Background:Value-based decision-making regarding nonoperative management versus early surgical stabilization for first-time anterior shoulder instability (ASI) events remains understudied.Purpose:To perform (1) a systematic review of the current literature and (2) a Markov model–based cost-effectiveness analysis comparing an initial trial of nonoperative management to arthroscopic Bankart repair (ABR) for first-time ASI.Study Design:Economic and decision analysis; Level of evidence, 3.Methods:A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 simulated patients (mean age, 20 years; range, 12-26 years) with first-time ASI undergoing nonoperative management versus ABR. Utility values, recurrence rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors’ institution. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER).Results:The Markov model with Monte Carlo microsimulation demonstrated mean (± standard deviation) 10-year costs for nonoperative management and ABR of $38,649 ± $10,521 and $43,052 ± $9352, respectively. Total QALYs acquired over the 10-year time horizon were 7.67 ± 0.43 and 8.44 ± 0.46 for nonoperative management and ABR, respectively. The ICER comparing ABR with nonoperative management was found to be just $5725/QALY, which falls substantially below the $50,000 willingness-to-pay (WTP) threshold. The mean numbers of recurrences were 2.55 ± 0.31 and 1.17 ± 0.18 for patients initially assigned to the nonoperative and ABR treatment groups, respectively. Of 1000 samples run over 1000 trials, ABR was the optimal strategy in 98.7% of cases, with nonoperative management the optimal strategy in 1.3% of cases.Conclusion:ABR reduces the risk for recurrent dislocations and is more cost-effective despite higher upfront costs when compared with nonoperative management for first-time ASI in the young patient. While all these factors are important to consider in surgical decision-making, ultimate treatment decisions should be made on an individual basis and occur through a shared decision-making process.

中文翻译：

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比较关节镜盂唇修复术和非手术治疗年轻患者原发性肩关节前脱位的复发率和成本效益


背景： 关于首次肩前部不稳定 （ASI） 事件的非手术管理与早期手术稳定的基于价值的决策仍未得到充分研究。目的： 进行 （1） 对当前文献的系统评价和 （2） 基于马尔可夫模型的成本效益分析，比较非手术管理与关节镜 Bankart 修复 （ABR） 的初始试验对首次 ASI 的治疗。研究设计： 经济与决策分析;证据水平， 3.方法： 开发了马尔可夫链蒙特卡洛概率模型，以评估 1000 例模拟患者 （平均年龄，20 岁;范围，12-26 岁） 接受非手术治疗与 ABR 的首次 ASI 患者的结果和成本。效用值、复发率和转换概率来自已发表的文献。费用是根据作者所在机构接受每种治疗策略的典型患者确定的。结局指标包括成本、质量调整生命年 （QALYs） 和增量成本效益比 （ICER）。结果： 带有蒙特卡洛微观模拟的马尔可夫模型显示非手术管理的平均 （± 标准差） 10 年成本，ABR 分别为 38,649 美元± 10,521 美元和 43,052 美元± 9352 美元。非手术管理和 ABR 在 10 年时间范围内获得的总 QALY 分别为 7.67 ± 0.43 和 8.44 ± 0.46。将 ABR 与非手术管理进行比较的 ICER 发现仅为 5725 美元/QALY，远低于 50,000 美元的支付意愿 （WTP） 门槛。最初分配到非手术组和 ABR 治疗组的患者的平均复发次数分别为 2.55 ± 0.31 和 1.17 ± 0.18。 在 1000 个样本中运行的 1000 次试验中，ABR 是 98.7% 的病例的最佳策略，非手术管理是 1.3% 的病例的最佳策略。结论： 与非手术治疗相比，ABR 降低了复发性脱位的风险，尽管年轻患者首次 ASI 的前期成本较高，但更具成本效益。虽然在手术决策中考虑所有这些因素都很重要，但最终的治疗决策应根据个人情况做出，并通过共同决策过程做出。