In Brief: cost-effectiveness analyses in orthopaedics

Cost-Effectiveness Analysis of Early versus Late Debridement of Superficial Triangular Fibrocartilage Complex Tears

Background

While initial nonoperative management is the conventional approach for superficial triangular fibrocartilage complex (TFCC) tears, a substantial portion of these cases go on to require surgery, and the optimal duration of nonoperative treatment is unknown. In this study, we evaluate the cost-effectiveness of early versus late arthroscopic debridement for the treatment of superficial TFCC tears without distal radioulnar joint (DRUJ) instability.

Methods

We created a decision tree to compare the following strategies from a healthcare payer perspective: immediate arthroscopic debridement versus immobilization for 4 or 6 weeks with late debridement as needed. Costs were obtained from the Centers for Medicaid and Medicare Services and a national administrative claims database. Probabilities and health-related quality-of-life measures were obtained from published sources. We conducted sensitivity analyses on model inputs, including a probabilistic sensitivity analysis consisting of 10,000 Monte Carlo simulations.

Results

Immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases was both the least costly and most effective strategy. Immediate arthroscopic debridement became cost-effective when success rates of immobilization for 4 or 6 weeks were less than 7.7 or 10.5%, respectively. Our probabilistic sensitivity analysis showed that immobilization for 6 weeks was preferred 97.6% of the time, and immobilization for 4 weeks was preferred 2.4% of the time.

Conclusion

Although various early and late debridement strategies can be used to treat superficial TFCC tears without DRUJ instability, immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases is the optimal strategy from a cost-effectiveness standpoint.

Clinical outcomes in the surgical management of ankle fractures: A systematic review and meta-analysis of fibular intramedullary nail fixation vs. open reduction and internal fixation in randomized controlled trials

BACKGROUND

What level I evidence exists to support the use of FNF for surgical management of ankle fractures in high risk patients? The purpose of this study was to compare clinical outcomes following fibular intramedullary nail fixation (FNF) and open reduction and internal fixation (ORIF) of ankle fractures.

METHODS

A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Certainty of evidence reported according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Our primary hypothesis was that patients undergoing FNF procedures to manage an ankle fracture would have significantly higher patient reported outcome scores (PROs) than patients undergoing ORIF. Primary study outcome measures were validated PROs. Secondary outcome measures included complication rate, secondary surgery rate, and bony union.

RESULTS

The primary outcome analysis revealed no evidence of a significant effect difference on Olerud and Molander Ankle Score (OMAS) PRO and no evidence of statistical heterogeneity. Secondary outcome analysis revealed a significant 0.30 (0.12-0.74 95CI) relative risk reduction for complications in FNF (P = 0.008). No evidence of an effect difference for bony union. The GRADE certainty of the evidence was rated as low for bone union. No evidence of reporting bias was appreciated. Sensitivity analyses did not significantly alter effect estimates.

CONCLUSION

This systematic review and meta-analysis restricted to evidence derived from RCTs revealed that the quality of evidence is reasonably strong and likely sufficient to conclude: (1) there is likely no clinically important difference between FNF and ORIF up to 12 months post-operatively, as defined by OMS (moderate certainty); (2) surgeons may reasonably expect reduced complications in 14 out of every 100 patients treated with FNF (moderate certainty); (3) there is likely no difference in bony union (low certainty). Future studies should investigate more patient-centered outcomes and if short-term findings are durable over time if these findings apply to lower risk populations.

LEVEL OF EVIDENCE

Systematic review and meta-analysis of level I evidence.

Cost-effectiveness analyses in shoulder arthroplasty: a critical review using the Quality of Health Economic Studies (QHES) instrument

HYPOTHESIS

The purpose of this study was to perform a systematic review to identify cost-analysis studies pertaining to shoulder arthroplasty, provide a comprehensive review of published studies, and critically evaluate the quality of the available literature using the Quality of Health Economic Studies (QHES) instrument.

METHODS

A systematic review of the literature was performed to identify cost analyses examining shoulder arthroplasty. The inclusion criteria included studies pertaining to either shoulder hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA. Articles were excluded based on the following: nonoperative studies, nonclinical studies, studies not based in the United States, and studies in which no cost analysis was performed. The quality of studies was assessed using the QHES instrument. One-sided Fisher exact testing was performed to identify predictors of both low-quality (ie, QHES score < 25th percentile) and high-quality (ie, QHES score > 75th percentile) cost analyses based on items within the QHES checklist.

RESULTS

Of the 196 studies screened, 9 were included. Seven studies conducted cost analyses comparing reverse TSA vs. arthroscopic rotator cuff repair, HA, or total hip arthroplasty, and 2 studies examined TSA vs. HA for primary glenohumeral arthritis. The average QHES score among all studies was 86.22 ± 13.39 points. Failure to include an annual cost discounting rate was associated with a low-quality QHES score (P = .03). In addition, including a discussion of the magnitude and direction of potential biases was associated with a high-quality score (P = .03).

CONCLUSIONS

Shoulder arthroplasty is a cost-effective procedure when used to treat a multitude of shoulder pathologies. The overall quality of cost analysis in shoulder arthroplasty is relatively good, with an average QHES score of 86.22 points. Studies failing to include an annual cost discounting rate are more likely to score below the 25th percentile, whereas those including a discussion of the magnitude and direction of potential biases are more likely to achieve a score in excess of the 75th percentile.

Patient Outcomes in Orthopaedic Trauma: How to Evaluate if Your Treatment Is Really Working?

Outcomes are critical to gauge the success of our treatments and, in particular, surgical interventions in orthopaedic trauma. Patient-reported outcomes have evolved to become the primary measurement of success in surgery. This article reviews the concepts relevant to understanding these outcomes including general health outcomes, extremity- and disease-specific outcomes, minimum clinically important difference, economic analysis of treatment cost/benefit, and the impact of psychosocial factors on outcomes. An understanding of these concepts is important to allow for effective interpretation and critical analysis of the literature as well as to facilitate the practice of evidence-based medicine.

Cost Determinants in the 90-Day Management of Isolated Ankle Fractures at a Large Urban Academic Hospital

OBJECTIVES

To determine the independent risk factors associated with increasing costs and unplanned hospital readmissions in the 90-day episode of care (EOC) for isolated operative ankle fractures at our institution.

DESIGN

Retrospective cohort study.

SETTING

Level I Trauma Center.

PATIENTS

Two hundred ninety-nine patients undergoing open reduction internal fixation for the treatment of an acute, isolated ankle fracture between 2010 and 2015.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Independent risk factors for increasing 90-day EOC costs and unplanned hospital readmission rates.

RESULTS

Orthopaedic (64.9%) and podiatry (35.1%) patients were included. The mean index admission cost was $14,048.65 ± $5,797.48. Outpatient cases were significantly cheaper compared to inpatient cases ($10,164.22 ± $3,899.61 vs. $15,942.55 ± $5,630.85, respectively, P < 0.001). Unplanned readmission rates were 5.4% (16/299) and 6.7% (20/299) at 30 and 90 days, respectively, and were often (13/20, 65.0%) due to surgical site infections. Independent risk factors for unplanned hospital readmissions included treatment by the podiatry service (P = 0.024) and an American Society of Anesthesiologists score of ≥3 (P = 0.017). Risk factors for increasing total postdischarge costs included treatment by the podiatry service (P = 0.011) and male gender (P = 0.046).

CONCLUSIONS

Isolated operative ankle fractures are a prime target for EOC cost containment strategy protocols. Our institutional cost analysis study suggests that independent financial clinical risk factors in this treatment cohort includes podiatry as the treating surgical service and patients with an American Society of Anesthesiologists score ≥3, with the former also independently increasing total postdischarge costs in the 90-day EOC. Outpatient procedures were associated with about a one-third reduction in total costs compared to the inpatient subgroup.

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.

Cost effectiveness of different techniques in hallux valgus surgery

BACKGROUND

Different surgical techniques are available to correct each type of Hallux Valgus (HV) deformity, and all present similar good results. No information is available relative to the cost of each technique compared to their individual success.

OBJECTIVE

To determine the cost-effectiveness-ratio (CER) of five different techniques for HV.

METHODS

We included 245HV surgeries performed in 179 patients. The severity was defined according to radiological parameters. For mild to moderate HV we included the Chevron, Modified-Scarf and Ludloff techniques; for severe HV: either Poscow-osteotomy or Lapidus-arthrodesis fixed with plates or screws. Weighted costs were estimated. CER was expressed in $US dollars per AOFAS-point.

RESULTS

The lowest weighted cost was observed for the Chevron-group, and the highest weighted cost was observed in the Poscow-osteotomy and Lapidus-arthrodesis fixed with plate groups. The AOFAS-score improvement was higher in the Chevron and Modified-Scarf groups. The CER found for Chevron and Modified-Scarf techniques were significantly less than for Poscow and Lapidus-techniques.

CONCLUSION

Cost-Effectiveness-Ratio was lower, and therefore better, in the groups with mild to moderate deformities operated with Chevron or Modified-Scarf techniques. In severe HV, the three techniques investigated presented similar CER. CER analysis is an additional factor that can be included in the decision making analysis in hallux valgus surgery. Level of Evidence Level IV, Retrospective Study.

Quality-Adjusted Life Years Gained by Hip and Knee Replacement Surgery and Its Aftercare

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.

Stakeholders in outcome measures: review from a clinical perspective

Modern interest in patient-reported outcomes measures (PROMs) in orthopaedics dates back to the mid-1980s. While gradual growth of activity in this area has occurred over the past 25 years, the extent to which this research methodology is applied in clinical practice to improve patient care is unclear. WHERE ARE WE NOW?: Historically, clinical research in orthopaedics has focused on the technical success of treatment, and objective indicators such as mortality, morbidity, and complications. By contrast, the PROMs framework focuses on effects of treatment described in terms of relief of symptoms, restoring functional ability, and improving quality of life. PROMs can be used to study the relative effects of disease, injury, and treatment across different health conditions. WHERE DO WE NEED TO GO?: All clinical research should begin with identifying clear and meaningful research questions so that the resources and efforts required for data collection result in useful data. Different consumers of research data have different perspectives on what comprises meaningful information. Involving stakeholders such as patients, providers, payers, and policy-makers when defining priorities in the larger research endeavor is one way to inform what type of data should be collected in a particular study. HOW DO WE GET THERE?: Widespread collection of outcomes data would potentially aid these stakeholders by identifying best practices, benefits and costs, and important patient or practice characteristics related to outcomes. Several initiatives currently underway may help systematic collection of PROMs, create efficient systems, and foster collaborations to provide support and resources to minimize costs.