff repair: an analysis of utility scores an cost-effectiveness. J Shouler Elbow Surg Mar-Apr;16(2):181-7.