Cost-effectiveness and quality-of-life outcomes of proximal humerus fracture treatment in adults aged 65 years and older in the United States

Proximal humerus fractures (PHFs) are the third most common fragility fracture in older adults, and their rising incidence in the United States contributes substantially to health care spending. Although several randomized trials have evaluated outcomes across treatment strategies, the optimal management strategy remains debated. Few studies have compared all five common PHF treatment options using an integrated cost effectiveness framework. A cost-utility analysis was performed to compare nonoperative management, intramedullary nailing, open reduction internal fixation, hemiarthroplasty, and reverse total shoulder arthroplasty (rTSA) for PHFs in 65-year-old patients. Costs and quality-adjusted life years (QALYs) were calculated using fixed probabilities for complication and revisions. Monte Carlo simulations were performed using distributions to model variation over 2-, 5-, and 10-year time horizons. Utility values were assigned based on complication status, and costs were derived from CPT/DRG codes using 2025 USD. Incremental cost-effectiveness ratios (ICERs) were calculated, with sensitivity analyses assessing model robustness. rTSA yielded the highest QALYs and emerged as the most cost-effective treatment across all time horizons. At 2 years, rTSA produced 1.69 QALYs at a mean cost of $18,661, resulting in the lowest ICER of $24,112/QALY. By 10 years, rTSA produced 7.16 QALYs at a cost of $23,311, with an ICER of $6,374/QALY. Open reduction internal fixation and hemiarthroplasty were consistently more costly and less effective than rTSA, while nonoperative care had the lowest costs but the fewest QALYs. At a willingness-to-pay threshold of $50,000/QALY, rTSA was the most cost-effective option in over half the simulations. Amid rising fragility fracture rates and increasing financial pressures on the health care system, reverse shoulder arthroplasty offers the greatest cost-effectiveness among treatment options for complex PHFs in adults over 65. Across all model timeframes, rTSA consistently yielded greater QALYs and superior cost-effectiveness, supporting its role as the preferred treatment strategy in this population.