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Perrier L, Balusson F, Morelle M, Castelli J, Thariat J, Benezery K, Hasbini A, Gery B, Berger A, Liem X, Guihard S, Chapet S, Thureau S, Auberdiac P, Pommier P, Ruffier A, Devillers A, Oger E, Campillo-Gimenez B, de Crevoisier R. Cost-effectiveness of weekly adaptive radiotherapy versus standard IMRT in head and neck cancer alongside the ARTIX trial. Radiother Oncol 2024; 193:110116. [PMID: 38316193 DOI: 10.1016/j.radonc.2024.110116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/21/2024] [Accepted: 01/28/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND AND PURPOSE We performed a cost-effectiveness analysis (CEA) comparing an adaptive radiotherapy (ART) strategy, based on weekly replanning, aiming to correct the parotid gland overdose during treatment and expecting therefore to decrease xerostomia, when compared to a standard IMRT. MATERIALS AND METHODS We conducted the ARTIX trial, a randomized, parallel-group, multicentric study comparing a systematic weekly replanning ART to a standard IMRT. The primary endpoint was the frequency of xerostomia at 12 months, measured by stimulating salivary flow with paraffin. The CEA was designed alongside the ARTIX trial which was linked to the French national health data system (SNDS). For each patient, healthcare consumptions and costs were provided by the SNDS. The reference case analysis was based on the primary endpoint of the trial. Sensitivity and scenario analyses were performed. RESULTS Of the 129 patients randomly assigned between 2013 and 2018, only 2 records were not linked to the SNDS, which provides a linkage proportion of 98.4%. All of the other 127 records were linked with good to very good robustness. On the intent-to-treat population at 12 months, mean total costs per patient were €41,564 (SD 23,624) and €33,063 (SD 16,886) for ART and standard IMRT arms, respectively (p = 0.033). Incremental cost effectiveness ratio (ICER) was €162,444 per xerostomia avoided. At 24 months, ICER was €194,521 per xerostomia avoided. For both progression-free and overall survival, ART was dominated by standard IMRT. CONCLUSION The ART strategy was deemed to be not cost-effective compared with standard IMRT for patients with locally advanced oropharyngeal cancer.
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Affiliation(s)
- Lionel Perrier
- Univ Lyon, Leon Berard Cancer Center, GATE UMR 5824, 28 Prom. Léa et Napoléon Bullukian F-69008, Lyon, France; Human and Social Science Department, Centre Léon Bérard, 28 Prom. Léa et Napoléon Bullukian F-69008, Lyon, France.
| | - Frédéric Balusson
- Pharmacovigilance and Pharmacoepidemiology, CHU Rennes, Rennes, France; Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Magali Morelle
- Univ Lyon, Leon Berard Cancer Center, GATE UMR 5824, 28 Prom. Léa et Napoléon Bullukian F-69008, Lyon, France
| | - Joël Castelli
- Department of Radiotherapy, Centre Eugene Marquis, Avenue Bataille Flandres Dunkerques F35000, Rennes, France
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Laboratoire de Physique Corpusculaire, IN2P3/ENISAEN-CNRS, Normandie Université, Caen, France
| | - Karen Benezery
- Department of Radiotherapy, Centre Antoine Lacassagne, Avenue de Valombrose F06000, Nice, France
| | - Ali Hasbini
- Radiotherapy, Clinique Pasteur-Lanroze, 32 Rue Auguste Kervern F29200, Brest, France
| | - Bernard Gery
- Department of Radiation Oncology, Centre François Baclesse, Laboratoire de Physique Corpusculaire, IN2P3/ENISAEN-CNRS, Normandie Université, Caen, France
| | - Antoine Berger
- Department of Radiotherapy, CHU Poitiers, 2 Rue de la Milétrie F86000, Poitiers, France
| | - Xavier Liem
- Academic Department of Radiation Oncology and Brachytherapy, Oscar Lambret Center, Lille, France
| | - Sébastien Guihard
- Department of Radiotherapy, ICANS, 17 rue Albert Calmette F67033, Strasbourg, France
| | - Sophie Chapet
- Department of Radiotherapy, Centre Jean-Bernard, institut inter-régional de cancérologie (ILC), CCS, 64, rue de Degré F-72000, Le Mans, France
| | - Sébastien Thureau
- Department of Radiotherapy, Centre Henri Becquerel, 1 Rue d'Amiens F76038, Rouen, France; Quantif LITIS EA 4108, University of Rouen, 22, Boulevard Gambetta F-76183, Rouen Cedex 1, France
| | - Pierre Auberdiac
- Radiotherapy, Clinique Claude Bernard, 1 rue du Père Colombier F81000, Albi, France
| | - Pascal Pommier
- Department of Radiotherapy, ICO-Angers, 15, rue André Boquel 49055, Angers cedex 02, France
| | - Amandine Ruffier
- Department of Radiotherapy, Centre Jean-Bernard, institut inter-régional de cancérologie (ILC), CCS, 64, rue de Degré F-72000, Le Mans, France
| | - Anne Devillers
- Department of Nuclear Medicine, Centre Eugene Marquis, Avenue Bataille Flandres Dunkerques F35000, Rennes, France
| | - Emmanuel Oger
- Pharmacovigilance and Pharmacoepidemiology, CHU Rennes, Rennes, France; Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Boris Campillo-Gimenez
- Department of Clinical Research, Centre Eugene Marquis, Avenue Bataille Flandres Dunkerques F35000, Rennes, France; Inserm, LTSI-UMR 1099, University of Rennes, F-35000, Rennes, France
| | - Renaud de Crevoisier
- Department of Radiotherapy, Centre Eugene Marquis, Avenue Bataille Flandres Dunkerques F35000, Rennes, France
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Sinha S, Laskar SG, Wadasadawala T, Krishnatry R, Lievens Y, Agarwal JP. Adopting Health Economic Research in Radiation Oncology: A Perspective From Low- or Middle-Income Countries. JCO Glob Oncol 2022; 8:e2100374. [PMID: 35853193 PMCID: PMC9812487 DOI: 10.1200/go.21.00374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Establishing a new radiation therapy (RT) setup is resource-intensive as it involves substantial capital costs and the recruitment of a skilled workforce. It is essential to incorporate health economic analysis that estimates recurring and nonrecurring expenses on the basis of the national and local needs, infrastructure, and future projections. RT costing exercises can be especially relevant for low- or middle-income countries (LMICs) with more than 70% of the global cancer burden, with access to < 20% of the available resources. This review article summarizes the scope of RT costing exercises in LMICs, the hurdles in conducting them, and possible ways to circumvent them. The purpose of performing costing studies in RT lies in their utility to improve the efficiency of the investment while at the same time helping to address the issues of uniformity and equitable distribution of resources. This will help assess the net benefit from RT in terms of utility and outcome-linked parameters like Quality-Adjusted Life Years. There are numerous barriers to conducting economic evaluations in LMICs, including the lack of national costing values for equipment, data on manpower salary, cost for public and private setups, and indirect costs. The situation is further complicated because of the nonuniform pay structure, lack of an organizational framework, robust real-world data on outcomes, and nonavailability of country-specific reference utility values. Collaborative national efforts are required to collect all elements required to perform health technology assessments. Information from the national and hospital databases can be made available in the public domain to ease access and broader adoption of health economic end points in routine care. Although resource-intensive at the onset, costing studies and health economic assessments are essential for improving the coverage and quality of RT in LMICs.
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Affiliation(s)
- Shwetabh Sinha
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Tabassum Wadasadawala
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India,Jai Prakash Agarwal, MD, Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai 400012, India; e-mail:
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Methodologic and Reporting Quality of Economic Evaluations in Hand and Wrist Surgery: A Systematic Review. Plast Reconstr Surg 2022; 149:453e-464e. [PMID: 35196683 DOI: 10.1097/prs.0000000000008845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Economic evaluations can inform decision-making; however, previous publications have identified poor quality of economic evaluations in surgical specialties. METHODS Study periods were from January 1, 2006, to April 20, 2020 (methodologic quality) and January 1, 2014, to April 20, 2020 (reporting quality). Primary outcomes were methodologic quality [Guidelines for Authors and Peer Reviewers of Economic Submissions to The BMJ (Drummond's checklist), 33 points; Quality of Health Economic Studies (QHES), 100 points; Consensus on Health Economic Criteria (CHEC), 19 points] and reporting quality (Consolidated Health Economic Evaluation Standards (CHEERS) statement, 24 points). RESULTS Forty-seven hand economic evaluations were included. Partial economic analyses (i.e., cost analysis) were the most common (n = 34; 72 percent). Average scores of full economic evaluations (i.e., cost-utility analysis and cost-effectiveness analysis) were: Drummond's checklist, 27.08 of 33 (82.05 percent); QHES, 79.76 of 100 (79.76 percent); CHEC, 15.54 of 19 (81.78 percent); and CHEERS, 20.25 of 24 (84.38 percent). Cost utility analyses had the highest methodologic and reporting quality scores: Drummond's checklist, 28.89 of 35 (82.54 percent); QHES, 86.56 of 100 (86.56 percent); CHEC, 16.78 of 19 (88.30 percent); and CHEERS, 20.8 of 24 (86.67 percent). The association (multiple R) between CHEC and CHEERS was strongest: CHEC, 0.953; Drummond's checklist, 0.907; and QHES, 0.909. CONCLUSIONS Partial economic evaluations in hand surgery are prevalent but not very useful. The Consensus on Health Economic Criteria and Consolidated Health Economic Evaluation Standards should be used in tandem when undertaking and evaluating economic evaluation in hand surgery.
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Chen G, Cui J, Qian J, Zhu J, Zhao L, Luo B, Cui T, Zhong L, Yang F, Yang G, Zhao X, Zhou Y, Geng M, Sun J. Rapid Progress in Intelligent Radiotherapy and Future Implementation. Cancer Invest 2022; 40:425-436. [PMID: 35225723 DOI: 10.1080/07357907.2022.2044842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Radiotherapy is one of the major approaches to cancer treatment. Artificial intelligence in radiotherapy (shortly, Intelligent radiotherapy) mainly involves big data, deep learning, extended reality, digital twin, radiomics, Internet plus and Internet of Things (IoT), which establish an automatic and intelligent network platform consisting of radiotherapy preparation, target volume delineation, treatment planning, radiation delivery, quality assurance (QA) and quality control (QC), prognosis judgment and post-treatment follow-up. Intelligent radiotherapy is an interdisciplinary frontier discipline in infancy. The review aims to summary the important implements of intelligent radiotherapy in various areas and put forward the future of unmanned radiotherapy center.
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Affiliation(s)
- Guangpeng Chen
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Jianxiong Cui
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China.,Department of Oncology, Sichuan Provincial Crops Hospital of Chinese People's Armed Police Forces, Leshan 614000, Sichuan, P.R. China
| | - Jindong Qian
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Jianbo Zhu
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Lirong Zhao
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Bangyu Luo
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Tianxiang Cui
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Liangzhi Zhong
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Fan Yang
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Guangrong Yang
- Qijiang District People's Hospital, Chongqing 401420, P.R. China
| | - Xianlan Zhao
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Yibing Zhou
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
| | - Mingying Geng
- Department of Cancer Center, Daping Hospital, Army Medical University, Chongqing 400042, P.R. China
| | - Jianguo Sun
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing 400037, P.R. China
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Masson I, Bellanger M, Perrocheau G, Mahé MA, Azria D, Pommier P, Mesgouez-Nebout N, Giraud P, Peiffert D, Chauvet B, Dudouet P, Salem N, Noël G, Khalifa J, Latorzeff I, Guérin-Charbonnel C, Supiot S. Cost and Toxicity Comparisons of Two IMRT Techniques for Prostate Cancer: A Micro-Costing Study and Weighted Propensity Score Analysis Based on a Prospective Study. Front Oncol 2022; 11:781121. [PMID: 35087753 PMCID: PMC8787862 DOI: 10.3389/fonc.2021.781121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/10/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Intensity modulated radiation therapy (IMRT) combined with androgen deprivation therapy (ADT) has become the standard treatment for patients with high-risk prostate cancer. Two techniques of rotational IMRT are commonly used in this indication: Volumetric Modulated Arc Therapy (VMAT) and helical tomotherapy (HT). To the best of our knowledge, no study has compared their related costs and clinical effectiveness and/or toxicity in prostate cancer. We aimed to assess differences in costs and toxicity between VMAT and HT in patients with high-risk prostate cancer with pelvic irradiation. MATERIAL AND METHODS We used data from the "RCMI pelvis" prospective multicenter study (NCT01325961) including 155 patients. We used a micro-costing methodology to identify cost differences between VMAT and HT. To assess the effects of the two techniques on total actual costs per patient and on toxicity we used stabilized inverse probability of treatment weighting. RESULTS The mean total cost for HT, €2019 3,069 (95% CI, 2,885-3,285) was significantly higher than the mean cost for VMAT €2019 2,544 (95% CI, 2,443-2,651) (p <.0001). The mean ± SD labor and accelerator cost for HT was €2880 (± 583) and €1978 (± 475) for VMAT, with 81 and 76% for accelerator, respectively. Acute GI and GU toxicity were more frequent in VMAT than in HT (p = .021 and p = .042, respectively). Late toxicity no longer differed between the two groups up to 24 months after completion of treatment. CONCLUSION Use of VMAT was associated with lower costs for IMRT planning and treatment than HT. Similar stabilized long-term toxicity was reported in both groups after higher acute GI and GU toxicity in VMAT. The estimates provided can benefit future modeling work like cost-effectiveness analysis.
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Affiliation(s)
- Ingrid Masson
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest René Gauducheau, Saint-Herblain, France
| | - Martine Bellanger
- Department of Human and Social Sciences, Institut de Cancérologie de l’Ouest René Gauducheau, Saint-Herblain, France
- UMR CNRS6051, EHESP (Ecole des Hautes Etudes en Santé Publique - School of Public Health), University of Rennes, Rennes, France
| | - Geneviève Perrocheau
- Department of Human and Social Sciences, Institut de Cancérologie de l’Ouest René Gauducheau, Saint-Herblain, France
| | - Marc-André Mahé
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest René Gauducheau, Saint-Herblain, France
- Department of Radiation Oncology, François Baclesse Cancer Center, Caen, France
| | - David Azria
- Fédération Universitaire d’Oncologie Radiothérapie (FOROM), Institut Régional du Cancer Montpellier (ICM), Université de Montpellier, Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Pascal Pommier
- Department of Radiation Oncology, Léon Bérard Center, Lyon, France
| | - Nathalie Mesgouez-Nebout
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest Paul Papin, Angers, France
| | - Philippe Giraud
- Department of Radiation Oncology, Georges Pompidou European Hospital, Paris, France
| | - Didier Peiffert
- Department of Radiation Oncology, Lorraine Cancer Institute, Vandœuvre-lès-Nancy, France
| | - Bruno Chauvet
- Department of Radiation Oncology, Sainte Catherine Institute, Avignon, France
| | - Philippe Dudouet
- Department of Radiation Oncology, Pont de Chaume Clinic, Montauban, France
| | - Naji Salem
- Department of Radiation Oncology, Paoli-Calmettes Institute, Marseille, France
| | - Georges Noël
- Department of Radiation Oncology, Cancerology Institute of Strasbourg-Europe, Strasbourg, France
| | - Jonathan Khalifa
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse-Oncopole (IUCT-Oncopole), Toulouse, France
| | - Igor Latorzeff
- Department of Radiation Oncology, Pasteur Clinic, Toulouse, France
| | - Catherine Guérin-Charbonnel
- Clinical Trial Sponsor Unit/Biometry, Institut de Cancérologie de l’Ouest René Gauducheau, Saint-Herblain, France
- Centre de Recherche en Cancérologie et Immunologie Nantes Angers - Center for Research in Cancerology and Immunology Nantes-Angers (CRCINA), Institut National de la Santé et de la Recherche Médicale - National Institute for Health and Medical Research (INSERM) UMR1232, Centre National de la Recherche Scientifique - National Center for Scientific Research (CNRS) ERL6001, University of Nantes, Nantes, France
| | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancérologie de l’Ouest René Gauducheau, Saint-Herblain, France
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Primeau CA, Zomar BO, Somerville LE, Joshi I, Giffin JR, Marsh JD. Health Economic Evaluations of Hip and Knee Interventions in Orthopaedic Sports Medicine: A Systematic Review and Quality Assessment. Orthop J Sports Med 2021; 9:2325967120987241. [PMID: 34262974 PMCID: PMC8243245 DOI: 10.1177/2325967120987241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 11/24/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The economic burden of musculoskeletal diseases is substantial and growing. Economic evaluations compare costs and health benefits of interventions simultaneously to help inform value-based care; thus, it is crucial to ensure that studies are using appropriate methodology to provide valid evidence on the cost-effectiveness of interventions. This is particularly the case in orthopaedic sports medicine, where several interventions of varying costs are available to treat common hip and knee conditions. PURPOSE To summarize and evaluate the quality of economic evaluations in orthopaedic sports medicine for knee and hip interventions and identify areas for quality improvement. STUDY DESIGN Systematic review; Level of evidence, 3. METHODS The Medline, AMED, OVID Health Star, and EMBASE databases were searched from inception to March 1, 2020, to identify economic evaluations that compared ≥2 interventions for hip and/or knee conditions in orthopaedic sports medicine. We assessed the quality of full economic evaluations using the Quality of Health Economic Studies (QHES) tool, which consists of 16 questions for a total score of 100. We classified studies into quartiles based on QHES score (extremely poor quality to high quality) and we evaluated the frequency of studies that addressed each of the 16 QHES questions. RESULTS A total of 93 studies were included in the systematic review. There were 41 (44%) cost analyses, of which 21 (51%) inappropriately concluded interventions were cost-effective. Only 52 (56%) of the included studies were full economic evaluations, although 40 of these (77%) fell in the high-quality quartile. The mean QHES score was 83.2 ± 19. Authors consistently addressed 12 of the QHES questions; questions that were missed or unclear were related to statistical uncertainty, appropriateness of costing methodology, and discussion of potential biases. The most frequently missed question was whether the cost perspective of the analysis was stated and justified. CONCLUSION The number of studies in orthopaedic sports medicine is small, despite their overall good quality. Yet, there are still many highly cited studies based on low-quality or partial economic evaluations that are being used to influence clinical decision-making. Investigators should follow international health economic guidelines for study design and critical appraisal of studies to further improve quality.
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Affiliation(s)
- Codie A. Primeau
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Bryn O. Zomar
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | | | - Ishita Joshi
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
| | - J. Robert Giffin
- Bone and Joint Institute, Western University, London, Ontario, Canada
- London Health Sciences
Centre, University Hospital, London, Ontario, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jacquelyn D. Marsh
- School of Physical Therapy, Western University, London, Ontario, Canada
- School of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada
- Bone and Joint Institute, Western University, London, Ontario, Canada
- London Health Sciences
Centre, University Hospital, London, Ontario, Canada
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Cost-Effectiveness of Arthroplasty Management in Hip and Knee Osteoarthritis: a Quality Review of the Literature. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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