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

Breaking the Disability Spiral: A Case Series Report Illustrating the Delivery of a Brief Skills Based Coaching Intervention to Prevent Chronic Dysfunction and Pain After Orthopedic Injury

Orthopedic traumas are common, costly, and burdensome - particularly for patients who transition from acute to chronic pain. Psychosocial factors, such as pain catastrophizing and pain anxiety, increase risk for poor outcomes after injury. The Toolkit for Optimal Recovery (TOR) is a novel multi-component mind-body intervention informed by the fear-avoidance model to promote re-engagement in daily activities and prevent transition toward chronic pain and physical dysfunction. The current case series aims to 1) describe the intervention and 2) showcase the treatment course of three TOR completers from diverse geographic locations in the U.S. with distinct injury types and varying personal identities to illustrate how the intervention can be delivered flexibly. Results indicate pre-to-post program improvement in physical function, pain severity, pain catastrophizing, pain anxiety, and other relevant outcomes targeted by the intervention (i.e., depression, mindfulness, coping). Experiences of our three TOR completers suggest that integrating TOR with standard orthopedic care may promote physical recovery after injury.

Basics of health economics for clinical trials in orthopaedic trauma

With the rise in global healthcare spending, medical decision-making is increasingly based on health economics outcomes. This narrative review aims to provide an overview of cost-effectiveness analysis (CEA) and cost-utility analysis (CUA), including their advantages and limitations, and outline practical aspects for implementing health economics in clinical trials for orthopaedic trauma. Both CEA and CUA offer several advantages. Firstly, they consider the costs as well as benefits of an intervention, providing a more comprehensive picture of its economic impact. Secondly, they provide a clear and straightforward metric for comparing interventions, which can help decision-makers make informed choices. However, there are methodological shortcomings that must be acknowledged, such as the lack of standardized instruments for assessing health utility measures, which can result in a wide range of cost-benefit ratios. In addition, a consensus on the willingness-to-pay threshold still needs to be reached to develop decision rules for cost-effectiveness similar to clinical effectiveness. Methods such as CEA and CUA should be incorporated into clinical trials in orthopaedic trauma research. Practical aspects for this include planning in advance, preferably in cooperation with a health economist. Selecting appropriate outcome measures is crucial, and both the medical effects of interventions and quality of life instruments should be carefully chosen to ensure comparability with previous studies. Additionally, the potential impact on clinical practice and healthcare policies should be considered. Direct as well as indirect costs should be assessed, and quality assurance with well-established checklists should be confirmed.

Is hospital volume related to quality of hip fracture care? Analysis of 43,538 patients and 68 hospitals from the Dutch Hip Fracture Audit

PURPOSE

Evidence for a hospital volume-outcome relationship in hip fracture surgery is inconclusive. This study aimed to analyze the association between hospital volume as a continuous parameter and several processes and outcomes of hip fracture care.

METHODS

Adult patients registered in the nationwide Dutch Hip Fracture Audit (DHFA) between 2018 and 2020 were included. The association between annual hospital volume and turnaround times (time on the emergency ward, surgery < 48 h and length of stay), orthogeriatric co-treatment and case-mix adjusted in-hospital and 30 days mortality was evaluated with generalized linear mixed models with random effects for hospital and treatment year. We used a fifth-degree polynomial to allow for nonlinear effects of hospital volume. P-values were adjusted for multiple comparisons using the Bonferoni method.

RESULTS

In total, 43,258 patients from 68 hospitals were included. The median annual hospital volume was 202 patients [range 1-546]. Baseline characteristics did not differ with hospital volume. Provision of orthogeriatric co-treatment improved with higher volumes but decreased at > 367 patients per year (p < 0.01). Hospital volume was not significantly associated with mortality outcomes. No evident clinical relation between hospital volume and turnaround times was found.

CONCLUSION

This is the first study analyzing the effect of hospital volume on hip fracture care, treating volume as a continuous parameter. Mortality and turnaround times showed no clinically relevant association with hospital volume. The provision of orthogeriatric co-treatment, however, increased with increasing volumes up to 367 patients per year, but decreased above this threshold. Future research on the effect of volume on complications and functional outcomes is indicated.

Economic evaluation of operative versus nonoperative treatment of a humeral shaft fracture: economic analyses alongside a multicenter prospective cohort study (HUMMER)

PURPOSE

Operative treatment of a humeral shaft fracture results in faster recovery than nonoperative treatment. The cost-effectiveness, in terms of costs per Quality-Adjusted Life Year (QALY) gained (Dutch threshold €20,000-€80,000) or minimal important change (MIC) in disability reduced (DASH 6.7), is unknown. The aim of this study was to determine cost-utility and cost-effectiveness of operative versus nonoperative treatment in adults with a humeral shaft fracture type 12A or 12B.

METHODS

This study was performed alongside a multicenter prospective cohort study. Costs for health care and lost productivity until one year after trauma were calculated. The incremental cost-utility ratio (ICUR) was reported in costs per QALY (based on the EuroQoL-5D-3L (EQ-5D)) gained. The incremental cost-effectiveness ratio (ICER) was reported in costs per MIC (based on the DASH score at three months) reduced.

RESULTS

Overall, 245 patients were treated operatively and 145 nonoperatively. In the operative group, the mean total costs per patient (€11,925 versus €8793; p < 0.001) and QALYs (0.806 versus 0.778; p < 0.001) were higher. The ICUR of operative treatment was €111,860 per QALY gained (i.e., €3132/0.028). The DASH was 7.3 points (p < 0.001) lower in the operative group. The ICER of operative treatment was €2880 per MIC in disability reduced (i.e., €3132/7.3*6.7).

CONCLUSION

Due to the limited effect of treatment on quality of life measured with the EQ-5D, the ICUR of operative treatment (€111,860 per QALY gained) exceeds the threshold. However, the incremental costs of €2880 per clinically meaningful difference in DASH are much lower and suggest that operative treatment for a humeral shaft fracture is cost-effective.

A systematic review on the cost-effectiveness of the computer-assisted orthopedic system

Computer-assisted orthopedic system (CAOS) is rapidly gaining popularity in the field of precision medicine. However, the cost-effectiveness of CAOS has not been well clarified. We performed this review to summarize and assess the cost-effectiveness analyses (CEAs) with regard to CAOS. Publications on CEA in CAOS have been searched in PubMed and CEA Registry up to May 31, 2022. The Quality of Health Economic Studies (QHES) instrument was used to estimate the quality of studies. Relationships between qualities and potential factors were also examined. There were 15 eligible studies in the present review. Twelve studies evaluated CAOS joint arthroplasties and found that CAOS joint arthroplasties were cost-effective compared to manual methods. Three studies focused on spinal surgery, two of which analyzed the cost-effectiveness of CAOS for patients after spinal fusion, with conflicting results. One study demonstrated that CAOS was cost-effective in spinal pedicle screw insertion. The mean QHES score of CEAs included was 86.1. The potential factors had no significant relationship with the quality of studies. Based on available studies, our review reflected that CAOS was cost-effective in the field of joint arthroplasty. While in spinal surgery, the answer was unclear. Current CEAs represent high qualities, and more CEAs are required in the different disciplines of orthopedics where CAOS is employed.

Treatment of tibial bone defects: pilot analysis of direct medical costs between distraction osteogenesis with an Ilizarov frame and the Masquelet technique

Purpose

The cost implications of limb reconstruction techniques have not been adequately investigated. Aim of this pilot study was to compare the direct medical cost of tibial bone defects managed with distraction osteogenesis–Ilizarov method (ILF), or with Masquelet technique (MIF).

Methods

Data of 20 random patients treated in a single centre were analysed. Inclusion criteria included acute tibial defects, or post-debridement of nonunions with complete follow-up and successful union. The endpoint of clinical efficacy was the time-to-defect union. Comparisons were made between equally sized subgroups (ILF vs. MIF).

Results

The average defect length was 5.6 cm (2.6–9.6 cm). The overall cost of 20 cases reached £452,974 (mean £22,339, range £13,459–£36,274). Statistically significant differences favoring the MIF were found regarding the average time-to-union; number of surgeries, of admissions and follow-up visits, as well as the mean intraoperative cost (£8857 vs. £14,087). These differences lead to significant differences of the mean cost of the overall treatment (MIF £18,131 vs. ILF £26,126). Power analysis based on these data indicated that 35 patients on each group would allow detection of a 25% difference, with an alpha value of 0.05 and probability (power) of 0.9.

Conclusions

The results and analysis presented highlight factors affecting the high financial burden, even in a best-case scenario, this type of surgery entails. Larger pivotal studies should follow to improve the cost efficiency of clinical practice.

Economic studies in medical research: 'Importance, targets, outcome evaluation'

Economic studies in healthcare are used to measure the cost and effectiveness of an intervention and are valuable in determining how healthcare resources can be distributed to achieve the greatest overall gain. Most economic studies in healthcare are cost-benefit analyses, cost-effectiveness analyses (CEAs), or cost-utility analyses (CUAs). CEAs and CUAs compare alternative interventions based on cost and effectiveness but are influenced by different methodologies and assumptions employed by researchers. The perspective from which an economic study is evaluated (the patient, the provider, the payor, or the society) should be carefully considered. The incremental cost effectiveness ratio (ICER) describes the difference between two interventions in cost and health outcomes and can be expressed in dollars per quality-adjusted life year (QALY). A threshold ICER <$50,000/QALY is often used to determine whether an intervention is cost-effective, in conjunction with patient factors, healthcare system factors, and opportunity cost associated with the intervention. The Consolidated Health Economic Evaluating Reporting Standards (CHEERS) statement provides guidelines for reporting healthcare economic studies. Key elements to be reported include the study design, target population and subgroups, time horizon, health outcomes, perspectives, comparison group, and sensitivity analyses performed. Economic studies are particularly important in orthopedics given the prevalence of musculoskeletal disease, high upfront costs, and potential quality of life improvements associated with orthopedic surgical procedures. An understanding of economic evaluations in healthcare is important to critically review the available literature.

The economic burden of open tibia fractures: A systematic review

BACKGROUND

Open tibia fractures are a common injury following road traffic collisions and place a large economic burden on patients and healthcare systems. Summarising their economic burden is key to inform policy and help prioritise treatment.

METHODS

All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. The primary outcome was any costs reported or patient return to work status. Secondary outcomes included average length of stay, wage loss, absenteeism and complications such as infection, amputation and nonunion. Data was extracted and we performed a descriptive narrative summary.

RESULTS

We reviewed 1,204 studies from our searches. A total of 34 studies were included from 14 different countries. The average age was 37.7 years old and 76% of the patients were male. 6.5% were Gustilo I, 12% Gustilo II and 82% Gustilo III. Initial direct hospitalisation costs were reported to be between £356 to £126,479 with an average length of stay of 56 days (3.1-244). 89% of participants were working pre-injury, 60% fully returned to work, 17% returned to work part time or changed profession and 22% did not return to work at one-year. The most common complications reported were 22% infection, 11% nonunion and 16% amputation. Mean follow-up duration for the studies was 25 months.

CONCLUSION

The economic burden of open tibia fractures varies greatly, but it is costly for both hospitals and patients. The current evidence is predominantly from high-income countries (HICs), especially the USA. Further research is required to investigate the costs of open tibia fractures using validated costing tools, especially in low-income countries (LICs), to help inform and direct policy.

Cost-Effectiveness of Hip Arthroscopy for Treatment of Femoroacetabular Impingement Syndrome and Labral Tears: A Systematic Review

Background:

Hip arthroscopy has frequently been shown to produce successful outcomes as a treatment for femoroacetabular impingement (FAI) and labral tears. However, there is less literature on whether the favorable results of hip arthroscopy can justify the costs, especially when compared with a nonoperative treatment.

Purpose:

To systematically review the cost-effectiveness of hip arthroscopy for treating FAI and labral tears.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

PubMed/MEDLINE, Embase, and Cochrane Library databases, and the Tufts University Cost-Effectiveness Analysis Registry were searched to identify articles that reported the cost per quality-adjusted life-year (QALY) generated by hip arthroscopy. The key terms used were “hip arthroscopy,” “cost,” “utility,” and “economic evaluation.” The threshold for cost-effectiveness was set at $50,000/QALY. The Methodological Index for Non-Randomized Studies instrument and Quality of Health Economic Studies (QHES) score were used to determine the quality of the studies. This study was prospectively registered on PROSPERO (CRD42020172991).

Results:

Six studies that reported the cost-effectiveness of hip arthroscopy were identified, and 5 of these studies compared hip arthroscopy to a nonoperative comparator. These studies were found to have a mean QHES score of 85.2 and a mean cohort age that ranged from 33-37 years. From both a health care system perspective and a societal perspective, 4 studies reported that hip arthroscopy was more costly but resulted in far greater gains than did nonoperative treatment. The preferred treatment strategy was most sensitive to duration of benefit, preoperative osteoarthritis, cost of the arthroscopy, and the improvement in QALYs with hip arthroscopy.

Conclusion:

In the majority of the studies, hip arthroscopy had a higher initial cost but provided greater gain in QALYs than did a nonoperative treatment. In certain cases, hip arthroscopy can be cost-effective given a long enough duration of benefit and appropriate patient selection. However, there is further need for literature to analyze willingness-to-pay thresholds.

Loss of Reduction after Cephalomedullary Nail Fixation of Intertrochanteric Femoral Fracture: A Brief Report

Objective

At present, cephalomedullary nail is the most frequently used implant in the management of intertrochanteric fractures around the world. The implant design and fixation techniques of the cephalomedullary nail have been continuously improved to ensure uncomplicated bone union during the past decade. However, a degree of reduction loss during bone healing is still not rare in clinical work. Many attributed this complication to misoperation during the surgery and hold that a series of techniques and tips could help to avoid the loss of reduction. However, until now there has been no research to explore whether the reduction loss after the operation can be fully prevented in the best cases. The purposes of the study are as follows: (i) to evaluate the efficiency of the current established CMN techniques; (ii) to quantify the loss of reduction under an appropriately implanted CMN to anatomically realigned intertrochanteric fractures; and (iii) to explore the possible underlying causes for the inevitable loss of reduction.

Methods

In the retrospective study, 163 consecutive cases with the intertrochanteric fractures fixed with standard cephalomedullary nail technique were reviewed. The anatomical reduction and optimal positioning of the nail were confirmed by postoperative imaging. The fracture types ranged from 31‐A1.1–2.3 according to the OTA/AO fracture classification. One hundred and fifteen cases with stable fracture types (31A1.1–2.1) were allocated to Group A, and 48 cases with unstable 31A2.2–2.3 fracture types were allocated to Group B. The radiological measurements included femoral neck shortening, loss of the neck‐shaft angle, cutout, and cut‐through of the blade. The outcomes between postoperative and 1 year after the operation were evaluated and compared.

Results

The patients consisted of 66 males and 97 females with an average age of 69.4 (range: 46–78, SD: 14.6) years. At the 1‐year follow‐up, no fixation failure or nonunion was observed in each group. The mean femoral neck shortening and loss of the neck‐shaft angle were 4.47 mm (range: 0.43–17.68, SD: 3.71) and 5.4° (range: 0.51–19.10, SD: 3.58) separately. The mean cutout and cut‐through were 1.84 mm (range: 0.24–11.30, SD: 2.33) and 1.25 mm (range: 0.51–10.29, SD: 1.74). The average femoral neck shortening and loss of the neck‐shaft angle were higher in Group B than Group A. Among the 23 cases with the femoral neck shortening more than 10 mm, 19 cases (16.5%) were from Group A and four cases (8.3%) were from Group B. There were nine (7.8%) cases with the loss of the neck‐shaft angle more than 10° in Group A and six (12.5%) cases in Group B.

Conclusions

Current established CMN techniques are efficient in treating intertrochanteric femoral fracture. However, even with currently consensual techniques of cephalomedullary nail, the process of fracture healing still risks the loss of reduction, although the migration of the blade could be minimized. This situation may associate with the intrinsic design of the CMN and further improvement is still needed.

Cost-utility analysis in chronic kidney disease patients undergoing kidney transplant; what pays? A systematic review

Background

Health systems are under pressure to deliver more effective care without expansion of resources. This is particularly pertinent to diseases like chronic kidney disease (CKD) that are exacting substantial financial burden to many health systems. The aim of this study is to systematically review the Cost Utility Analysis (CUA) evidence generated across interventions for CKD patients undergoing kidney transplant (KT).

Methods

A systemic review of CUA on the interventions for CKD patients undergoing KT was carried out using a search of the MEDLINE, CINAHL, EMBASE, PsycINFO and NHS-EED. The CHEERS checklist was used as a set of good practice criteria in determining the reporting quality of the economic evaluation. Quality of the data used to inform model parameters was determined using the modified hierarchies of data sources.

Results

A total of 330 articles identified, 16 met the inclusion criteria. Almost all (n = 15) the studies were from high income countries. Out of the 24 characteristics assessed in the CHEERS checklist, more than 80% of the selected studies reported 14 of the characteristics. Reporting of the CUA were characterized by lack of transparency of model assumptions, narrow economic perspective and incomplete assessment of the effect of uncertainty in the model parameters on the results. The data used for the economic model were satisfactory quality. The authors of 13 studies reported the intervention as cost saving and improving quality of life, whereas three studies were cost increasing and improving quality of life. In addition to the baseline analysis, sensitivity analysis was performed in all the evaluations except one. Transplanting certain high-risk donor kidneys (high risk of HIV and Hepatitis-C infected kidneys, HLA mismatched kidneys, high Kidney Donor Profile Index) and a payment to living donors, were found to be cost-effective.

Conclusions

The quality of economic evaluations reviewed in this paper were assessed to be satisfactory. Implementation of these strategies will significantly impact current systems of KT and require a systematic implementation plan and coordinated efforts from relevant stakeholders.

Value Denominator: The Fundamentals of Costing for Orthopaedic Surgeons

In any discipline, improving quality and efficiency of services acts as a unifying goal. In health care, the goal of achieving high-value care is the new doctrine for all individual entities: payors, providers, and patients. Value is defined as the ratio of outcomes to costs incurred. Therefore, a strong understanding and interpretation of cost measures is crucial to accurately deriving health care value. Health care costing is not simply limited to the costs of implants or the procedure but the costs required to deliver treatment throughout the episode of care. Consequently, physicians serve a keystone role toward driving change in health care costs and initiate high-value care practices. However, physicians require a better understanding of health care costs and institutional accounting practices. To this effort, it is critical that health care providers begin to close the knowledge gap around health care costing and provide leadership when advocating for high-value patient care. This review is purposed to provide a basic review of fundamental components for health care economics, deciphering health care costing, and preview current strategies that prioritize high-value patient care.

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.