Cost-effectiveness of cemented versus cementless total hip arthroplasty. A Markov decision analysis based on implant cost

Cost-effectiveness analysis of proximal femoral nail versus bipolar hemiarthroplasty for femoral neck fracture

BACKGROUND

Hip fractures are a serious public health problem with high rates of morbidity, mortality, disability and care costs. The aim of the research was to perform cost effectiveness analysis of hip fracture treatments using proximal femoral nail and bipolar hemiarthroplasty surgeries.

METHODS

The analysis was completed based on the perspectives of the paying institution and patient. A decision tree model was used to determine whether proximal femoral nail or bipolar arthroplasty was most cost effective for the management of a femoral neck fracture in this patient population.

RESULTS

The findings from the decision tree model suggested that ICERs for BHP were TRY 43,164.53 TL/QALY based on reimbursement and TRY 3,977.35 TL/QALY based on patient expenditures. Compared to the calculated threshold value of TRY 60.575 TL, we concluded BHP to be a cost-effective option. Moreover, all parameter changes yielded stable results on the one-way sensitivity analysis. When it comes to the probabilistic sensitivity analysis, BHP with specified threshold value was found to be cost-effective in all the comparisons. Currently available data the use of bipolar hemiarthroplasty as the more cost- effective treatment strategy in this specific population.

CONCLUSION

Overall, our findings showed HA as a cost-effective surgical technique at the calculated threshold in a population over 60 years of age. The impacts of HA on patients' quality of life and costs are remarkable.

Analysis of modified surface topographies of titanium-based hip implants using finite element method

BACKGROUND

In order to ensure the proper function of the cementless hip implant, the connection between the femoral bone and the implant has to be as strong as possible. According to experimental studies, implants with a rough surface reduce micro-movements between femoral bone and implant, which helps form a stronger connection between them.

OBJECTIVE

The goal of this study was to analyze how half-cylinder surface topographies of different diameter values affect shear stress values and their distribution on the surface of the hip implant and trabecular femoral bone.

METHODS

Nine models with different half-cylinder diameter values (200 μm, 400 μm, and 500 μm) and distances between half-cylinders were created for the analysis using the finite element method. Each model consisted of three layers: implant, trabecular, and cortical femoral bone.

RESULTS

For all three diameter values, the highest shear stress value, for the implant layer, was located after the first half-cylinder on the side where force was defined. For the trabecular bone, the first half-cylinder was under lower amounts of shear stress.

CONCLUSION

If we only consider shear stress values, we can say that models with 400 μm and 500 μm diameter values are a better choice than models with 100 μm diameter values.

Comparing Intraoperative Blood Loss in Cemented, Uncemented, and Hybrid Total Hip Replacement for Neck of Femur Fractures

Background As the aging population increases, osteoporotic neck of femur fracture cases will continue to rise. Although hemiarthroplasty or half hip replacement is the treatment of choice in a majority of patients, a small but definite cohort of patients would need a total hip replacement. In these elderly patients who often have comorbidities, the use of cement to fix the prosthesis is often quoted as beneficial in view of perceived lower blood loss compared to uncemented fixation of the prosthesis. However, the cementation of the implant in itself has inherent problems. This study examined three modalities of fixation of a prosthesis for total hip replacement in the neck of femur fractures, namely, cemented, hybrid, and uncemented, and compared their relative intraoperative blood loss. Methodology This is a retrospective study with a follow-up of two years. Patients who presented to a level 1 trauma center in an inner city metropolitan with neck of femur fractures and were treated by total hip replacement were included in the study. Intraoperative blood loss was calculated using Nadler's formula. Results There was no statistical difference in intraoperative blood loss in either of the three groups of patients, namely, cemented, hybrid, or uncemented total hip replacement for neck of femur fractures. Conclusions Intraoperative blood loss should not influence the modality of prosthesis fixation for total hip replacement in neck of femur fractures.

Is the Direct Anterior Approach to THA Cost-effective? A Markov Analysis

BACKGROUND

The use of the direct anterior approach, a muscle-sparing technique for THA, has increased over the years; however, this approach is associated with longer procedure times and a more expensive direct cost. Furthermore, studies have shown a higher revision rate in the early stages of the learning curve. Whether the clinical advantages of the direct anterior compared with the posterior approach-such as less soft tissue damage, decreased short-term postoperative pain, a lower dislocation rate, decreased length of stay in the hospital, and higher likelihood of being discharged home-outweigh the higher cost is still debatable. Determining the cost-effectiveness of the approach may inform its utility and justify its use at various stages of the learning curve.

QUESTIONS/PURPOSES

We used a Markov modeling approach to ask: (1) Is the direct anterior approach more likely to be a cost-effective approach than the posterior approach over the long-term for more experienced or higher volume hip surgeons? (2) How many procedures does a surgeon need to perform for the direct anterior approach to be a cost-effective choice?

METHODS

A Markov model was created with three health states (well-functioning THA, revision THA, and death) to compare the cost-effectiveness of the direct anterior approach with that of the posterior approach in five scenarios: surgeons who performed one to 15, 16 to 30, 31 to 50, 51 to 100, and more than 100 direct anterior THAs during a 6-year span. Procedure costs (not charges), dislocation costs, and fracture costs were derived from published reports, and model was run using two different cost differentials between the direct anterior and posterior approaches (USD 219 and USD 1800, respectively). The lower cost was calculated as the total cost differential minus pharmaceutical and implant costs to account for differences in implant use and physician preference regarding postoperative pain management. The USD 1800 cost differential incorporated pharmaceutical and implant costs. Probabilities were derived from systematic review of the evidence as well as from the Australian Orthopaedic Association National Joint Replacement Registry. Utilities were estimated from best available literature and disutilities associated with dislocation and fracture were incorporated into the model. Quality of life was expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in that health state. The primary outcome measure was the incremental cost-effectiveness ratio, or the change in costs divided by the change in QALYs when the direct anterior approach was used for THA. USD 100,000 per quality-adjusted life years was used as a threshold for willingness to pay. One-way and probabilistic sensitivity analyses were performed for the scenario in which the direct anterior approach is cost-effective to further account for uncertainty in model inputs.

RESULTS

At a cost differential of USD 219 (95% CI 175 to 263), the direct anterior approach was associated with lower cost and higher effectiveness compared with the posterior approach for surgeons with an experience level of more than 100 operations during a 6-year span. At a cost differential of USD 1800 (95% CI 1440 to 2160), the direct anterior approach remained a cost-effective strategy for surgeons who performed more than 100 operations. At both cost differentials, the direct anterior approach was not cost-effective for surgeons who performed fewer than 100 operations. One-way sensitivity analyses revealed the model to be the most sensitive to fluctuations in the utility of revision THA, probability of revision after the posterior approach THA, probability of dislocation after the posterior approach THA, fluctuations in the probability of dislocation after direct anterior THA, cost of direct anterior THA, and probability of intraoperative fracture with the direct anterior approach. At the cost differential of USD 219 and for surgeons with a surgical experience level of more than 100 direct anterior operations, the direct anterior approach was still the cost-effective strategy for the entire range of values.

CONCLUSION

For high-volume hip surgeons, defined here as surgeons who perform more than 100 procedures during a 6-year span, the direct anterior approach may be a cost-effective strategy within the limitations imposed by our analysis. For lower volume hip surgeons, performing a more familiar approach appears to be more cost-effective.

Imaging of Patients Suspected of SLAP Tear: A Cost-Effectiveness Study

Background: Superior labral anterior-to-posterior (SLAP) tears are a common shoulder pathology. While MRI is the imaging gold standard for diagnosis of this pathology, the cost-effectiveness of the common MRI strategies is unclear. Objective: The primary objective of our study was to determine the cost-effectiveness of the common MRI-based strategies used for the diagnosis of SLAP tears. Methods: We created decision analytic models from the U.S. health care system perspective over a two-year time horizon for a hypothetical patient population of 25-year-olds with a previous diagnosis of SLAP tear. We used the decision models to compare the differences in incremental cost-effectiveness of the common MRI strategies and resulting treatment applied for this patient type, which included combinations of 1.5T and 3T imaging and unenhanced MRI and MR arthrogram protocols. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2017 U.S. dollars. Results: When all imaging strategies were considered, the unenhanced 3T MRI based imaging strategy was the preferred and dominant option over 3T MR arthrography (MRA) and 1.5T imaging (MRI/MRA). When the model was run without 3T imaging as an option, 1.5T MRA was the favored option. Probabilistic sensitivity analyses confirmed the same preferred imaging strategy results. Conclusion: An unenhanced 3T MRI based strategy is the most cost-effective imaging option for patients with suspected SLAP tear. When 3T imaging is not available, 1.5T MRA is more cost-effective than 1.5T imaging. The main driver of these results is the fact that 3T MRI and 1.5T MRA are the most specific tests in these respective scenarios which results in fewer false positives and prevents unnecessary surgeries leading to decreased costs. Clinical Impact: Our cost-effectiveness model findings complement prior diagnostic accuracy work, helping produce a more comprehensive approach to define imaging utility for the SLAP patient population for radiologists, clinicians, and patients who have access to various types of MRI options.

Cost-effectiveness analyses comparing cemented, cementless, hybrid and reverse hybrid fixation in total hip arthroplasty: a systematic overview and critical appraisal of the current evidence

Background: This study aims to present an overview and critical appraisal of all previous studies comparing costs and outcomes of the different modes of fixation in total hip arthroplasty (THA). A secondary aim is to provide conclusions regarding the most cost-effective mode of implant fixation per gender and age-specific population in THA, based on high quality studies.Methods: A systematic search was conducted to identify cost-effectiveness analyses (CEAs) comparing different modes of implant fixation in THA. Analysis of results was done with solely CEAs that had a high methodological quality.Results: A total of 12 relevant studies were identified and presented, of which 5 were considered to have the methodological rigor for inclusion in the analysis of results. These studies found that either cemented or hybrid fixation was the most cost-effective implant fixation mode for most age- and gender-specific subgroups.Conclusion: Currently available well performed CEAs generally support the use of cemented and hybrid fixation for all age-groups relevant for THA and both genders. However, these findings were mainly based on a single database and depended on assumptions made in the studies' methodology. Issues discussed in this paper have to be considered and future work is needed.

Cost effectiveness analyses of total hip arthroplasty for hip osteoarthritis: A PRISMA systematic review

BACKGROUND

Healthcare services are facing economic constraints globally with an increasingly elderly population, and greater burdens of osteoarthritis. Because of the chronic nature of osteoarthritis and the costs associated with surgery, arthroplasty is seen as potentially cost saving. There have been no systematic reviews conducted on cost effectiveness analysis (CEA) studies of total hip arthroplasty (THA) in the management of osteoarthritis. The aim of this systematic review was to evaluate CEAs conducted on THA for osteoarthritis to determine if THA is a cost-effective intervention.

MATERIALS AND METHODS

A systematic review was conducted using five databases to identify all clinical CEAs of THA for osteoarthritis conducted after 1 January 1997. Twenty-eight studies were identified that met the inclusion criteria. The Quality of Health Economic Analysis (QHES) checklist was employed to assess the quality of the studies.

RESULTS

The average QHES score was 86 indicating high quality studies. All studies reviewed concluded that THA was a cost-effective intervention. In younger patients, cementless THA and ceramic on polyethylene implants were found to be most cost effective. Hybrid THA and metal on polyethylene implants had the greatest cost utility in older patients. In patients with acetabular defects, cemented cup with impaction bone grafting was most cost effective, while dual mobility THA was most cost effective in patients with high risk of dislocation.

CONCLUSION

We have shown that THA is a cost-effective treatment for hip osteoarthritis. These findings should be implemented into clinical practice to improve cost utility in health services across the world.

Cemented versus uncemented hip implant fixation: Should there be age thresholds?

There is continued debate as to whether cemented or cementless implants should be utilized in particular cases based upon chronological age. This debate has been rekindled in the UK and other countries by directives mandating certain forms of acetabular and femoral component fixation based exclusively on the chronological age of the patient. This editorial focuses on the literature-based arguments to support the use of cementless total hip arthroplasty (THA), while addressing potential concerns surrounding safety and cost-effectiveness. Cite this article: Bone Joint Res. 2019;8(12):604-607.

Health state utilities associated with post-surgical Staphylococcus aureus infections

INTRODUCTION

Surgical site infections (SSIs) are among the most common and potentially serious complications after surgery. Staphylococcus aureus is a virulent pathogen frequently identified as a cause of SSI. As vaccines and other infection control measures are developed to reduce SSI risk, cost-utility analyses (CUA) of these interventions are needed to inform resource allocation decisions. A recent systematic review found that available SSI utilities are of "questionable quality." Therefore, the purpose of this study was to estimate the disutility (i.e., utility decrease) associated with SSIs.

METHODS

In time trade-off interviews, general population participants in the UK (London, Edinburgh) valued health states drafted based on literature and clinician interviews. Health states described either joint or spine surgery, with or without an SSI. The utility difference between otherwise identical health states with and without the SSI represented the disutility associated with the SSI.

RESULTS

A total of 201 participants completed interviews (50.2% female; mean age = 46.2 years). Mean (SD) utilities of health states describing joint and spine surgery without infections were 0.79 (0.23) and 0.78 (0.23). Disutilities of SSIs ranged from - 0.03 to - 0.32, depending on severity of the infection and subsequent medical interventions. All differences between corresponding health with and without SSIs were statistically significant (all p < 0.001).

CONCLUSION

The preference-based SSI disutilities derived in this study may be used to represent mild and serious SSIs in CUAs assessing and comparing the value of vaccinations that may reduce the risk of SSIs.

Choice of Prosthetic Implant Combinations in Total Hip Replacement: Cost-Effectiveness Analysis Using UK and Swedish Hip Joint Registries Data

BACKGROUND

Prosthetic implants used in total hip replacements (THR) have a range of bearing surface combinations (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, and metal-on-metal), head sizes (small [<36 mm in diameter] and large [≥36 mm in diameter]), and fixation techniques (cemented, uncemented, hybrid, and reverse hybrid). These can influence prosthesis survival, patients' quality of life, and healthcare costs.

OBJECTIVES

To compare the lifetime cost-effectiveness of implants for patients of different age and sex profiles.

METHODS

We developed a Markov model to compare the cost-effectiveness of various implants against small-head cemented metal-on-polyethylene implants. The probability that patients required 1 or more revision surgeries was estimated from analyses of more than 1 million patients in the UK and Swedish hip joint registries, for men and women younger than 55, 55 to 64, 65 to 74, 75 to 84, and 85 years and older. Implant and healthcare costs were estimated from local procurement prices, national tariffs, and the literature. Quality-adjusted life-years were calculated using published utility estimates for patients undergoing THR in the United Kingdom.

RESULTS

Small-head cemented metal-on-polyethylene implants were the most cost-effective for men and women older than 65 years. These findings were robust to sensitivity analyses. Small-head cemented ceramic-on-polyethylene implants were most cost-effective in men and women younger than 65 years, but these results were more uncertain.

CONCLUSIONS

The older the patient group, the more likely that the cheapest implants, small-head cemented metal-on-polyethylene implants, were cost-effective. We found no evidence that uncemented, hybrid, or reverse hybrid implants were the most cost-effective option for any patient group. Our findings can influence clinical practice and procurement decisions for healthcare payers worldwide.

Cost-utility analysis in orthopaedic trauma; what pays? A systematic review

BACKGROUND

As healthcare systems come under ever-increasing pressure to provide more care with fewer resources, emphasis is being placed on value-based systems that maximise quality and minimize cost. The aim of this study was to determine which interventions in fracture care have been demonstrated to be cost effective.

METHODS

A systemic review of cost-utility studies on the management of fractures from 1976 to 2015 was carried out using a search of the Cost-Effectiveness Analysis Registry, National Health Service Economic Evaluation Database (NHS EED) and MEDLINE.

RESULTS

20 studies were included with 15 (75%) studies assessing interventions in lower limb trauma and 8 (25%) studies assessing interventions in upper limb trauma. 50% of studies used a decision tree model and 50% used collected data alongside a randomised clinical trial. Interventions which were shown to be cost effective in lower limb trauma were total hip replacement in displaced femoral neck fractures, the SHS in stable (A1 and A2) fractures and IM nailing for unstable (A3) fractures, salvage treatment for grade IIIB and IIIC open tibial fractures and operative treatment of ankle and calcaneal fractures. For systems-based strategies, there is evidence demonstrating cost effectiveness to treating hip fractures in high volume centres and to having resources in place to facilitate fractures being treated within 48 h of injury. In upper limb trauma there was evidence showing operative treatment of displaced proximal humerus fractures to be neither clinically nor cost effective. There was evidence supporting the operative treatment of non-displaced scaphoid fractures. Overall the quality of the studies was poor with only 50% (10) of studies able to make a treatment recommendation. Reasons for this included poor quality primary source data and poor reporting methodological practices.

CONCLUSION

Certain aspects of fracture management have been shown to be cost effective. However, there is a paucity of evidence in this area and further research is required so that value-based interventions are chosen by healthcare providers engaged in orthopaedic trauma care.

In-Hospital Cost Analysis of Total Hip Arthroplasty: Does Surgical Approach Matter?

The purposes of this study were to determine the impact of surgical approach on costs of total hip arthroplasty (THA) from a hospital perspective and to provide an updated cost estimation of THA. A prospective, microcosting analysis was performed on 118 patients undergoing a THA through an anterior, lateral, or posterior approach. We determined that overall costs (intraoperative costs and hospital stay) were significantly less for the anterior ($7300.22; 95% confidence interval [CI], 7064.49-7535.95) vs lateral ($7853.10; 95% CI, 7577.29-8128.91; P = .031) and anterior vs posterior approach ($8287.46; 95% CI, 7906.42-8668.51; P < .001). A reduction in hospital length of stay when THA was performed through an anterior approach contributed significantly to an overall reduction in costs from a hospital perspective.

Health Utility Values Associated with Surgical Site Infection: A Systematic Review

BACKGROUND

Surgical site infection (SSI) is a costly postoperative complication whose impact on patients' health-related quality of life is highly uncertain and has not been summarized to date.

OBJECTIVE

The objective was to summarize the evidence base on SSI health utility values reported in patient-level studies and decision models.

METHODS

A systematic review of SSI utility values reported in patient-level and decision modeling studies was carried out. Studies in which utility values for SSI were either invoked (e.g., model-based economic evaluations) or elicited (e.g., valuation exercises), or at least one non-preference-based instrument was administered to patients with SSI after open surgery were included. Mapping algorithms were used, where appropriate, to calculate utilities from primary data. Results were summarized narratively, and the quality of the utility values used in the included modeling studies was assessed.

RESULTS

Of 6552 records identified in the database search, 28 studies were included in the review: 19 model-based economic evaluations and 9 patient-level studies. SSI utility decrements ranged from 0.04 to 0.48, of which 19 ranged from 0.1 to 0.3. SSI utility decrements could be calculated for three patient-level studies, and their values ranged from 0.05 (7 days postoperatively) to 0.124 (1 year postoperatively). In most modeling studies, SSI utilities were informed by authors' assumptions or by secondary sources.

CONCLUSIONS

SSI may substantially affect patients' health utility and needs to be considered when modeling decision problems in surgery. The evidence base for SSI utilities is of questionable quality and skewed toward orthopedic surgery. Further research must concentrate on producing reliable estimates for patients without orthopedic problems.

Total hip replacement and surface replacement for the treatment of pain and disability resulting from end-stage arthritis of the hip (review of technology appraisal guidance 2 and 44): systematic review and economic evaluation

BACKGROUND

Total hip replacement (THR) involves the replacement of a damaged hip joint with an artificial hip prosthesis. Resurfacing arthroplasty (RS) involves replacement of the joint surface of the femoral head with a metal surface covering.

OBJECTIVES

To undertake clinical effectiveness and cost-effectiveness analysis of different types of THR and RS for the treatment of pain and disability in people with end-stage arthritis of the hip, in particular to compare the clinical effectiveness and cost-effectiveness of (1) different types of primary THR and RS for people in whom both procedures are suitable and (2) different types of primary THR for people who are not suitable for hip RS.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials and UK Clinical Research Network (UKCRN) Portfolio Database were searched in December 2012, with searches limited to publications from 2008 and sample sizes of ≥ 100 participants. Reference lists and websites of manufacturers and professional organisations were also screened.

REVIEW METHODS

Systematic reviews of the literature were undertaken to appraise the clinical effectiveness and cost-effectiveness of different types of THR and RS for people with end-stage arthritis of the hip. Included randomised controlled trials (RCTs) and systematic reviews were data extracted and risk of bias and methodological quality were independently assessed by two reviewers using the Cochrane Collaboration risk of bias tool and the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A Markov multistate model was developed for the economic evaluation of the technologies. Sensitivity analyses stratified by sex and controlled for age were carried out to assess the robustness of the results.

RESULTS

A total of 2469 records were screened of which 37 were included, representing 16 RCTs and eight systematic reviews. The mean post-THR Harris Hip Score measured at different follow-up times (from 6 months to 10 years) did not differ between THR groups, including between cross-linked polyethylene and traditional polyethylene cup liners (pooled mean difference 2.29, 95% confidence interval -0.88 to 5.45). Five systematic reviews reported evidence on different types of THR (cemented vs. cementless cup fixation and implant articulation materials) but these reviews were inconclusive. Eleven cost-effectiveness studies were included; four provided relevant cost and utility data for the model. Thirty registry studies were included, with no studies reporting better implant survival for RS than for all types of THR. For all analyses, mean costs for RS were higher than those for THR and mean quality-adjusted life-years (QALYs) were lower. The incremental cost-effectiveness ratio for RS was dominated by THR, that is, THR was cheaper and more effective than RS (for a lifetime horizon in the base-case analysis, the incremental cost of RS was £11,284 and the incremental QALYs were -0.0879). For all age and sex groups RS remained clearly dominated by THR. Cost-effectiveness acceptability curves showed that, for all patients, THR was almost 100% cost-effective at any willingness-to-pay level. There were age and sex differences in the populations with different types of THR and variations in revision rates (from 1.6% to 3.5% at 9 years). For the base-case analysis, for all age and sex groups and a lifetime horizon, mean costs for category E (cemented components with a polyethylene-on-ceramic articulation) were slightly lower and mean QALYs for category E were slightly higher than those for all other THR categories in both deterministic and probabilistic analyses. Hence, category E dominated the other four categories. Sensitivity analysis using an age- and sex-adjusted log-normal model demonstrated that, over a lifetime horizon and at a willingness-to-pay threshold of £20,000 per QALY, categories A and E were equally likely (50%) to be cost-effective.

LIMITATIONS

A large proportion of the included studies were inconclusive because of poor reporting, missing data, inconsistent results and/or great uncertainty in the treatment effect estimates. This warrants cautious interpretation of the findings. The evidence on complications was scarce, which may be because of the absence or rarity of these events or because of under-reporting. The poor reporting meant that it was not possible to explore contextual factors that might have influenced study results and also reduced the applicability of the findings to routine clinical practice in the UK. The scope of the review was limited to evidence published in English in 2008 or later, which could be interpreted as a weakness; however, systematic reviews would provide summary evidence for studies published before 2008.

CONCLUSIONS

Compared with THR, revision rates for RS were higher, mean costs for RS were higher and mean QALYs gained were lower; RS was dominated by THR. Similar results were obtained in the deterministic and probabilistic analyses and for all age and sex groups THR was almost 100% cost-effective at any willingness-to-pay level. Revision rates for all types of THR were low. Category A THR (cemented components with a polyethylene-on-metal articulation) was more cost-effective for older age groups. However, across all age-sex groups combined, the mean cost for category E THR (cemented components with a polyethylene-on-ceramic articulation) was slightly lower and the mean QALYs gained were slightly higher. Category E therefore dominated the other four categories. Certain types of THR appeared to confer some benefit, including larger femoral head sizes, use of a cemented cup, use of a cross-linked polyethylene cup liner and a ceramic-on-ceramic as opposed to a metal-on-polyethylene articulation. Further RCTs with long-term follow-up are needed.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003924.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Medical technology as a key driver of rising health expenditure: disentangling the relationship

Health care spending has risen steadily in most countries, becoming a concern for decision-makers worldwide. Commentators often point to new medical technology as the key driver for burgeoning expenditures. This paper critically appraises this conjecture, based on an analysis of the existing literature, with the aim of offering a more detailed and considered analysis of this relationship. Several databases were searched to identify relevant literature. Various categories of studies (eg, multivariate and cost-effectiveness analyses) were included to cover different perspectives, methodological approaches, and issues regarding the link between medical technology and costs. Selected articles were reviewed and relevant information was extracted into a standardized template and analyzed for key cross-cutting themes, ie, impact of technology on costs, factors influencing this relationship, and methodological challenges in measuring such linkages. A total of 86 studies were reviewed. The analysis suggests that the relationship between medical technology and spending is complex and often conflicting. Findings were frequently contingent on varying factors, such as the availability of other interventions, patient population, and the methodological approach employed. Moreover, the impact of technology on costs differed across technologies, in that some (eg, cancer drugs, invasive medical devices) had significant financial implications, while others were cost-neutral or cost-saving. In light of these issues, we argue that decision-makers and other commentators should extend their focus beyond costs solely to include consideration of whether medical technology results in better value in health care and broader socioeconomic benefits.

The cost-effectiveness of total joint arthroplasty: a systematic review of published literature

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.

Cemented, cementless, and hybrid prostheses for total hip replacement: cost effectiveness analysis

OBJECTIVE

To compare the cost effectiveness of the three most commonly chosen types of prosthesis for total hip replacement.

DESIGN

Lifetime cost effectiveness model with parameters estimated from individual patient data obtained from three large national databases.

SETTING

English National Health Service.

PARTICIPANTS

Adults aged 55 to 84 undergoing primary total hip replacement for osteoarthritis.

INTERVENTIONS

Total hip replacement using either cemented, cementless, or hybrid prostheses.

MAIN OUTCOME MEASURES

Cost (£), quality of life (EQ-5D-3L, where 0 represents death and 1 perfect health), quality adjusted life years (QALYs), incremental cost effectiveness ratios, and the probability that each prosthesis type is the most cost effective at alternative thresholds of willingness to pay for a QALY gain.

RESULTS

Lifetime costs were generally lowest with cemented prostheses, and postoperative quality of life and lifetime QALYs were highest with hybrid prostheses. For example, in women aged 70 mean costs were £6900 ($11 000; €8200) for cemented prostheses, £7800 for cementless prostheses, and £7500 for hybrid prostheses; mean postoperative EQ-5D scores were 0.78, 0.80, and 0.81, and the corresponding lifetime QALYs were 9.0, 9.2, and 9.3 years. The incremental cost per QALY for hybrid compared with cemented prostheses was £2500. If the threshold willingness to pay for a QALY gain exceeded £10 000, the probability that hybrid prostheses were most cost effective was about 70%. Hybrid prostheses have the highest probability of being the most cost effective in all subgroups, except in women aged 80, where cemented prostheses were most cost effective.

CONCLUSIONS

Cemented prostheses were the least costly type for total hip replacement, but for most patient groups hybrid prostheses were the most cost effective. Cementless prostheses did not provide sufficient improvement in health outcomes to justify their additional costs.

Can choices between alternative hip prostheses be evidence based? a review of the economic evaluation literature

Background

Total hip replacement surgery places a considerable financial burden on health services and society. Given the large number of hip prostheses available to surgeons, reliable economic evidence is crucial to inform resource allocation decisions. This review summarises published economic evidence on alternative hip prostheses to examine the potential for the literature to inform resource allocation decisions in the UK.

Methods

We searched nine medical and economics electronic databases. 3,270 studies were initially identified, 17 studies were included in the review. Studies were critically appraised using three separate guidelines.

Results

Several methodological problems were identified including a lack of observed long term prosthesis survival data, limited up-to-date and UK based evidence and exclusion of patient and societal perspectives.

Conclusions

More clinical trials including long term follow-up and economic evaluation are needed. These should compare the cost-effectiveness of different prostheses with longer-term follow-up and including a wider perspective.

Modeling the cost-effectiveness for cement-less and hybrid prosthesis in total hip replacement in Emilia Romagna, Italy

BACKGROUND

The aim of the present study was to assess the cost-effectiveness of cement-less versus hybrid prostheses in total hip replacement (THR) in patients diagnosed with primary osteoarthritis.

METHODS

Effectiveness data were obtained from the Emilia-Romagna Regional Registry on Orthopaedic Prosthesis (RIPO), which collects information on all orthopaedic intervention performed in Emilia-Romagna (41,199 total hip replacements performed from 2000 to 2007), and from which we obtained survival curves and transition probabilities for the cement-less and hybrid prostheses, respectively. Conversely, costs were derived from regional databases through a specific procedure, which allowed us to register individual component's costs for both primary and subsequent revision interventions. A specific Markov transition model was constructed in order to consider the 3 types of revisions that an implant could possibly undergo through its life-span: total, cup or stem, head insert or neck. The cost-effectiveness was expressed in terms of cost per "revision-free" life year.

RESULTS AND CONCLUSIONS

Considering a 70-y old patient undergoing THR, the cementless strategy resulted more effective but more costly than the hybrid solution, with an incremental cost effectiveness ratio of 2401.63 € per revision-free life year. Following a deterministic sensitivity analysis, hybrid and cementless fixation showed, respectively, a dominance profile for patients older than 83 y and younger than 43 y, whereas for all ages in between, we report a progressive increase in the ICER of cementless prostheses. Our results proved to be robust, as underlined by the probabilistic sensitivity analysis performed using cost distributions.