Patient-level value analysis in reverse total shoulder arthroplasty: evaluating a 1-year episode of care in a single-institution retrospective cohort

Background: Reverse total shoulder arthroplasty (rTSA) utilization is rising rapidly in the United States, with increasing emphasis on delivering high-value care. Patient-level value analysis (PLVA) offers a framework for quantifying value by integrating individualized cost and outcome data. While PLVA has been applied to other orthopedic procedures, its use in rTSA has not been established. We hypothesized that higher episode-of-care (EOC) costs would not be associated with greater patient-level value, defined as improvement in American Shoulder and Elbow Surgeons (ASES) score per dollar spent, at 1 year following primary rTSA. Methods: A retrospective cohort study was conducted using prospectively collected data on patients undergoing primary, unilateral rTSA between 2018 and 2022 at a single institution. Patients were excluded if they lacked 1-year patient-reported outcome data, underwent revision procedures, or experienced postoperative complications. The ASES score was used as the primary patient-reported outcome. Total EOC costs were calculated using time-driven activity-based costing, incorporating direct and indirect costs across the 1-year postoperative period. A value quotient was computed for each patient by dividing the change in ASES score by total EOC cost, multiplied by 100. Multivariable regression analyses were performed to identify predictors of cost and outcome. Results: A total of 119 patients met inclusion criteria. The average improvement in ASES score was 23.3 ± 23.1, and the mean 1-year cost of care was $18,265 ± 3,431. The average patient value quotient was 0.11 ± 0.12. No correlation was found between total EOC cost and ASES score improvement (r = 0.02, P = .848). Implant costs accounted for 49.5% of total spending. Discharge to a skilled nursing facility was associated with significantly higher costs (β = $9,566, P ≤ .001), while patients discharged directly home, and those not requiring inpatient hospitalization had significantly lower costs (β = –$4,728, P ≤ .001). Conclusion: In this single-institution, complication-free cohort, value in rTSA may be influenced by implant selection and discharge planning. The absence of an association between cost and functional improvement highlights opportunities to optimize resource utilization without compromising outcomes. Applying PLVA can help guide evidence-based, cost-conscious decision-making in the delivery of high-value orthopedic care.