101
|
Blom AW, Artz N, Beswick AD, Burston A, Dieppe P, Elvers KT, Gooberman-Hill R, Horwood J, Jepson P, Johnson E, Lenguerrand E, Marques E, Noble S, Pyke M, Sackley C, Sands G, Sayers A, Wells V, Wylde V. Improving patients’ experience and outcome of total joint replacement: the RESTORE programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BackgroundTotal hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.ObjectiveTo undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.MethodsWe used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.ResultsSystematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.ConclusionsThe RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.Study registrationCurrent Controlled Trials ISRCTN52305381.FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Ashley W Blom
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Neil Artz
- School of Health Professions, Faculty of Health and Human Sciences, Plymouth University, Plymouth, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Paul Dieppe
- Medical School, University of Exeter, Exeter, UK
| | - Karen T Elvers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Jepson
- School of Sport, Exercise and Rehabilitation Sciences, Birmingham, UK
| | - Emma Johnson
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Elsa Marques
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sian Noble
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mark Pyke
- North Bristol NHS Trust, Bristol, UK
| | | | - Gina Sands
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Victoria Wells
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| |
Collapse
|
102
|
Lodhia P, Gui C, Chandrasekaran S, Suarez-Ahedo C, Dirschl DR, Domb BG. The Economic Impact of Acetabular Labral Tears: A Cost-effectiveness Analysis Comparing Hip Arthroscopic Surgery and Structured Rehabilitation Alone in Patients Without Osteoarthritis. Am J Sports Med 2016; 44:1771-80. [PMID: 27190068 DOI: 10.1177/0363546516645532] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hip arthroscopic surgery has emerged as a successful procedure to manage acetabular labral tears and concurrent hip injuries, which if left untreated, may contribute to hip osteoarthritis (OA). Therefore, it is essential to analyze the economic impact of this treatment option. PURPOSE To investigate the cost-effectiveness of hip arthroscopic surgery versus structured rehabilitation alone for acetabular labral tears, to examine the effects of age on cost-effectiveness, and to estimate the rate of symptomatic OA and total hip arthroplasty (THA) in both treatment arms over a lifetime horizon. STUDY DESIGN Economic and decision analysis; Level of evidence, 2. METHODS A cost-effectiveness analysis of hip arthroscopic surgery compared with structured rehabilitation for symptomatic labral tears was performed using a Markov decision model constructed over a lifetime horizon. It was assumed that patients did not have OA. Direct costs (in 2014 United States dollars), utilities of health states (in quality-adjusted life years [QALYs] gained), and probabilities of transitioning between health states were estimated from a comprehensive literature review. Costs were estimated using national averages of Medicare reimbursements, adjusted for all payers in the United States from a societal perspective. Utilities were estimated from the Harris Hip Score. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were performed to determine the effect of uncertainty on the model outcomes. RESULTS For a cohort representative of patients undergoing hip arthroscopic surgery at our facility, arthroscopic surgery was more costly (additional $2653) but generated more utility (additional 3.94 QALYs) compared with rehabilitation over a lifetime. The mean ICER was $754/QALY, well below the conventional willingness to pay of $50,000/QALY. Arthroscopic surgery was cost-effective for 94.5% of patients. Although arthroscopic surgery decreased in cost-effectiveness with increasing age, arthroscopic surgery remained more cost-effective than rehabilitation for patients in the second to seventh decades of life. The lifetime incidence of symptomatic hip OA was over twice as high for patients treated with rehabilitation compared with arthroscopic surgery. The preferred treatment was sensitive to the utility after successful hip arthroscopic surgery, although the utility at which arthroscopic surgery becomes less cost-effective than rehabilitation is far below our best estimate. For older patients, the lifetime cost of arthroscopic surgery was greater, while the lifetime utility of arthroscopic surgery was less, approaching that of the rehabilitation arm. CONCLUSION Hip arthroscopic surgery is more cost-effective and results in a considerably lower incidence of symptomatic OA than structured rehabilitation alone in treating symptomatic labral tears of patients in the second to seventh decades of life without pre-existing OA.
Collapse
Affiliation(s)
| | | | | | | | | | - Benjamin G Domb
- American Hip Institute, Westmont, Illinois, USA Hinsdale Orthopaedics, Hinsdale, Illinois, USA
| |
Collapse
|
103
|
Zheng L, Lee WY, Hwang DS, Kang C, Noh CK. Could Patient Undergwent Surgical Treatment for Periprosthetic Femoral Fracture after Hip Arthroplasty Return to Their Status before Trauma? Hip Pelvis 2016; 28:90-7. [PMID: 27536650 PMCID: PMC4972891 DOI: 10.5371/hp.2016.28.2.90] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/26/2016] [Accepted: 05/02/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to compare preoperative clinical outcomes before occurrence of periprosthetic femoral fracture (status before trauma) with postoperative clinical outcomes (status after operation) in patients with periprosthetic femoral fracture after hip arthroplasty. Materials and Methods A retrospective review was performed of all periprosthetic femoral fracture after hip arthroplasty treated surgically at our institution from January 2010 to January 2014. Among 29 patients who underwent surgical treatment for periprosthetic femoral fracture after hip arthroplasty, 3 patients excluded because of non-union of the fracture site. The clinical outcomes were determined by using visual analogue scale for pain (VAS), Harris hip score (HHS), and ambulatory ability using Koval classification. VAS, HHS and ambulatory ability was assessed for all the included patients at the last follow-up of status before trauma and after operation. Results The mean VAS, HHS and ambulatory ability at the last follow-up of status before trauma was 2.2 (range, 0-4), 78.9 (range, 48-92) and 1.9 (range, 1-5), respectively. The mean VAS, HHS and ambulatory ability at the last follow-up of status after operation was 3.1 (range, 1-5), 68.4 (range, 46-81) and 2.9 (range, 2-6), respectively. The clinical outcome of VAS, HHS and ambulatory ability were significantly worsened after surgical treatment for periprosthetic femoral fracture (P=0.010, P=0.001, and P=0.002, respectively). Conclusion Patients with periprosthetic femoral fracture after hip arthroplasty could not return to their status before trauma, although patients underwent appropriate surgical treatment and the fracture union achieved.
Collapse
Affiliation(s)
- Long Zheng
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea
| | - Woo-Yong Lee
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea
| | - Deuk-Soo Hwang
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea
| | - Chan Kang
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea
| | - Chang-Kyun Noh
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea
| |
Collapse
|
104
|
Takura T, Miki K. The future of medical reimbursement for orthopedic surgery in Japan from the viewpoint of the health economy. J Orthop Sci 2016; 21:273-81. [PMID: 27020176 DOI: 10.1016/j.jos.2016.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 01/04/2016] [Accepted: 02/09/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The financial burden of medical insurance on the government of Japan has recently become severe, which has led to the control of outpatient orthopedic reimbursements for common procedures. On the other hand, the overall disease burden for total hip or knee arthroplasty, decompression for cervical myelopathy or lumbar spinal canal stenosis, and new surgical technologies to treat other painful conditions and the post-surgical care related to these procedures has been reduced. METHODS Medical insurance systems in Japan are generally influenced by budget-balancing action. Consequently, the further development of interventional evaluation methods should be promoted. From the viewpoint of health economics, the value (meaning) of medical intervention can partly be explained by its cost-effectiveness. In order for appropriate medical reimbursement levels to be set for orthopedic surgery, the financial status of medical institutions needs to be concurrently reviewed. In particular, the relationship between the expense structure and medical reimbursement must be discussed to evaluate its role in community medicine system. RESULTS Over the past 10 years, medical expenditures have increased by 9.6% in all fields, whereas the monthly medical reimbursements per patient have dropped by an average of 17.5%. Remarkably, surgery-related costs have increased by 36.5%, while other medical costs have decreased by 19.8%. There are a few reports of cost-utility analyses which investigate interventions such as total hip arthroplasty for hip osteoarthritis patients (US$ 4,600-70,500/QALY) and laminectomy for patients with spinal canal stenosis. Interventions may be an inevitable part of relative expense control under the current trend; however, there has been a slight increase in other parameters in response to changes in medical reimbursement evaluations - specifically, in the total income of medical institutions. CONCLUSIONS If medical professionals such as orthopedic surgeons contribute to the economic value of orthopedic surgery, it is crucial to clearly establish interventions among the different performances of medical reimbursement to motivate the increased allocation of management resources. To further develop this concept, discussions between stakeholders should involve the value of medicine based on cost and benefit.
Collapse
Affiliation(s)
- Tomoyuki Takura
- Department of Health Care Economics and Industrial Policy, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita-shi, Osaka 565-0871, Japan.
| | - Kenji Miki
- Department of Pain Medicine, Graduate School of Medicine, Osaka University, Japan
| |
Collapse
|
105
|
Sculco PK, Cottino U, Abdel MP, Sierra RJ. Avoiding Hip Instability and Limb Length Discrepancy After Total Hip Arthroplasty. Orthop Clin North Am 2016; 47:327-34. [PMID: 26772941 DOI: 10.1016/j.ocl.2015.09.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Two complications after total hip arthroplasty (THA) are hip instability and limb length discrepancy; instability is a common indication for revision THA. The goal of a successful THA is to maximize impingement-free range of motion, recreate appropriate offset, and equalize limb length discrepancies to produce a pain-free and dynamically stable THA. In this article, the patient risk factors for dislocation and limb length discrepancy, key elements of the preoperative template, the anatomic landmarks for accurate component placement, the leg positions for soft tissue stability testing, and the management of postoperative instability are reviewed.
Collapse
Affiliation(s)
- Peter K Sculco
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA.
| | - Umberto Cottino
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA
| | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA
| |
Collapse
|
106
|
Falavigna A, Scheverin N, Righesso O, Teles AR, Gullo MC, Cheng JS, Riew KD. Economic value of treating lumbar disc herniation in Brazil. J Neurosurg Spine 2016; 24:608-14. [DOI: 10.3171/2015.7.spine15441] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECT
Lumbar discectomy is one of the most common surgical spine procedures. In order to understand the value of this surgical care, it is important to understand the costs to the health care system and patient for good results. The objective of this study was to evaluate for the first time the cost-effectiveness of spine surgery in Latin America for lumbar discectomy in terms of cost per quality-adjusted life year (QALY) gained for patients in Brazil.
METHODS
The authors performed a prospective cohort study involving 143 consecutive patients who underwent open discectomy for lumbar disc herniation (LDH). Patient-reported outcomes were assessed utilizing the SF-6D, which is derived from a 12-month variation of the SF-36. Direct medical costs included medical reimbursement, costs of hospital care, and overall resource consumption. Disability losses were considered indirect costs. A 4-year horizon with 3% discounting was applied to health-utilities estimates. Sensitivity analysis was performed by varying utility gain by 20%. The costs were expressed in Reais (R$) and US dollars ($), applying an exchange rate of 2.4:1 (the rate at the time of manuscript preparation).
RESULTS
The direct and indirect costs of open lumbar discectomy were estimated at an average of R$3426.72 ($1427.80) and R$2027.67 ($844.86), respectively. The mean total cost of treatment was estimated at R$5454.40 ($2272.66) (SD R$2709.17 [$1128.82]). The SF-6D utility gain was 0.044 (95% CI 0.03197–0.05923, p = 0.017) at 12 months. The 4-year discounted QALY gain was 0.176928. The estimated cost-utility ratio was R$30,828.35 ($12,845.14) per QALY gained. The sensitivity analysis showed a range of R$25,690.29 ($10,714.28) to R$38,535.44 ($16,056.43) per QALY gained.
CONCLUSIONS
The use of open lumbar discectomy to treat LDH is associated with a significant improvement in patient outcomes as measured by the SF-6D. Open lumbar discectomy performed in the Brazilian supplementary health care system provides a cost-utility ratio of R$30,828.35 ($12,845.14) per QALY. The value of acceptable cost-effectiveness will vary by country and region.
Collapse
Affiliation(s)
- Asdrubal Falavigna
- 1Department of Neurosurgery, Laboratory of Clinical Studies and Basic Models of Spinal Disorders and
| | - Nicolas Scheverin
- 2Department of Orthopaedics, Hospital Dr. Diego E. Thompson, Buenos Aires, Argentina
| | - Orlando Righesso
- 1Department of Neurosurgery, Laboratory of Clinical Studies and Basic Models of Spinal Disorders and
| | - Alisson R. Teles
- 1Department of Neurosurgery, Laboratory of Clinical Studies and Basic Models of Spinal Disorders and
| | - Maria Carolina Gullo
- 3Accountancy and Economic Sciences Center, University of Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil
| | - Joseph S. Cheng
- 4Department of Neurosurgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - K. Daniel Riew
- 5Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri
| |
Collapse
|
107
|
Waugh EJ, Badley EM, Borkhoff CM, Croxford R, Davis AM, Dunn S, Gignac MA, Jaglal SB, Sale J, Hawker GA. Primary care physicians' perceptions about and confidence in deciding which patients to refer for total joint arthroplasty of the hip and knee. Osteoarthritis Cartilage 2016; 24:451-7. [PMID: 26432986 DOI: 10.1016/j.joca.2015.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 09/09/2015] [Accepted: 09/22/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of this study is to examine the perceptions of primary care physicians (PCPs) regarding indications, contraindications, risks and benefits of total joint arthroplasty (TJA) and their confidence in selecting patients for referral for TJA. DESIGN PCPs recruited from among those providing care to participants in an established community cohort with hip or knee osteoarthritis (OA). Self-completed questionnaires were used to collect demographic and practice characteristics and perceptions about TJA. Confidence in referring appropriate patients for TJA was measured on a scale from 1 to 10; respondents scoring in the lowest tertile were considered to have 'low confidence'. Descriptive analyses were conducted and multiple logistic regression was used to determine key predictors of low confidence. RESULTS 212 PCPs participated (58% response rate) (65% aged 50+ years, 45% female, 77% >15 years of practice). Perceptions about TJA were highly variable but on average, PCPs perceived that a typical surgical candidate would have moderate pain and disability, identified few absolute contraindications to TJA, and overestimated both the effectiveness and risks of TJA. On average, PCPs indicated moderate confidence in deciding who to refer. Independent predictors of low confidence were female physicians (OR = 2.18, 95% confidence interval (CI): 1.06-4.46) and reporting a 'lack of clarity about surgical indications' (OR = 3.54, 95% CI: 1.87-6.66). CONCLUSIONS Variability in perceptions and lack of clarity about surgical indications underscore the need for decision support tools to inform PCP - patient decision making regarding referral for TJA.
Collapse
Affiliation(s)
- E J Waugh
- Women's College Hospital, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.
| | - E M Badley
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Healthcare and Outcomes Research, Toronto Western Research Institute, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - C M Borkhoff
- Women's College Hospital, Toronto, Ontario, Canada
| | - R Croxford
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - A M Davis
- Division of Healthcare and Outcomes Research, Toronto Western Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - S Dunn
- Women's College Hospital, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M A Gignac
- Division of Healthcare and Outcomes Research, Toronto Western Research Institute, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - S B Jaglal
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - J Sale
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - G A Hawker
- Women's College Hospital, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
108
|
Liao CY, Chan HT, Chao E, Yang CM, Lu TC. Comparison of total hip and knee joint replacement in patients with rheumatoid arthritis and osteoarthritis: a nationwide, population-based study. Singapore Med J 2016; 56:58-64. [PMID: 25640101 DOI: 10.11622/smedj.2015011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Patients with rheumatoid arthritis (RA) and osteoarthritis (OA) may require total hip replacement (THR) or total knee replacement (TKR). The present study aimed to compare the demographic characteristics and medical costs of RA and OA patients from Taiwan who underwent either THR or TKR. METHODS The medical records of patients who had undergone THR or TKR from 1 January 1996 to 31 December 2010 were obtained from the Taiwan National Health Insurance Research Database (NHIRD). In all, we found 49 and 146 RA patients who received THR and TKR, respectively, and 1,191 and 6,574 OA patients who received THR and TKR, respectively. The gender, age, Charlson comorbidity index (CCI), hospital grade, age at registration in the catastrophic illness dataset, and medical utilisation costs of the different groups were compared. RESULTS There were statistically significant differences in age, CCI score, drug costs and surgery costs between RA and OA patients. Joint replacement incidence was lower in RA patients than in OA patients, and among patients who underwent THR, total medical costs incurred were higher for RA patients than OA patients. RA patients who underwent THR incurred a significantly greater total medical utilisation cost in the outpatient department (3 months before surgery and 12 months after surgery) than OA patients who underwent THR. CONCLUSION Analysis of Taiwan NHIRD with regard to patients who had undergone either THR or TKR indicated that RA patients were younger than OA patients, and that significantly more medical resources were used for RA patients before, during and after hospitalisation for these procedures.
Collapse
Affiliation(s)
| | | | | | | | - Tzu-Chuan Lu
- Department of Orthopaedics, Sung Shan Branch, Tri-Service General Hospital, No 131 Chien-Kang Road, Taipei, Taiwan.
| |
Collapse
|
109
|
Sinclair C, Brunton N, Hopman WM, Kelly L. Length of Stay and Achievement of Functional Milestones in a Rural First Nations Population in Northwestern Ontario during Acute-Care Admission after Total Hip Replacement: A Retrospective Chart Review. Physiother Can 2016; 67:268-72. [PMID: 26839456 DOI: 10.3138/ptc.2014-45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To understand the postoperative acute-care physiotherapy course for First Nations people returning after total hip replacement (THR) to remote communities with limited rehabilitation services and to evaluate length of stay and attainment of functional milestones after THR to determine to what extent an urban-based clinical pathway is transferrable to and effective for First Nations patients in a rural setting. METHODS Data were collected retrospectively by reviewing charts of patients who underwent THR in the Northwest Ontario catchment area from 2007 through 2012. RESULTS For the 36 patient charts reviewed, median length of stay (LOS) at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) was 7.5 days (range 2-335); median LOS from time of surgery at the regional hospital (Thunder Bay Regional Health Centre) to discharge from SLMHC was 13.5 days; and median time for mobilizing and stairs was 9 days (range 1-93). CONCLUSION Commonly accepted urban clinical pathways are not a good fit for smaller rural hospitals from which First Nations patients return to remote communities without rehabilitation services. LOS in a rural acute-care facility is similar to LOS in an urban rehabilitation facility.
Collapse
Affiliation(s)
| | | | - Wilma M Hopman
- Clinical Research Centre, Kingston General Hospital; Department of Public Health Sciences, Queen's University, Kingston, Ont
| | - Len Kelly
- Division of Clinical Sciences, Northern Ontario School of Medicine, Sioux Lookout
| |
Collapse
|
110
|
Quality-Adjusted Life Years Gained by Hip and Knee Replacement Surgery and Its Aftercare. Arch Phys Med Rehabil 2016; 97:691-700. [PMID: 26792619 DOI: 10.1016/j.apmr.2015.12.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/06/2015] [Accepted: 12/15/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To determine the lifetime quality-adjusted life years (QALYs) gained by total joint arthroplasty (TJA), and assess the QALYs attributed to specific postoperative rehabilitation interventions. DESIGN Secondary analysis of 2 multicenter, randomized controlled trials (RCTs) with 3-, 6-, 12-, and 24-month follow-up. SETTING Two university hospitals, 2 municipal hospitals, and 1 rural hospital. PARTICIPANTS Patients (N=827) who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA). INTERVENTIONS RCT A: 465 patients were randomly assigned to receive aquatic therapy (pool exercises aimed at training of proprioception, coordination, and strengthening) 6 versus 14 days after THA or TKA. RCT B 362 patients were randomly assigned to either perform or not perform ergometer cycling beginning 2 weeks after THA or TKA. MAIN OUTCOME MEASURE QALYs, based on the Short Form-6 Dimensions utility, measured at baseline and 3, 6, 12, and 24 months' follow-up. RESULTS After hip arthroplasty, the lifetime QALYs increased by 2.35 years in the nonergometer group, and by 2.30 years in the early aquatic therapy group. However, after knee arthroplasty, the lifetime QALYs increased by 1.81 years in the nonergometer group, and by 1.60 years in the early aquatic therapy group. By ergometer cycling, .55 additional QALYs could be gained after hip and .10 additional QALYs after knee arthroplasty, while the additional QALYs attributed to the timing of aquatic therapy were .12 years after hip and .01 years after knee arthroplasty. CONCLUSIONS This analysis provides a sound estimate for the determination of the lifetime QALYs gained by THA and TKA. In addition, this analysis demonstrates that specific postoperative rehabilitation can result in an additional mean QALY gain of .55 years, which represents one fourth of the effect of surgery. Even if this is interpreted as a small effect at an individual level, it is important when extrapolated to all patients undergoing TJA. At a national level, these improvements appear to have a similar magnitude of QALY gain when compared with published data regarding medications to lower blood pressure in all persons with arterial hypertension.
Collapse
|
111
|
Scott AR, Rush AJ, Naik AD, Berger DH, Suliburk JW. Surgical follow-up costs disproportionately impact low-income patients. J Surg Res 2015; 199:32-8. [DOI: 10.1016/j.jss.2015.04.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/03/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
|
112
|
Parry MC, Povey J, Blom AW, Whitehouse MR. Comparison of Acetabular Bone Resection, Offset, Leg Length and Post Operative Function Between Hip Resurfacing Arthroplasty and Total Hip Arthroplasty. J Arthroplasty 2015; 30:1799-803. [PMID: 25981328 DOI: 10.1016/j.arth.2015.04.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/29/2015] [Accepted: 04/20/2015] [Indexed: 02/01/2023] Open
Abstract
Controversy exists regarding the amount of acetabular bone resection, biomechanics and function of patients receiving either total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA). A cohort of patients undergoing 36 mm ceramic-on-ceramic THA (89) or metal-on-metal HRA (86) were compared. No difference was observed when the ratio of native femoral head size was compared to the implanted acetabular component size (1.15 ± 0.1 HRA c.f. 1.13 ± 0.1 THA). No difference was observed in acetabular offset, vertical centre of rotation or function (OHS mean 47 in both groups) but leg length discrepancy (1.8 mm c.f. 5.5 mm) and femoral offset did differ (0.6 mm c.f. 4.1 mm). This demonstrates that 36 mm ceramic-on-ceramic THA is not associated with more bone resection than HRA and achieves equivalent function whilst avoiding the problems of metal-on-metal bearings.
Collapse
Affiliation(s)
- Michael C Parry
- Muculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - James Povey
- Muculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Ashley W Blom
- Muculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Michael R Whitehouse
- Muculoskeletal Research Unit, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| |
Collapse
|
113
|
Subedi N, Chew NS, Chandramohan M, Scally AJ, Groves C. Effectiveness of fluoroscopy-guided intra-articular steroid injection for hip osteoarthritis. Clin Radiol 2015; 70:1276-80. [PMID: 26350147 DOI: 10.1016/j.crad.2015.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 06/14/2015] [Accepted: 07/03/2015] [Indexed: 11/17/2022]
Abstract
AIM To demonstrate the benefits of fluoroscopy-guided intra-articular steroid injection in the hip with varying degrees of disease severity, and to investigate the financial aspects of the procedure and impact on waiting time. MATERIALS AND METHODS A prospective study was undertaken of patients who underwent fluoroscopic intra-articular steroid injection over the 9-month study period. Comparative analysis of the Oxford hip pain score pre- and 6-8 weeks post-intra-articular injection was performed. Hip radiographs of all patients were categorised as normal, mild, moderate, or severe disease (four categories) based on the modified Kellgren-Lawrence severity scale, and improvement on the Oxford hip pain score on each of these four severity categories were assessed. RESULTS Within the study cohort of 100 patients, the mean increase in post-procedure hip score of 7.32 points confirms statistically significant benefits of the therapy (p<0.001, 95% confidence interval: 5.55-9.09). There was no significant difference in pre-injection hip score or change in score between the four severity categories (p=0.51). Significant improvement in hip score (p<0.05) was demonstrated in each of the four severity categories 6-8 weeks post-injection. No associated complications were observed. CONCLUSION The present study confirms that fluoroscopy-guided intra-articular steroid injection is a highly effective therapeutic measure for hip osteoarthritis across all grades of disease severity with significant cost savings and the potential to reduce waiting times.
Collapse
Affiliation(s)
- N Subedi
- Department of Radiology, Royal Preston Hospital, Lancashire Teaching Hospitals, UK.
| | - N S Chew
- Clinical Radiology Department, Bradford Teaching Hospitals NHS Trust, Bradford, UK
| | - M Chandramohan
- Clinical Radiology Department, Bradford Teaching Hospitals NHS Trust, Bradford, UK
| | - A J Scally
- School of Health Studies, University of Bradford, Bradford, UK
| | - C Groves
- Clinical Radiology Department, Bradford Teaching Hospitals NHS Trust, Bradford, UK
| |
Collapse
|
114
|
Abstract
Introduction: The heath care system in the United States is in the midst of a transition, in large part to help accommodate an older and more medically complex population. Central to the current evolution is the reassessment of value based on the cost utility of a particular procedure compared to alternatives. The existing contribution of geriatric orthopedics to the societal burden of disease is substantial, and literature focusing on the economic value of treating elderly populations with musculoskeletal injuries is growing. Materials and Methods: A literature review of peer-reviewed publications and abstracts related to the cost-effectiveness of treating geriatric patients with orthopedic injuries was carried out. Results: In our review, we demonstrate that while cost-utility studies generally demonstrate net society savings for most orthopedic procedures, geriatric populations often contribute to negative net society savings due to decreased working years and lower salaries while in the workforce. However, the incremental cost-effective ratio for operative intervention has been shown to be below the financial willingness to treat threshold for common procedures including joint replacement surgery of the knee (ICER US$8551), hip (ICER US$17 115), and shoulder (CE US$957) as well as for spinal procedures and repair of torn rotator cuffs (ICER US$12 024). We also discuss the current trends directed toward improving institutional value and highlight important complementary next steps to help overcome the growing demands of an older, more active society. Conclusion: The geriatric population places a significant burden on the health care system. However, studies have shown that treating this demographic for orthopedic-related injuries is cost effective and profitable for providers under certain scenarios.
Collapse
Affiliation(s)
- Jeremy Truntzer
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Christopher Nacca
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - David Paller
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| |
Collapse
|
115
|
Lavernia CJ, Iacobelli DA, Brooks L, Villa JM. The Cost-Utility of Total Hip Arthroplasty: Earlier Intervention, Improved Economics. J Arthroplasty 2015; 30:945-9. [PMID: 25865813 DOI: 10.1016/j.arth.2014.12.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/23/2014] [Accepted: 12/30/2014] [Indexed: 02/01/2023] Open
Abstract
We estimated the cost of Quality-Adjusted-Life-Years gained according to preoperative disease severity. We studied 159 primary unilateral THA, mean follow-up: 4 years. A median split of preoperative WOMAC scores was done to set apart a low (better) and a high (worse) score group. The groups with worse preoperative WOMAC were consistently associated with a less cost-effective intervention. The highest mean cost-effectiveness was achieved by patients with better WOMAC-total ($8256.32/QALY-gained). As patients aged, the cost-effectiveness of THA decreased. Patients 75 years of age or older and with worse scores had the least cost-effective interventions ($25,937.33/QALY-gained). THA remains a very cost-effective intervention even when performed in older "sicker" patients. Waiting for the patient to deteriorate will make the intervention more "expensive".
Collapse
Affiliation(s)
- Carlos J Lavernia
- The Center for Advanced Orthopedics at Larkin Hospital South Miami, Florida
| | - David A Iacobelli
- The Center for Advanced Orthopedics at Larkin Hospital South Miami, Florida; Arthritis Surgery Research Foundation South Miami, Florida
| | - Larry Brooks
- Arthritis Surgery Research Foundation South Miami, Florida
| | - Jesus M Villa
- The Center for Advanced Orthopedics at Larkin Hospital South Miami, Florida; Arthritis Surgery Research Foundation South Miami, Florida
| |
Collapse
|
116
|
Koh IJ, Kim GH, Kong CG, Park SW, Park TY, In Y. The Patient's Age and American Society of Anesthesiologists Status Are Reasonable Criteria for Deciding Whether to Perform Same-Day Bilateral TKA. J Arthroplasty 2015; 30:770-5. [PMID: 25512032 DOI: 10.1016/j.arth.2014.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 10/15/2014] [Accepted: 12/02/2014] [Indexed: 02/01/2023] Open
Abstract
We investigated whether basing a decision to perform same-day bilateral TKA (SD BTKA) on the patient's age and American Society of Anesthesiologists (ASA) status was reasonable. We retrospectively reviewed the records of 1386 patients who underwent 2086 TKAs (686 unilateral TKAs [UTKAs], 1038 SD BTKAs, and 362 one-week staged BTKAs). For the entire cohort, patients undergoing SD BTKA had a higher risk of major complications compared to those undergoing UTKA. However, there was no difference in the incidence of complications for patients aged<75 years with an ASA status of 1 or 2 who underwent UTKA or SD BTKA. If patients are selected based on age and ASA status, SD BTKA may have a risk of postoperative complication similar to UTKA.
Collapse
Affiliation(s)
- In Jun Koh
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Korea; Department of Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Geon-Hyeong Kim
- Department of Orthopaedic Surgery, Uijeongbu St. Mary's Hospital, Uijeongbu-si, Gyeonggi-do, Korea
| | - Chae-Gwan Kong
- Department of Orthopaedic Surgery, Uijeongbu St. Mary's Hospital, Uijeongbu-si, Gyeonggi-do, Korea; Department of Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Se-Wook Park
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Korea
| | - Tae Yong Park
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Korea
| | - Yong In
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, Seoul, Korea; Department of Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea
| |
Collapse
|
117
|
Higgins BT, Barlow DR, Heagerty NE, Lin TJ. Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. J Arthroplasty 2015; 30:419-34. [PMID: 25453632 DOI: 10.1016/j.arth.2014.10.020] [Citation(s) in RCA: 237] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 10/13/2014] [Indexed: 02/06/2023] Open
Abstract
The objective of this study is to compare the clinical, radiographic and surgical outcomes among patients undergoing primary THA performed via the anterior versus posterior approach. We searched numerous sources and eventually included 17 studies, totaling 2302 participants. In terms of post-operative pain and function, the anterior approach was significantly favored in 4 studies at short-term follow-up. Pooled estimates showed a significant difference in favor of the anterior approach in terms of length of stay and dislocations. Current evidence comparing outcomes following anterior versus posterior THA does not demonstrate clear superiority of either approach. Until more rigorous, randomized evidence is available, we recommend choice of surgical approach for THA be based on patient characteristics, surgeon experience and surgeon and patient preference.
Collapse
Affiliation(s)
- Brendan T Higgins
- Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Daniel R Barlow
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Nathan E Heagerty
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Tim J Lin
- Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| |
Collapse
|
118
|
Cost-effectiveness of prophylactic granulocyte colony-stimulating factor for febrile neutropenia in breast cancer patients receiving FEC-D. Breast Cancer Res Treat 2015; 150:169-80. [DOI: 10.1007/s10549-015-3309-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/09/2015] [Indexed: 10/24/2022]
|
119
|
Abstract
This review examines the future of total hip arthroplasty, aiming to avoid past mistakes
Collapse
Affiliation(s)
- A. Manktelow
- Nottingham University NHS Hospitals Trust, Hucknall Road, Nottingham NG5 1BP, UK
| | - B. Bloch
- Nottingham University NHS Hospitals Trust, Hucknall Road, Nottingham NG5 1BP, UK
| |
Collapse
|
120
|
Goodman SM, Ravi B, Hawker G. Outcomes in rheumatoid arthritis patients undergoing total joint arthroplasty. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/ijr.14.47] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
121
|
Parry MC, Duncan CP. The challenge of methicillin resistant staphylococcal infection after total hip replacement. Bone Joint J 2014; 96-B:60-5. [PMID: 25381410 DOI: 10.1302/0301-620x.96b11.34333] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Advances in the treatment of periprosthetic joint infections of the hip have once more pushed prosthesis preserving techniques into the limelight. At the same time, the common infecting organisms are evolving to become more resistant to conventional antimicrobial agents. Whilst the epidemiology of resistant staphylococci is changing, a number of recent reports have advocated the use of irrigation and debridement and one-stage revision for the treatment of periprosthetic joint infections due to resistant organisms. This review presents the available evidence for the treatment of periprosthetic joint infections of the hip, concentrating in particular on methicillin resistant staphylococci. Cite this article: Bone Joint J 2014;96-B(11 Suppl A):60–5.
Collapse
Affiliation(s)
- M. C. Parry
- University of British Columbia, Department
of Orthopaedics, 3114-910 West 10th Avenue, Vancouver, British
Columbia, Canada
| | - C. P. Duncan
- University of British Columbia, Department
of Orthopaedics, 3114-910 West 10th Avenue, Vancouver, British
Columbia, Canada
| |
Collapse
|
122
|
Brennan SL, Lane SE, Lorimer M, Buchbinder R, Wluka AE, Page RS, Osborne RH, Pasco JA, Sanders KM, Cashman K, Ebeling PR, Graves SE. Associations between socioeconomic status and primary total knee joint replacements performed for osteoarthritis across Australia 2003-10: data from the Australian Orthopaedic Association National Joint Replacement Registry. BMC Musculoskelet Disord 2014; 15:356. [PMID: 25348054 PMCID: PMC4223827 DOI: 10.1186/1471-2474-15-356] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 10/17/2014] [Indexed: 02/01/2023] Open
Abstract
Background Relatively little is known about the social distribution of total knee joint replacement (TKR) uptake in Australia. We examine associations between socioeconomic status (SES) and TKR performed for diagnosed osteoarthritis 2003–10 for all Australian males and females aged ≥30 yr. Methods Data of primary TKR (n = 213,018, 57.4% female) were ascertained from a comprehensive national joint replacement registry. Residential addresses were matched to Australian Census data to identify area-level social disadvantage, and categorised into deciles. Estimated TKR rates were calculated. Poisson regression was used to model the relative risk (RR) of age-adjusted TKR per 1,000py, stratified by sex and SES. Results A negative relationship was observed between TKR rates and SES deciles. Females had a greater rate of TKR than males. Surgery utilisation was greatest for all adults aged 70-79 yr. In that age group differences in estimated TKR per 1,000py between deciles were greater for 2010 than 2003 (females: 2010 RR 4.32 and 2003 RR 3.67; males: 2010 RR 2.04 and 2003 RR 1.78). Conclusions Identifying factors associated with TKR utilisation and SES may enhance resource planning and promote surgery utilisation for end-stage osteoarthritis. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-356) contains supplementary material, which is available to authorized users.
Collapse
|
123
|
Assmann G, Kasch R, Maher CG, Hofer A, Barz T, Merk H, Flessa S. Comparison of health care costs between aseptic and two stage septic hip revision. J Arthroplasty 2014; 29:1925-31. [PMID: 24927869 DOI: 10.1016/j.arth.2014.04.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 04/23/2014] [Accepted: 04/30/2014] [Indexed: 02/01/2023] Open
Abstract
The number of septic and aseptic total hip arthroplasty (THA) revisions will increase, which involves a greater financial burden. We here provide a retrospective consecutive analysis of the major variable direct costs involved in revision THA for aseptic and septic failure. A total of 144 patients (30 septic, 114 aseptic) treated between January 1, 2009 and March 31, 2012 was included. The management of septic THA loosening is much more expensive than that of aseptic loosening ($14,379.8 vs. $5,487.4). This difference is mainly attributable to the two-stage exchange technique used for septic failure (hospital stay: 40.2 vs. 15.6 days) and significantly higher implant costs ($3,930.9 vs. $2,298.2). The septic implantation part is on average $3,384.6 more expensive than aseptic procedures (P < .001).
Collapse
Affiliation(s)
- Grit Assmann
- Department of Health Care Management, Faculty of Law and Economics, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - Richard Kasch
- Clinic and Outpatient Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany; The George Institute, The University of Sydney, Sydney, Australia.
| | | | - André Hofer
- Clinic and Outpatient Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Thomas Barz
- Department of Orthopaedics and Trauma Surgery, Asklepios Hospital Uckermark, Schwedt, Germany
| | - Harry Merk
- Clinic and Outpatient Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Steffen Flessa
- Department of Health Care Management, Faculty of Law and Economics, Ernst-Moritz-Arndt-University, Greifswald, Germany
| |
Collapse
|
124
|
Raphael DR, Cannesson M, Schwarzkopf R, Garson LM, Vakharia SB, Gupta R, Kain ZN. Total joint Perioperative Surgical Home: an observational financial review. Perioper Med (Lond) 2014; 3:6. [PMID: 25177486 PMCID: PMC4149757 DOI: 10.1186/2047-0525-3-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 07/25/2014] [Indexed: 12/01/2022] Open
Abstract
Background The numbers of people requiring total arthroplasty is expected to increase substantially over the next two decades. However, increasing costs and new payment models in the USA have created a sustainability gap. Ad hoc interventions have reported marginal cost reduction, but it has become clear that sustainability lies only in complete restructuring of care delivery. The Perioperative Surgical Home (PSH) model, a patient-centered and physician-led multidisciplinary system of coordinated care, was implemented at UC Irvine Health in 2012 for patients undergoing primary elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). This observational study examines the costs associated with this initiative. Methods The direct cost of materials and services (excluding professional fees and implants) for a random index sample following the Total Joint-PSH pathway was used to calculate per diem cost. Cost of orthopedic implants was calculated based on audit-verified direct cost data. Operating room and post-anesthesia care unit time-based costs were calculated for each case and analyzed for variation. Benchmark cost data were obtained from literature search. Data are presented as mean ± SD (coefficient of variation) where possible. Results Total per diem cost was $10,042 ± 1,305 (13%) for TKA and $9,952 ± 1,294 (13%) for THA. Literature-reported benchmark per diem cost was $17,588 for TKA and $16,267 for THA. Implant cost was $7,482 ± 4,050 (54%) for TKA and $9869 ± 1,549 (16%) for THA. Total hospital cost was $17,894 ± 4,270 (24%) for TKA and $20,281 ± 2,057 (10%) for THA. In-room to incision time cost was $1,263 ± 100 (8%) for TKA and $1,341 ± 145 (11%) for THA. Surgery time cost was $1,558 ± 290 (19%) for TKA and $1,930 ± 374 (19%) for THA. Post-anesthesia care unit time cost was $507 ± 187 (36%) for TKA and $557 ± 302 (54%) for THA. Conclusions Direct hospital costs were driven substantially below USA benchmark levels using the Total Joint-PSH pathway. The incremental benefit of each step in the coordinated care pathway is manifested as a lower average length of stay. We identified excessive variation in the cost of implants and post-anesthesia care.
Collapse
Affiliation(s)
- Darren R Raphael
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, University of California, 101 The City Drive South Pavilion III, Building 29A Orange, Irvine, California 92868, USA
| | - Leslie M Garson
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
| | - Shermeen B Vakharia
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
| | - Ranjan Gupta
- Department of Orthopedic Surgery, University of California, 101 The City Drive South Pavilion III, Building 29A Orange, Irvine, California 92868, USA
| | - Zeev N Kain
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
| |
Collapse
|
125
|
Vogl M, Wilkesmann R, Lausmann C, Plötz W. The impact of preoperative patient characteristics on the cost-effectiveness of total hip replacement: a cohort study. BMC Health Serv Res 2014; 14:342. [PMID: 25128014 PMCID: PMC4139612 DOI: 10.1186/1472-6963-14-342] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 08/07/2014] [Indexed: 11/21/2022] Open
Abstract
Background To facilitate the discussion on the increasing number of total hip replacements (THR) and their effectiveness, we apply a joint evaluation of hospital case costs and health outcomes at the patient level to enable comparative effectiveness research (CER) based on the preoperative health state. Methods In 2012, 292 patients from a German orthopedic hospital participated in health state evaluation before and 6 months after THR, where health-related quality of life (HRQoL) and disease specific pain and dysfunction were analyzed using EQ-5D and WOMAC scores. Costs were measured with a patient-based DRG costing scheme in a prospective observation of a cohort. Costs per quality-adjusted life year (QALY) were calculated based on the preoperative WOMAC score, as preoperative health states were found to be the best predictors of QALY gains in multivariate linear regressions. Results Mean inpatient costs of THR were 6,310 Euros for primary replacement and 7,730 Euros for inpatient lifetime costs including revisions. QALYs gained using the U.K. population preference-weighted index were 5.95. Lifetime costs per QALY were 1,300 Euros. Conclusions The WOMAC score and the EQ-5D score before operation were the most important predictors of QALY gains. The poorer the WOMAC score or the EQ-5D score before operation, the higher the patient benefit. Costs per QALY were far below common thresholds in all preoperative utility score groups and with all underlying calculation methodologies.
Collapse
Affiliation(s)
- Matthias Vogl
- Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, P,O, Box 1129, Neuherberg 85758, Germany.
| | | | | | | |
Collapse
|
126
|
Jones MD, Parry MC, Whitehouse MR, Blom AW. Early death following primary total hip arthroplasty. J Arthroplasty 2014; 29:1625-8. [PMID: 24650899 DOI: 10.1016/j.arth.2014.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Revised: 01/30/2014] [Accepted: 02/03/2014] [Indexed: 02/01/2023] Open
Abstract
This study aims to describe the timing, cause of death, and excess surgical mortality associated with primary total hip arthroplasty when compared to a population awaiting primary total hip arthroplasty. Mortality rates were calculated at cutoffs of 30 and 90 days post-operation or following the addition to the waiting list. Cause of death was recorded from the death certificate. An excess surgical mortality of 0.256% at 30 days (P = 0.002) and 0.025% at 90 days post-operation (P = 0.892), unaffected by age or gender, was seen with myocardial infarction and pneumonia the cause of death in the majority of cases. By using a more appropriate control population, an excess surgical mortality at 30 days post-operation is demonstrated; the effect diminishes at 90 days post-operation.
Collapse
Affiliation(s)
- Mark D Jones
- Musculoskeletal Research Unit, University of Bristol, Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Michael C Parry
- Musculoskeletal Research Unit, University of Bristol, Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, University of Bristol, Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, University of Bristol, Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| |
Collapse
|
127
|
Allen KD, Golightly YM, Callahan LF, Helmick CG, Ibrahim SA, Kwoh CK, Renner JB, Jordan JM. Race and sex differences in willingness to undergo total joint replacement: the Johnston County Osteoarthritis Project. Arthritis Care Res (Hoboken) 2014; 66:1193-202. [PMID: 24470235 PMCID: PMC4207433 DOI: 10.1002/acr.22295] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 01/21/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Using data from the community-based Johnston County Osteoarthritis Project, we examined race and sex variations in willingness to undergo, and perceptions regarding, total joint replacement (TJR). METHODS Analyses were conducted for the total sample who participated in a followup measurement period from 2006-2010 (n = 1,522) and a subsample with symptomatic hip and/or knee osteoarthritis (sOA; n = 445). Participants indicated how willing they would be to have TJR (hip or knee) if their doctor recommended it; responses were categorized as "definitely" or "probably" willing versus "unsure," "probably not," or "definitely not" willing, or "don't know." Participants answered 7 questions regarding perceptions of TJR outcomes. Multivariable logistic regression models of willingness included participant characteristics (including socioeconomic status) and TJR perception variables that were associated with willingness at the P < 0.1 level in bivariate analyses. RESULTS African Americans had lower odds of willingness to undergo TJR than whites in the total sample (adjusted odds ratio [OR] 0.47 [95% confidence interval (95% CI) 0.31-0.72]) and the sOA subsample (adjusted OR 0.42 [95% CI 0.25-0.69]). There were no sex differences in willingness. African Americans expected poorer TJR outcomes than whites, but sex differences were minimal; perceptions of TJR outcomes were not significantly associated with willingness. CONCLUSION In this community sample, race differences in TJR willingness and perceptions were substantial, but sex differences were small. Perceptions of TJR did not appear to affect willingness or explain race differences in willingness.
Collapse
Affiliation(s)
- Kelli D. Allen
- Health Services Research and Development Service, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Yvonne M. Golightly
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
- Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Leigh F. Callahan
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, NC, USA
- Department of Medicine, University of North Carolina at Chapel Hill, NC, USA
- Department of Orthopaedics, University of North Carolina at Chapel Hill, NC, USA
- Department of Social Medicine, University of North Carolina at Chapel Hill, NC, USA
| | | | - Said A. Ibrahim
- Center for Health Equity Research and Promotion, Veterans Affairs Medical Center; Perelman University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - C. Kent Kwoh
- Division of Rheumatology and University of Arizona Arthritis Center, University of Arizona, Tucson, AZ
| | - Jordan B. Renner
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, NC, USA
- Department of Radiology, University of North Carolina at Chapel Hill, NC, USA
| | - Joanne M. Jordan
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, NC, USA
- Department of Medicine, University of North Carolina at Chapel Hill, NC, USA
- Department of Orthopaedics, University of North Carolina at Chapel Hill, NC, USA
| |
Collapse
|
128
|
The association between comorbidity and length of hospital stay and costs in total hip arthroplasty patients: a systematic review. J Arthroplasty 2014; 29:1009-14. [PMID: 24287128 DOI: 10.1016/j.arth.2013.10.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 10/03/2013] [Accepted: 10/06/2013] [Indexed: 02/01/2023] Open
Abstract
We performed a systematic review on the relationship between comorbidity and length of hospital stay (LOS) and hospital costs (HC). Electronic databases were systematically searched for relevant studies, conducting methodological quality assessment and best-evidence synthesis: 317 articles were identified, 10 of which fit the inclusion criteria; nine studies determined the relationship between comorbidity and LOS, with eight reporting a positive correlation; five studies were considered to be of high quality, four of which found a positive correlation; two studies analyzed the relationship between comorbidity and HC and reported significantly higher HC for patients with comorbidities, and were considered to be of high quality. In conclusion, there is limited evidence that patient comorbidity has a positive correlation with LOS and HC.
Collapse
|
129
|
Brown ML, Reed JD, Drinkwater CJ. Imageless computer-assisted versus conventional total hip arthroplasty: one surgeon's initial experience. J Arthroplasty 2014; 29:1015-20. [PMID: 24287127 DOI: 10.1016/j.arth.2013.10.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 10/01/2013] [Accepted: 10/07/2013] [Indexed: 02/01/2023] Open
Abstract
Computer-assisted surgery (CAS) systems are advocated to improve component positioning in THA, though potential operative risks and costs of CAS have fueled debate. The present study examines the radiographic outcomes, operative efficiency, cost, and midterm functional outcomes for patients who underwent THA, either with CAS or conventional instrumentation. Patient baseline characteristics were recorded for 126 lower-extremities in the CAS series, and 215 in the conventional series. There was no difference in Harris Hip Score or leg length discrepancy between series. Inclination angle, blood loss, and operating room times were increased for CAS. These results suggest that CAS confers no advantage over conventional methods regarding accuracy of THA component placement, drives unreimbursed increases in procedure costs, may expose patients to additional operative risk, and produces no functional benefit at midterm follow-up.
Collapse
Affiliation(s)
- Matthew L Brown
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.
| | - Jeffrey D Reed
- CTSI Research Fellow, Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York.
| | - Christopher J Drinkwater
- Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, New York.
| |
Collapse
|
130
|
Stacey D, Hawker G, Dervin G, Tugwell P, Boland L, Pomey MP, O'Connor AM, Taljaard M. Decision aid for patients considering total knee arthroplasty with preference report for surgeons: a pilot randomized controlled trial. BMC Musculoskelet Disord 2014; 15:54. [PMID: 24564877 PMCID: PMC3937455 DOI: 10.1186/1471-2474-15-54] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 02/18/2014] [Indexed: 12/21/2022] Open
Abstract
Background To evaluate feasibility and potential effectiveness of a patient decision aid (PtDA) for patients and a preference report for surgeons to reduce wait times and improve decision quality in patients with osteoarthritis considering total knee replacement. Methods A prospective two-arm pilot randomized controlled trial. Patients with osteoarthritis were eligible if they understood English and were referred for surgical consultation about an initial total knee arthroplasty at a Canadian orthopaedic joint assessment clinic. Patients were randomized to the PtDA intervention or usual education. The intervention was an osteoarthritis PtDA for patients and a one-page preference report summarizing patients’ clinical and decisional data for their surgeon. The main feasibility outcomes were rates of recruitment and questionnaire completion; the preliminary effectiveness outcomes were wait times and decision quality. Results Of 180 patients eligible for surgical consultation, 142 (79%) were recruited and randomized to the PtDA intervention (n = 71) or usual education (n = 71). Data collection yielded a 93% questionnaire completion rate with less than 1% missing items. After one year, 13% of patients remained on the surgical wait list. The median time from referral to being off the wait list (censored using survival analysis techniques) was 33.4 weeks for the PtDA group (n = 69, 95% CI: 26.0, 41.4) and 33.0 weeks for usual education (n = 71, 95% CI: 26.1, 39.9). Patients exposed to the PtDA had higher decision quality based on knowledge (71% versus 47%; p < 0.0001) and quality decision being an informed choice that is consistent with their values for option outcomes (56.4% versus 25.0%; p < 0.001). Conclusions Recruitment of patients with osteoarthritis considering surgery and data collection were feasible. As some patients remained on the surgical waiting list after one year, follow-up should be extended to two years. Patients exposed to the PtDA achieved higher decision quality compared to those receiving usual education but there was no difference in wait for surgery. Trials registration ClinicalTrials.Gov NCT00743951
Collapse
Affiliation(s)
- Dawn Stacey
- University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5, Canada.
| | | | | | | | | | | | | | | |
Collapse
|
131
|
Rampersaud YR, Lewis SJ, Davey JR, Gandhi R, Mahomed NN. Comparative outcomes and cost-utility after surgical treatment of focal lumbar spinal stenosis compared with osteoarthritis of the hip or knee--part 1: long-term change in health-related quality of life. Spine J 2014; 14:234-43. [PMID: 24325880 DOI: 10.1016/j.spinee.2013.12.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 12/02/2013] [Accepted: 12/04/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT It is well accepted that total hip and knee arthroplasty (THA/TKA) for osteoarthritis (OA) is associated with reliable and sustained improvements in postoperative health-related quality of life (HRQoL). Although several studies have demonstrated comparable outcomes with THA/TKA after surgical intervention for lumbar spinal stenosis (LSS), the sustainability of the outcome after LSS surgery compared with THA/TKA remains uncertain. PURPOSE The primary purpose of this study is to assess whether improvements in HRQoL after surgical management of focal lumbar spinal stenosis (FLSS) with or without spondylolisthesis are sustainable over the long term compared with that of THA/TKA for OA. STUDY DESIGN Single-center, retrospective, longitudinal matched cohort study of prospectively collected outcomes, with a minimum of 5-year follow-up (FU). PATIENT SAMPLE Patients who had primary one- to two-level spinal decompression with or without instrumented fusion for FLSS and THA/TKA for primary OA. OUTCOME MEASURES Postoperative change from baseline to last FU in Short-Form 36 physical component summary (PCS) and mental component summary (MCS) scores among groups was used as the primary outcome measure. METHODS An age, sex-matched inception cohort of primary one- to two-level spinal decompression with or without instrumented fusion for FLSS (n=99) was compared with a cohort of primary THA (n=99) and TKA (n=99) for OA and followed for a minimum of 5 years. Linear regression was used for the primary analysis. RESULTS Mean (percent) FUs in months were 80.5+16.04 (79%), 94.6+16.62 (92%), and 80.6+16.84 (85%) for the FLSS, THA, and TKA cohorts, respectively, with a range of 5 to 10 years for all three cohorts. The number of patients who have undergone revision including those lost to FU for the FLSS, THA, and TKA cohorts were n=20 (20.2%, same site [n=7] and adjacent segment [n=13]) requiring 27 operations, n=3 (3%, same site) requiring 5 operations, and n=8 (8.1%, same site) requiring 12 operations, respectively (p<.01). The average time to first revision was 56/65/43 months, respectively. Mean postoperative PCS (p<.0001) and MCS (p<.02) scores improved significantly and were durable for all groups at the last FU. The mean changes from baseline PCS/MCS scores to last FU were 8.5/6.4, 12.3/7.0, and 8.3/4.9 for FLSS, THA, and TKA, respectively. Adjusting for baseline age, sex, body mass index, PCS score, and MCS score, there was a strong trend in favor of greater sustained change in the PCS score of THA over FLSS (p=.07) and TKA (p=.08). No difference was noted for change in PCS score between FLSS and TKA (p=.95). No differences were noted for change in MCS score among all three cohorts (p>.1). CONCLUSIONS Significant improvements in HRQoL after surgical treatment of FLSS with or without spondylolisthesis and hip and knee OA are sustained for a mean of 7 to 8 years, with a minimum of 5-year FU. Despite a higher revision rate, patients undergoing surgery for FLSS can expect a comparable long-term average improvement in HRQoL from baseline compared with their peers undergoing TKA and to a lesser extent THA.
Collapse
Affiliation(s)
- Y Raja Rampersaud
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, Toronto, Ontario, Canada M5T-2S8; Arthritis Program, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Stephen J Lewis
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, Toronto, Ontario, Canada M5T-2S8; Arthritis Program, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - J Roderick Davey
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, Toronto, Ontario, Canada M5T-2S8; Arthritis Program, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rajiv Gandhi
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, Toronto, Ontario, Canada M5T-2S8; Arthritis Program, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nizar N Mahomed
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, Toronto, Ontario, Canada M5T-2S8; Arthritis Program, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
132
|
Rampersaud YR, Tso P, Walker KR, Lewis SJ, Davey JR, Mahomed NN, Coyte PC. Comparative outcomes and cost-utility following surgical treatment of focal lumbar spinal stenosis compared with osteoarthritis of the hip or knee: part 2--estimated lifetime incremental cost-utility ratios. Spine J 2014; 14:244-54. [PMID: 24239803 DOI: 10.1016/j.spinee.2013.11.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 08/22/2013] [Accepted: 11/07/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been widely accepted as highly cost-effective procedures, spine surgery for the treatment of degenerative conditions does not share the same perception among stakeholders. In particular, the sustainability of the outcome and cost-effectiveness following lumbar spinal stenosis (LSS) surgery compared with THA/TKA remain uncertain. PURPOSE The purpose of the study was to estimate the lifetime incremental cost-utility ratios for decompression and decompression with fusion for focal LSS versus THA and TKA for osteoarthritis (OA) from the perspective of the provincial health insurance system (predominantly from the hospital perspective) based on long-term health status data at a median of 5 years after surgical intervention. STUDY DESIGN/SETTING An incremental cost-utility analysis from a hospital perspective was based on a single-center, retrospective longitudinal matched cohort study of prospectively collected outcomes and retrospectively collected costs. PATIENT SAMPLE Patients who had undergone primary one- to two-level spinal decompression with or without fusion for focal LSS were compared with a matched cohort of patients who had undergone elective THA or TKA for primary OA. OUTCOME MEASURES Outcome measures included incremental cost-utility ratio (ICUR) ($/quality adjusted life year [QALY]) determined using perioperative costs (direct and indirect) and Short Form-6D (SF-6D) utility scores converted from the SF-36. METHODS Patient outcomes were collected using the SF-36 survey preoperatively and annually for a minimum of 5 years. Utility was modeled over the lifetime and QALYs were determined using the median 5-year health status data. The primary outcome measure, cost per QALY gained, was calculated by estimating the mean incremental lifetime costs and QALYs for each diagnosis group after discounting costs and QALYs at 3%. Sensitivity analyses adjusting for +25% primary and revision surgery cost, +25% revision rate, upper and lower confidence interval utility score, variable inpatient rehabilitation rate for THA/TKA, and discounting at 5% were conducted to determine factors affecting the value of each type of surgery. RESULTS At a median of 5 years (4-7 years), follow-up and revision surgery data was attained for 85%-FLSS, 80%-THA, and 75%-THA of the cohorts. The 5-year ICURs were $21,702/QALY for THA; $28,595/QALY for TKA; $12,271/QALY for spinal decompression; and $35,897/QALY for spinal decompression with fusion. The estimated lifetime ICURs using the median 5-year follow-up data were $5,682/QALY for THA; $6,489/QALY for TKA; $2,994/QALY for spinal decompression; and $10,806/QALY for spinal decompression with fusion. The overall spine (decompression alone and decompression and fusion) ICUR was $5,617/QALY. The estimated best- and worst-case lifetime ICURs varied from $1,126/QALY for the best-case (spinal decompression) to $39,323/QALY for the worst case (spinal decompression with fusion). CONCLUSION Surgical management of primary OA of the spine, hip, and knee results in durable cost-utility ratios that are well below accepted thresholds for cost-effectiveness. Despite a significantly higher revision rate, the overall surgical management of FLSS for those who have failed medical management results in similar median 5-year and lifetime cost-utility compared with those of THA and TKA for the treatment of OA from the limited perspective of a public health insurance system.
Collapse
Affiliation(s)
- Y Raja Rampersaud
- Department of Surgery, Division of Orthopedic Surgery, Toronto Western Hospital, University Health Network, 399 Bathurst St. East Wing, 1-441, Toronto, ON, Canada M5T-2S8.
| | - Peggy Tso
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Suite 425, 155 College St, Toronto, ON, Canada M5T 3M7
| | - Kevin R Walker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Suite 425, 155 College St, Toronto, ON, Canada M5T 3M7
| | - Stephen J Lewis
- Department of Surgery, Division of Orthopedic Surgery, Toronto Western Hospital, University Health Network, 399 Bathurst St. East Wing, 1-441, Toronto, ON, Canada M5T-2S8
| | - J Roderick Davey
- Department of Surgery, Division of Orthopedic Surgery, Toronto Western Hospital, University Health Network, 399 Bathurst St. East Wing, 1-441, Toronto, ON, Canada M5T-2S8
| | - Nizar N Mahomed
- Department of Surgery, Division of Orthopedic Surgery, Toronto Western Hospital, University Health Network, 399 Bathurst St. East Wing, 1-441, Toronto, ON, Canada M5T-2S8
| | - Peter C Coyte
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Suite 425, 155 College St, Toronto, ON, Canada M5T 3M7
| |
Collapse
|
133
|
|
134
|
Abstract
Total hip replacement (THR) is a very common procedure undertaken in up to 285 000 Americans each year. Patient satisfaction with THR is very high, with improvements in general health, quality of life, and function while at the same time very cost effective. Although the majority of patients have a high degree of satisfaction with their THR, 27% experience some discomfort, and up to 6% experience severe chronic pain. Although it can be difficult to diagnose the cause of the pain in these patients, this clinical issue should be approached systematically and thoroughly. A detailed history and clinical examination can often provide the correct diagnosis and guide the appropriate selection of investigations, which will then serve to confirm the clinical diagnosis made.
Collapse
Affiliation(s)
- B A Lanting
- London Health Sciences Center, 336 Windermere Ave, London, Ontario, Canada
| | | |
Collapse
|
135
|
Grosse SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res 2014; 8:165-78. [DOI: 10.1586/14737167.8.2.165] [Citation(s) in RCA: 487] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
136
|
Sloan FA, Hanrahan BW. Cost offsets to medicare attributable to receipt of hip, knee, and shoulder arthroplasty. Arthritis Care Res (Hoboken) 2013; 66:1203-12. [PMID: 24339239 DOI: 10.1002/acr.22260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 12/03/2013] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To estimate trends in numbers of and Medicare payments for hip, knee, and shoulder arthroplasties for beneficiaries with osteoarthritis (OA) and potential savings to Medicare from arthroplasty during followup. METHODS The analysis was based on longitudinal 5% Medicare enrollment and claims data for 1992-2010. The analysis of changes in Medicare payments attributable to total arthroplasty receipt used propensity score matching to obtain beneficiary control groups matched on demographic characteristics, general health, joint pain, and Medicare payments by major condition in the year preceding the index arthroplasty. An average treatment effect on the treated (ATT) overall and for each major condition was calculated for payments for care 7-36 months following the index arthroplasty procedure. RESULTS Growth in incident OA diagnoses of the hip, knee, and shoulder was substantially higher than growth in real Medicare spending on hip, knee, and shoulder arthroplasties. ATTs showed a mean saving to Medicare of $471/beneficiary/procedure for hip, no difference for knee, and a payment increase of $1,062 for shoulder arthroplasty during followup. For hip arthroplasty, the largest savings was for the circulatory system. For shoulder arthroplasty, increased payments during followup reflected increased payments for musculoskeletal care, especially for hip and knee arthroplasty. Overall, payment differences during followup by major condition were small. CONCLUSIONS Provision of hip but not knee and shoulder arthroplasty generated savings to Medicare during followup, but even for hip arthroplasty, the cost offset during followup was small relative to the program cost for the procedure itself.
Collapse
|
137
|
Virani NA, Williams CD, Clark R, Polikandriotis J, Downes KL, Frankle MA. Preparing for the bundled-payment initiative: the cost and clinical outcomes of total shoulder arthroplasty for the surgical treatment of glenohumeral arthritis at an average 4-year follow-up. J Shoulder Elbow Surg 2013; 22:1601-11. [PMID: 23510749 DOI: 10.1016/j.jse.2012.12.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 12/11/2012] [Accepted: 12/14/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study is to report on cost, outcomes, reliability, and safety of total shoulder arthroplasty (TSA) in patients with symptomatic glenohumeral joint arthritis. MATERIALS AND METHODS Eighty-three primary TSA patients operated on at a single institution by a single surgeon were prospectively studied for a mean of 48 months (range, 32-69 months). For each patient, validated subjective and independently evaluated objective outcome measures were collected to determine clinical reliability of TSA. In addition, safety-defined as the lack of major complications-and direct costs specific to each patient were collected and analyzed. RESULTS There were significant improvements (P < .01) in all clinical measures with the exception of the general health component of the Short Form 36 version 2. In addition, the majority of the patients met the criteria set forth for clinical reliability (76 of 83 [92%]) and safety (80 of 83 [96%]). The mean 4-year cost was $17,587, with the hospitalization accounting for 88% of this cost. Fiscal year was found to be responsible for the greatest fluctuation in total cost (P < .001). In addition, greater improvements in American Shoulder and Elbow Surgeons function scores (P = .022), higher preoperative social functioning scores on the Short Form 36 version 2 (P < .001), and female gender (P = .001) were correlated with lower cost. CONCLUSION Before operative treatment, patients had moderate to severe shoulder pain and were limited in performing their activities. The mean 4-year cost of $17,587 allowed the purchase of treatment with TSA, leading to a greater than 5-fold reduction in pain and a nearly double improvement in shoulder function with a small risk of harm.
Collapse
Affiliation(s)
- Nazeem A Virani
- Clinical Research Department, Foundation for Orthopaedic Research and Education, Tampa, FL, USA
| | | | | | | | | | | |
Collapse
|
138
|
Nwachukwu BU, Hamid KS, Bozic KJ. Measuring Value in Orthopaedic Surgery. JBJS Rev 2013; 1:01874474-201311000-00002. [PMID: 27490397 DOI: 10.2106/jbjs.rvw.m.00067] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Kamran S Hamid
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157
| | - Kevin J Bozic
- Department of Orthopaedic Surgery, University of California San Francisco, 500 Parnassus Avenue, MU320W, San Francisco, CA 94143-0728
| |
Collapse
|
139
|
What proportion of people with hip and knee osteoarthritis meet physical activity guidelines? A systematic review and meta-analysis. Osteoarthritis Cartilage 2013; 21:1648-59. [PMID: 23948979 DOI: 10.1016/j.joca.2013.08.003] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 07/15/2013] [Accepted: 08/03/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the proportion of people with hip and knee osteoarthritis that meet physical activity guidelines recommended for adults and older adults. METHOD Systematic review with meta-analysis of studies measuring physical activity of participants with hip and knee osteoarthritis using an activity monitor. Physical activity levels were calculated using the mean average [95% confidence interval (CI)] weighted according to sample size. Meta-analyses determined the proportion of people meeting physical activity guidelines and recommendations of (1) ≥150 min per week of moderate to vigorous physical activity (MVPA) in bouts of ≥10 min; (2) ≥150 min per week of MVPA in absence of bouts; (3) ≥10,000 steps per day and ≥7000 steps per day. The Grades of Research, Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of the evidence. RESULTS For knee osteoarthritis, 21 studies involving 3266 participants averaged 50 min per week (95% CI = 46, 55) of MVPA when measured in bouts of ≥10 min, 131 min per week (95% CI = 125, 137) of MVPA, and 7753 daily steps (95% CI = 7582, 7924). Proportion meta-analyses provided high quality evidence that 13% (95% CI = 7, 20) completed ≥150 min per week of MVPA in bouts of ≥10 min, low quality evidence that 41% (95% CI = 23, 61) completed ≥150 min per week of MVPA in absence of bouts, moderate quality evidence that 19% (95% CI = 8, 33) completed ≥10,000 steps per day, and low quality evidence that 48% (95% CI = 31, 65) completed ≥7000 steps per day. For hip osteoarthritis, 11 studies involving 325 participants averaged 160 min per week (95% CI = 114, 216) of MVPA when measured in bouts of ≥10 min, 189 min per week (95% CI = 166, 212) of MVPA, and 8174 daily steps (95% CI = 7670, 8678). Proportion meta-analyses provided low quality evidence that 58% (95% CI = 18, 92) completed ≥150 min per week of MVPA in absence of bouts, low quality evidence that 30% (95% CI = 13, 50) completed ≥10,000 steps per day, and low quality evidence that 60% (95% CI = 47, 73) completed ≥7000 steps per day. CONCLUSION A small to moderate proportion of people with knee and hip osteoarthritis met physical activity guidelines and recommended daily steps. Future research should establish the effects of increasing physical activity in this population to meet the current physical activity guidelines.
Collapse
|
140
|
Machin JT, Phillips S, Parker M, Carrannante J, Hearth MW. Patient satisfaction with the use of an enhanced recovery programme for primary arthroplasty. Ann R Coll Surg Engl 2013; 95:577-81. [DOI: 10.1308/rcsann.2013.95.8.577] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Enhanced recovery programmes (ERPs) are increasingly being used for arthroplasty. One of the core aims of an ERP is to improve the quality of patient experience. However, there is currently no published evaluation of patient satisfaction in relation to this new programme of care within orthopaedic surgery. The aim of this study was to compare the ERP against the standard care programme (SCP) at one centre. Methods A satisfaction survey addressing patient opinions on the key objectives of the ERP was conducted by telephone, using a set script. Of the 226 patients contacted, 143 (63.3%) responded (69 from the ERP and 74 from the SCP). Of the respondents, 71 received a total hip arthroplasty and 72 a total knee arthroplasty. Patients were contacted at a mean time from operation to survey of 27.2 weeks. They were asked to rate satisfaction on a five-point scale and complete the EQ-5D™ health questionnaire (EuroQol, Rotterdam, Netherlands) to measure healthcare outcomes. Results The mean patient satisfaction score of 4.07 for speed of recovery in the ERP group was significantly higher than the SCP group’s score of 3.68 (p=0.037). Adjusting for the preoperative health score, the postoperative health score was higher for ERP patients at 74.1 compared with 64.7 for SCP patients (p=0.0029). Furthermore, the percentage of patients who had a better than expected recovery was significantly greater in the ERP group at 85.5% compared with 58.1% (p=0.0004) in the SCP group. Conclusions We believe that the previously established reduction in length of hospital stay delivered by ERPs is not achieved at the expense of the patient’s experience.
Collapse
Affiliation(s)
- JT Machin
- Basildon and Thurrock University Hospitals NHS Foundation Trust, UK
| | - S Phillips
- Basildon and Thurrock University Hospitals NHS Foundation Trust, UK
| | - M Parker
- Basildon and Thurrock University Hospitals NHS Foundation Trust, UK
| | - J Carrannante
- Basildon and Thurrock University Hospitals NHS Foundation Trust, UK
| | - MW Hearth
- Basildon and Thurrock University Hospitals NHS Foundation Trust, UK
| |
Collapse
|
141
|
Pinto D, Robertson MC, Abbott JH, Hansen P, Campbell AJ. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial. Osteoarthritis Cartilage 2013; 21:1504-13. [PMID: 23811491 DOI: 10.1016/j.joca.2013.06.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 04/28/2013] [Accepted: 06/13/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the cost effectiveness of manual physiotherapy, exercise physiotherapy, and a combination of these therapies for patients with osteoarthritis of the hip or knee. METHODS 206 Adults who met the American College of Rheumatology criteria for hip or knee osteoarthritis were included in an economic evaluation from the perspectives of the New Zealand health system and society alongside a randomized controlled trial. Resource use was collected using the Osteoarthritis Costs and Consequences Questionnaire. Quality-adjusted life years (QALYs) were calculated using the Short Form 6D. Willingness-to-pay threshold values were based on one to three times New Zealand's gross domestic product (GDP) per capita of NZ$ 29,149 (in 2009). RESULTS All three treatment programmes resulted in incremental QALY gains relative to usual care. From the perspective of the New Zealand health system, exercise therapy was the only treatment to result in an incremental cost utility ratio under one time GDP per capita at NZ$ 26,400 (-$34,081 to $103,899). From the societal perspective manual therapy was cost saving relative to usual care for most scenarios studied. Exercise therapy resulted in incremental cost utility ratios regarded as cost effective but was not cost saving. For most scenarios combined therapy was not as cost effective as the two therapies alone. CONCLUSIONS In this study, exercise therapy and manual therapy were more cost effective than usual care at policy relevant values of willingness-to-pay from both the perspective of the health system and society. Trial registration number Australian New Zealand Clinical Trials Registry ACTRN12608000130369.
Collapse
Affiliation(s)
- D Pinto
- Department of Physical Therapy and Human Movement Sciences, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | | | | | | |
Collapse
|
142
|
Morris MJ, Barrett M, Lombardi AV, Tucker TL, Berend KR. Randomized blinded study comparing a bipolar sealer and standard electrocautery in reducing transfusion requirements in anterior supine intermuscular total hip arthroplasty. J Arthroplasty 2013; 28:1614-7. [PMID: 23507071 DOI: 10.1016/j.arth.2013.01.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 01/04/2013] [Accepted: 01/28/2013] [Indexed: 02/01/2023] Open
Abstract
Managing blood loss in total hip arthroplasty (THA) minimizes complications and decreases cost. Tissue-sparing anterior supine intermuscular THA (ASI-THA) may offer a quicker recovery but increases blood loss and transfusion requirements. This double-blinded prospective study compared a bipolar sealer (Aquamantys 6.0 bipolar sealer) to standard monopolar electrocautery in reducing blood loss in ASI-THA. Differences in calculated actual blood loss (ABL), hemoglobin, and transfusion requirements were examined. One hundred hips were randomized to each group. Transfusion rates were similar, 6% and 4%, respectively (p>0.05). ABL and change in hemoglobin were identical (1.35 and 3.3g). No significant differences in transfusion, blood loss, or hemoglobin were seen with a bipolar sealer device. Routine use of this bipolar sealer device has been discontinued in ASI-THA.
Collapse
Affiliation(s)
- Michael J Morris
- Joint Implant Surgeons, Inc., New Albany, OH, USA; Mount Carmel Health System, New Albany, OH, USA
| | | | | | | | | |
Collapse
|
143
|
Tsai JC, Sheng WH, Lo WY, Jiang CC, Chang SC. Clinical characteristics, microbiology, and outcomes of prosthetic joint infection in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 48:198-204. [PMID: 24064293 DOI: 10.1016/j.jmii.2013.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/04/2013] [Accepted: 08/13/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prosthetic joint infection (PJI) after total knee or hip replacement is a devastating complication associated with substantial morbidity and economic cost. The incidence of prosthetic joint infection is increasing as the use of mechanical joint replacement increases. The treatment approach to prosthetic joint infection is based on different clinical situations such as a patient's comorbidities, epidemic microbiology data, and surgical procedures. The aim of our study was to understand clinical characteristics of prosthetic joint infection, the microbiology of the prosthetic joint infection, and the outcomes of different treatment strategies during 2006-2011. METHODS We retrospectively collected cases of prosthetic joint infection in the National Taiwan University Hospital between January 1, 2006 and December 31, 2011. The patients' characteristics, microbiology, outcomes, and factors associated with treatment success were recorded. RESULTS One hundred and forty-four patients were identified as having PJI. Of these, 92 patients were entered into per-protocol analysis. Staphylococcus aureus was the most common causative organism (29.9%), followed by coagulase-negative Staphylococci (16.7%), and Enterococci (9.7%). The overall treatment success rate was 50%. Patients who received a two-stage revision had a better outcome, compared to patients who underwent other types of surgeries (70% vs. 32.7%, respectively; p < 0.001). In multivariate analysis, the two-stage revision was significantly associated with treatment success (odds ratio = 3.923, 95% confidence interval = 1.53-10.04). CONCLUSION Our study demonstrates that Staphylococcus aureus was the most common causative organisms in PJI. Performing two-stage revisions was significantly associated with a better outcome.
Collapse
Affiliation(s)
- Jen-Chih Tsai
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan; Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan.
| | - Wan-Yu Lo
- Department of Orthopedic Surgery, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Ching-Chuan Jiang
- Department of Orthopedic Surgery, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
| |
Collapse
|
144
|
Qureshi SA, McAnany S, Goz V, Koehler SM, Hecht AC. Cost-effectiveness analysis: comparing single-level cervical disc replacement and single-level anterior cervical discectomy and fusion: clinical article. J Neurosurg Spine 2013; 19:546-54. [PMID: 24010896 DOI: 10.3171/2013.8.spine12623] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In recent years, there has been increased interest in the use of cervical disc replacement (CDR) as an alternative to anterior cervical discectomy and fusion (ACDF). While ACDF is a proven intervention for patients with myelopathy or radiculopathy, it does have inherent limitations. Cervical disc replacement was designed to preserve motion, avoid the limitations of fusion, and theoretically allow for a quicker return to activity. A number of recently published systematic reviews and randomized controlled trials have demonstrated positive clinical results for CDR, but no studies have revealed which of the 2 treatment strategies is more cost-effective. The purpose of this study was to evaluate the cost-effectiveness of CDR and ACDF by using the power of decision analysis. Additionally, the authors aimed to identify the most critical factors affecting procedural cost and effectiveness and to define thresholds for durability and function to focus and guide future research. METHODS The authors created a surgical decision model for the treatment of single-level cervical disc disease with associated radiculopathy. The literature was reviewed to identify possible outcomes and their likelihood following CDR and ACDF. Health state utility factors were determined from the literature and assigned to each possible outcome, and procedural effectiveness was expressed in units of quality-adjusted life years (QALYs). Using ICD-9 procedure codes and data from the Nationwide Inpatient Sample, the authors calculated the median cost of hospitalization by multiplying hospital charges by the hospital-specific cost-to-charge ratio. Gross physician costs were determined from the mean Medicare reimbursement for each current procedural terminology (CPT) code. Uncertainty as regards both cost and effectiveness numbers was assessed using sensitivity analysis. RESULTS In the reference case, the model assumed a 20-year duration for the CDR prosthesis. Cervical disc replacement led to higher average QALYs gained at a lower cost to society if both strategies survived for 20 years ($3042/QALY for CDR vs $8760/QALY for ACDF). Sensitivity analysis revealed that CDR needed to survive at least 9.75 years to be considered a more cost-effective strategy than ACDF. Cervical disc replacement becomes an acceptable societal strategy as the prosthesis survival time approaches 11 years and the $50,000/QALY gained willingness-to-pay threshold is crossed. Sensitivity analysis also indicated that CDR must provide a utility state of at least 0.796 to be cost-effective. CONCLUSIONS Both CDR and ACDF were shown to be cost-effective procedures in the reference case. Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF. Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR, future long-term studies are required to validate the present analysis.
Collapse
Affiliation(s)
- Sheeraz A Qureshi
- Mount Sinai Hospital, Mount Sinai School of Medicine, Department of Orthopaedic Surgery, New York, New York
| | | | | | | | | |
Collapse
|
145
|
Abstract
OBJECTIVE Describe resource utilization and costs for total hip replacement (THR) and total knee replacement (TKR) for the 90 days before hospitalization for surgery, the hospital event, and the 90 and 360 days after hospitalization for surgery with emphasis on 90 days after hospitalization. METHODS A large insurance database was used to identify outpatient and summarized hospital resource use and payments (insurer perspective) for THR and TKR. A second large US database provided hospital details (charge description master level) of inpatient services, costs, and charges (hospital perspective) for a different sample of THR and TKR patients. Included patients were ≥45 years old, had no hospitalization record within 1 year before surgery, and THR length of stay (LOS) of 2-8 days or TKR LOS 2-6 days. RESULTS There were 22 618 THR and 50 686 TKR patients in the insurance database and 81 635 THR and 158 990 TKR in the hospital database. Average age was ∼66 years for THR and TKR patients. Median LOS was 4 days (both surgeries). Hospital costs (hospital perspective) were $17 588 in US dollars (USD) and $16 267 (USD) for THR and TKR, respectively. Reimbursement for hospital services (insurer perspective) were $22 967 (USD) and $21 583 (USD) for THR and TKR, respectively. In 90 days post-surgery, THR and TKR total payments were $3827 (USD) and $4237 (USD), respectively. Payments for the first 90 days post-surgery were 57.5% of the 360-day post-period for THR-related payments and 59.9% for TKR-related payments. CONCLUSION Payers considering use of episode-of-care payment models for THR and TKR may wish to concentrate efforts on the 90 days post-discharge. LIMITATIONS While this study used large samples of subjects, generalisability of the results may be limited since the samples were not randomized samples of THR and TKR patients. It is noteworthy that patients in the hospital sample are not the same as those in the insurer sample. Selection of hip-related and knee-related procedures and associated costs was based on qualitative review. Payers may use different billing codes or aggregate costs differently.
Collapse
Affiliation(s)
- Chris M Kozma
- C-K Consulting Associates, LLC, St. Helena Island, SC, USA.
| | | | | | | |
Collapse
|
146
|
Krischak G, Kaluscha R, Kraus M, Tepohl L, Nusser M. [Return to work after total hip arthroplasty]. Unfallchirurg 2013; 116:755-9. [PMID: 23756786 DOI: 10.1007/s00113-013-2424-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Return to work is an important prerequisite to achieve subjective success of an operation. The analysis of the routine data from the German Federal Pension Fund allows a comprehensive evaluation and investigation of factors which influence reintegration into employment. METHODS A random 2 % sample of rehabilitants was drawn from the scientific use file "Abgeschlossene Rehabilitation im Versicherungsverlauf 2002-2009" (completed rehabilitation in the course of health insurance 2002-2009) of the German Federal Pension Fund. Patients were included if they were 18-60 years old and had participated in rehabilitation due to the diagnosis arthritis of the hip. To obtain information on employment status the national insurance contributions and labor force groups in the year before and 2 years after rehabilitation were used. Using regression analysis the influence of sociodemographic factors was analyzed. RESULTS Of the 736 patients included in the survey 625 (84.9 %) were employed again 2 years after rehabilitation. Out of these 519 (83.0 %) returned to their previous profession and 228 (36.5 %) paid less insurance contributions. Increasing age and a manual job were identified as risk factors for re-entry into employment. CONCLUSION In Germany a high percentage of 84.9 % of patients return to work after joint replacement due to coxarthrosis. Nevertheless, the results indicate that the social situation becomes worse for approximately one sixth of the patients.
Collapse
Affiliation(s)
- G Krischak
- Institut für Rehabilitationsmedizinische Forschung, Universität Ulm, Wuhrstraße 2/1, Bad Buchau, Germany.
| | | | | | | | | |
Collapse
|
147
|
Clyde CT, Goyal N, Matar WY, Witmer D, Restrepo C, Hozack WJ. Workers' Compensation patients after total joint arthroplasty: do they return to work? J Arthroplasty 2013; 28:883-7. [PMID: 23583541 DOI: 10.1016/j.arth.2013.01.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 12/07/2012] [Accepted: 01/29/2013] [Indexed: 02/01/2023] Open
Abstract
Clinicians identify patients receiving Workers' Compensation (WC) as unlikely to fully benefit from total joint arthroplasty (TJA), with possibly decreased ability to return to work. We completed follow-up for 164 patients undergoing 177 arthroplasties while receiving WC between 2000 and 2009. Inquiry was made regarding work status, nature of work, and return to work time frame. Patients undergoing primary versus revision TJA returned to work 70.2% versus 43.9%, respectively (p=0.002). The mean time frame for return to work following primary TJA was 16.4 weeks. Manual laborers versus sedentary workers returned to work 67.1% versus 84.8%, respectively (p=0.05). As this group is limited by the strenuous nature of their employment, clinicians should be aware that receiving WC may modestly impact return to work following arthroplasty.
Collapse
Affiliation(s)
- Corey T Clyde
- The Rothman Institute of Orthopaedic at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | |
Collapse
|
148
|
Hawker GA, Badley EM, Borkhoff CM, Croxford R, Davis AM, Dunn S, Gignac MA, Jaglal SB, Kreder HJ, Sale JEM. Which Patients Are Most Likely to Benefit From Total Joint Arthroplasty? ACTA ACUST UNITED AC 2013; 65:1243-52. [DOI: 10.1002/art.37901] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 02/07/2013] [Indexed: 01/14/2023]
|
149
|
Ravi B, Escott B, Shah PS, Jenkinson R, Chahal J, Bogoch E, Kreder H, Hawker G. A systematic review and meta-analysis comparing complications following total joint arthroplasty for rheumatoid arthritis versus for osteoarthritis. ACTA ACUST UNITED AC 2013. [PMID: 23192790 DOI: 10.1002/art.37690] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is based on studies of patients with osteoarthritis (OA), with little being known about outcomes in patients with rheumatoid arthritis (RA). The objective of the present study was to review the current evidence regarding rates of THA/TKA complications in RA versus OA. METHODS Data sources used were Medline, EMBase, Cinahl, Web of Science, and reference lists of articles. We included reports published between 1990 and 2011 that described studies of primary total joint arthroplasty of the hip or knee and contained information on outcomes in ≥200 RA and OA joints. Outcomes of interest included revision, hip dislocation, infection, 90-day mortality, and venous thromboembolic events. Two reviewers independently assessed each study for quality and extracted data. Where appropriate, meta-analysis was performed; if this was not possible, the level of evidence was assessed qualitatively. RESULTS Forty studies were included in this review. The results indicated that patients with RA are at increased risk of dislocation following THA (adjusted odds ratio 2.16 [95% confidence interval 1.52-3.07]). There was fair evidence to support the notion that risk of infection and risk of early revision following TKA are increased in RA versus OA. There was no evidence of any differences in rates of revision at later time points, 90-day mortality, or rates of venous thromboembolic events following THA or TKA in patients with RA versus OA. RA was explicitly defined in only 3 studies (7.5%), and only 11 studies (27.5%) included adjustment for covariates (e.g., age, sex, and comorbidity). CONCLUSION The findings of this literature review and meta-analysis indicate that, compared to patients with OA, patients with RA are at higher risk of dislocation following THA and higher risk of infection following TKA.
Collapse
|
150
|
The cost-effectiveness of total joint arthroplasty: a systematic review of published literature. Best Pract Res Clin Rheumatol 2013; 26:649-58. [PMID: 23218429 DOI: 10.1016/j.berh.2012.07.013] [Citation(s) in RCA: 249] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To summarise the state of the literature evaluating the cost-effectiveness of elective total hip and knee arthroplasty (THA and TKA). METHODS We conducted a systematic review of published cost-effectiveness analyses of THA and TKA. To limit our search to high-quality published papers, we selected those papers included in the Cost-Effectiveness Analysis Registry (created by the Center for the Evaluation of Value and Risk in Health at Tufts University) and augmented the search with papers listed in PubMed. The data abstracted included incremental cost-effectiveness ratios, perspective of the analysis, time frame, sensitivity analyses conducted, and utility assessment. All cost-effectiveness ratios were converted to 2011 USD. RESULTS Seven studies presenting cost-effectiveness ratios for TKA and six studies for THA were included in our review. All economic evaluations of TKA were published between 2006 and 2012. By contrast, THA studies were published between 1996 and 2008. Out of the 13 studies evaluated in this review, four were from the societal perspective and eight were from the payer perspective. Five studies spanned the lifetime horizon. Of the selected studies, six used probabilistic sensitivity analysis to address uncertainty in data parameters. Both procedures have been shown to be highly cost-effective from the societal perspective over the entire lifespan. CONCLUSION THA and TKA have been found to be highly cost-effective in a number of high-quality studies. Further analyses are needed on the cost-effectiveness of alternative surgical options, particularly osteotomy. Future economic evaluations should address the expanding indications of THA and TKA to younger, more physically active individuals.
Collapse
|