Economic evaluations in the hip arthroplasty literature: lessons to be learned

Patient-Level Value Analysis in Total Hip Arthroplasty: Optimizing the Value of Care Delivery

BACKGROUND

Value is defined as the ratio of patient outcomes to the cost of care. One method to assess value is through patient-level value analysis (PLVA). To our knowledge, this tool has not previously been implemented in the setting of total hip arthroplasty (THA). The purposes of this study were to perform PLVA for a 1-year episode of care among patients undergoing primary THA and to identify characteristics that affect value in a metropolitan health-care system.

METHODS

The patient-reported outcome (PRO) measure database of the institution was queried for all primary THAs from 2018 to 2019. The PRO measure that was utilized was the Hip disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS-JR). Cost was evaluated with use of time-driven activity-based costing (TDABC) for a 1-year episode of care (consisting of the day of surgery, inpatient stay, discharge facility, postoperative appointments, and physical therapy). The primary outcome was the 1-year value quotient, or the ratio of the 1-year change in HOOS-JR to the cost of the episode of care (VHOOS). The value quotient was compared among all included patients and evaluated for variables that may affect the overall value of the episode of care.

RESULTS

In total, 480 patients were included in the analysis. The mean improvement in the HOOS-JR was +34.9 ± 16.1 (95% confidence interval [CI]: 33.5, 36.3). The mean cost was $13,835 ± $3,471 (95% CI: $13,524, $14,146). The largest contributor to cost was implants (39.0%), followed by post-recovery care (i.e., inpatient stay and specialized nursing facilities; 24.1%). Change in the HOOS-JR was poorly correlated with the cost of care (r = -0.06; p = 0.19). THAs performed at an ambulatory surgery center (ASC) with discharge to home demonstrated higher value (VHOOS = 0.42) than THAs performed at a hospital with discharge to a rehabilitation facility (VHOOS = 0.15; analysis of variance F-test, p < 0.01).

CONCLUSIONS

Our study found that PROs did not correlate with costs in the setting of primary THA. Implants were the largest cost driver. Surgical setting (an ASC versus a hospital) and discharge destination influenced value as well. PLVA is a value measurement tool that can be utilized to optimize components of the care delivery pathway.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Methodologic and Reporting Quality of Economic Evaluations in Hand and Wrist Surgery: A Systematic Review

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.

Cost-effectiveness of enhanced recovery in hip and knee replacement: a systematic review protocol

INTRODUCTION

Hip and knee replacement represents a significant burden to the UK healthcare system. 'Enhanced recovery' pathways have been introduced in the National Health Service (NHS) for patients undergoing hip and knee replacement, with the aim of improving outcomes and timely recovery after surgery. To support policymaking, there is a need to evaluate the cost-effectiveness of enhanced recovery pathways across jurisdictions. Our aim is to systematically summarise the published cost-effectiveness evidence on enhanced recovery in hip and knee replacement, both as a whole and for each of the various components of enhanced recovery pathways.

METHODS AND ANALYSIS

A systematic review will be conducted using MEDLINE, EMBASE, Econlit and the National Health Service Economic Evaluations Database. Separate search strategies were developed for each database including terms relating to hip and knee replacement/arthroplasty, economic evaluations, decision modelling and quality of life measures.We will extract peer-reviewed studies published between 2000 and 2017 reporting economic evaluations of preoperative, perioperative or postoperative enhanced recovery interventions within hip or knee replacement. Economic evaluations alongside cohort studies or based on decision models will be included. Only studies with patients undergoing elective replacement surgery of the hip or knee will be included. Data will be extracted using a predefined pro forma following best practice guidelines for economic evaluation, decision modelling and model validation.Our primary outcome will be the cost-effectiveness of enhanced recovery (entire pathway and individual components) in terms of incremental cost per quality-adjusted life year. A narrative synthesis of all studies will be presented, focussing on cost-effectiveness results, study design, quality and validation status.

ETHICS AND DISSEMINATION

This systematic review is exempted from ethics approval because the work is carried out on published documents. The results of the review will be disseminated in a peer-reviewed academic journal and at conferences.

PROSPERO REGISTRATION NUMBER

CRD42017059473.

Excess Length of Stay Attributable to Surgical Site Infection Following Hip Replacement: A Nested Case-Control Study

Objective.

We estimated the impact of hip replacement-associated surgical site infection (SSI) on morbidity and length of stay.

Methods.

This was a pairwise matched (1 : 1) case-control study nested in a cohort. All patients who underwent hip replacement from January 1, 2000, to June 30, 2004, were prospectively enrolled for the nested case-control design analysis and were monitored from the time of surgery until hospital discharge, including any patients readmitted because of infection.

Results.

Among the 1,260 hip replacements performed, 28 SSIs were detected, yielding a crude SSI rate of 2.2%. The median excess length of stay attributable to SSI was 32.5 days (P< .001), whereas the median prolonged postoperative stay due to SSI was 31 days (P< .001). Deep-wound SSI was the type that prolonged hospital stay the most (up to 49 days). Of the patients who developed an SSI, 4 required revision surgery, for an SSI-related morbidity rate of 14.3%.

Conclusion.

SSI prolongs hospital stay; however, although hospital stay is a rough indicator of the cost of this complication, to accurately estimate the costs of SSI, we would need to consider individual costs in a linear regression model adjusted for all possible confounding factors.

Excess Length of Stay Attributable to Surgical Site Infection Following Hip Replacement: A Nested Case-Control Study

Objective.

We estimated the impact of hip replacement-associated surgical site infection (SSI) on morbidity and length of stay.

Methods.

This was a pairwise matched (1 : 1) case-control study nested in a cohort. All patients who underwent hip replacement from January 1, 2000, to June 30, 2004, were prospectively enrolled for the nested case-control design analysis and were monitored from the time of surgery until hospital discharge, including any patients readmitted because of infection.

Results.

Among the 1,260 hip replacements performed, 28 SSIs were detected, yielding a crude SSI rate of 2.2%. The median excess length of stay attributable to SSI was 32.5 days (P< .001), whereas the median prolonged postoperative stay due to SSI was 31 days (P< .001). Deep-wound SSI was the type that prolonged hospital stay the most (up to 49 days). Of the patients who developed an SSI, 4 required revision surgery, for an SSI-related morbidity rate of 14.3%.

Conclusion.

SSI prolongs hospital stay; however, although hospital stay is a rough indicator of the cost of this complication, to accurately estimate the costs of SSI, we would need to consider individual costs in a linear regression model adjusted for all possible confounding factors.

Methodological reviews of economic evaluations in health care: what do they target?

INTRODUCTION AND OBJECTIVES

An increasing number of published studies of economic evaluations of health technologies have been reviewed and summarized with different purposes, among them to facilitate decision-making processes. These reviews have covered different aspects of economic evaluations, using a variety of methodological approaches. The aim of this study is to analyze the methodological characteristics of the reviews of economic evaluations in health care, published during the period 1990-2010, to identify their main features and the potential missing elements. This may help to develop a common procedure for elaborating these kinds of reviews.

METHODS

We performed systematic searches in electronic databases (Scopus, Medline and PubMed) of methodological reviews published in English, period 1990-2010. We selected the articles whose main purpose was to review and assess the methodology applied in the economic evaluation studies. We classified the data according to the study objectives, period of the review, number of reviewed studies, methodological and non-methodological items assessed, medical specialty, type of disease and technology, databases used for the review and their main conclusions. We performed a descriptive statistical analysis and checked how generalizability issues were considered in the reviews.

RESULTS

We identified 76 methodological reviews, 42 published in the period 1990-2001 and 34 during 2002-2010. The items assessed most frequently (by 70% of the reviews) were perspective, type of economic study, uncertainty and discounting. The reviews also described the type of intervention and disease, funding sources, country in which the evaluation took place, type of journal and author's characteristics. Regarding the intertemporal comparison, higher frequencies were found in the second period for two key methodological items: the source of effectiveness data and the models used in the studies. However, the generalizability issues that apparently are creating a growing interest in the economic evaluation literature did not receive as much attention in the reviews of the second period. The remaining items showed similar frequencies in both periods.

CONCLUSIONS

Increasingly more reviews of economic evaluation studies aim to analyze the application of methodological principles, and offer summaries of papers classified by either diseases or health technologies. These reviews are useful for finding literature trends, aims of studies and possible deficiencies in the implementation of methods of specific health interventions. As no significant methodological improvement was clearly detected in the two periods analyzed, it would be convenient to pay more attention to the methodological aspects of the reviews.

Economical analysis on prophylaxis, diagnosis, and treatment of periprosthetic infections

The economic burden of periprosthetic infections is enormous, but the number of economic studies dealing with this issue is very scarce. This review tries to know the economic literature existing, assess the value of current data, and recognize the less costly and more effective procedures for prevention, diagnosis and treatment of periprosthetic infections. Forty five studies meeting the inclusion criteria and adhering to the quality criteria used were carefully analyzed to extract the economic data of relevance in evaluating the magnitude of problem and the more cost-effective solutions. However, because the heterogeneity and the low-quality of most of these studies meta-analytical technique has not been possible. Instead, the studies have been reviewed descriptively. Optimizing the antibiotic use in the prevention and treatment of periprosthetic infection, combined with systemic and behavioral changes in the operating room; detecting and treating the high-risk groups; a quick, simple, reliable, safe, and cost-effective diagnosis, and the rationale management of the instituted infection, specifically using the different procedures according to each particular case, could allow to improve outcomes and produce the highest quality of life for patients and the lowest economic impact. Nevertheless, the cost effectiveness of different interventions to prevent and to treat the periprosthetic infection remains unclear.

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.

Cost-outcome analysis of joint replacement: evidence from a Spanish public hospital

BACKGROUND AND OBJECTIVES

Efficiency-based healthcare decision-making has been widely accepted for some time, with cost per quality-adjusted life year (QALY) as the main outcome measure. Nevertheless, for numerous medical procedures, little data are available on the cost per QALY gained. The aim of the present study was to calculate the cost per QALY gained with primary hip and knee replacement and to compare the result with the cost per QALY for other medical procedures, as well as with the maximum threshold cost considered acceptable in Spain.

METHODS

We performed a prospective cohort pre-test/post-test study of patients undergoing primary hip or knee arthroplasty. Age, sex, and clinical variables were recorded. Functional status and quality of life were measured by means of the WOMAC and EuroQol instruments, respectively, before the intervention and 6 months later. The direct costs of the intervention were calculated, with length of hospital stay and the prosthesis as the main cost drivers.

RESULTS

A total of 80 patients, 40 from each intervention, were included in this study. Both functional and perceived health status improved after the intervention. The number of QALYs gained in the knee cohort was 4.64, while that in the hip cohort was 0.86. The total cost of knee replacement was lower (6,865.52 euro) than that of hip replacement (7,891.21 euro). The cost per QALY gained was 1,275.84 euro and 7,936.12 euro for knee and hip interventions, respectively. The calculations performed included a 6% discount rate for health outcomes, a 3% inflation rate for costs, and a success rate of 95% at 15 years.

CONCLUSIONS

The costs of both knee and hip replacement were lower than the threshold of 30,000 euro per QALY considered acceptable in Spain, and compared favorably with other medical and surgical procedures.

Cost-effectiveness analysis of periacetabular osteotomy

BACKGROUND

A lack of long-term outcomes data following periacetabular osteotomy makes it difficult for surgeons to recommend the most appropriate procedure to young patients who might be candidates for a joint-preserving procedure. In this study, we compared the cost-effectiveness of periacetabular osteotomy with total hip arthroplasty in terms of cost per quality-adjusted life year for the young adult.

METHODS

A decision model was constructed for a cost-utility analysis of periacetabular osteotomy compared with total hip arthroplasty. Outcome probabilities and effectiveness were derived from the literature. Effectiveness was expressed in quality-adjusted life years gained. Cost data were compiled and verified from our institution. Costs and utilities were discounted in accord with the United States Panel on Cost-Effectiveness in Health and Medicine. Principal outcome measures were average incremental costs, incremental effectiveness, incremental quality-adjusted life years, and net health benefits. Multivariate sensitivity analysis was used to assess the contribution of included variables in the model's outcomes.

RESULTS

For Tönnis grade-1 coxarthrosis, periacetabular osteotomy dominates with an average incremental cost-effectiveness of $7856 per quality-adjusted life year and an average incremental effectiveness of 0.15. For Tönnis grade-2 coxarthrosis, periacetabular osteotomy is, on the average, more cost-effective than total hip arthroplasty with an incremental cost-effectiveness of $824 per quality-adjusted life year, but it is less effective than total hip arthroplasty, on the average, with an incremental effectiveness of -1.4 quality-adjusted life years. Periacetabular osteotomy becomes more cost-effective at a longevity of 5.5 years for Tönnis grade-1 coxarthrosis and 18.25 years for Tönnis grade-2 coxarthrosis. In Tönnis grade-3 coxarthrosis, total hip replacement becomes the dominant treatment strategy.

CONCLUSIONS

Periacetabular osteotomy is, on the average, more cost-effective in Tönnis grade-1 and grade-2 coxarthrosis, while it is both more costly and less effective in Tönnis grade-3 coxarthrosis. These findings can inform clinical decision-making in the absence of long-term data. On the basis of this model, periacetabular osteotomy is preferable to total hip arthroplasty in Tönnis grade-1 and grade-2 coxarthrosis when the patient is sufficiently young and when functionality in sports is important.

Patient out-of-pocket expenses in major orthopedic procedures: total hip arthroplasty as a case study

Total hip arthroplasty (THA) is a successful procedure for improving quality of life. There are few publications regarding out-of-pocket expenses incurred by individuals undergoing uncomplicated THA. Detailed billing and record reviews and patient phone surveys were conducted on 34 Medicare patients identifying charges and reimbursements recorded by the health care system and all out-of-pocket expenses incurred by patients undergoing uncomplicated THA (diagnostic related group [DRG] 209/current procedural terminology [CPT] 27130). Mean THA total billed charges were $46378, 89% of that from inpatient hospitalization and 5% incurred preoperatively and 7% postoperatively. Medicare reimbursement was $14647, supplemental reimbursement was $744, and patients paid a mean out-of-pocket expense of $758 (95% CI, 614-904; range, 102-1889). Our study supports the policy that THA remains an excellent value to both the patient and society.

Factors affecting aseptic loosening of 4750 total hip arthroplasties: multivariate survival analysis

BACKGROUND

Total hip arthroplasty is a successful surgery, that fails at a rate of approximately 10% at ten years from surgery. Causes for failure are mainly aseptic loosening of one or both components partially due to wear of articular surfaces and partially to design. The present analysis aimed to identify risk factors and quantify their effects on aseptic failure.

METHODS

Multivariate survival analysis was applied to 4,750 primary total hip arthroplasties performed between 1995 and 2000.

RESULTS

The survival of the prosthesis is affected by gender, age, pathology, type of the prosthesis and skill of the. The worst conditions are male patients, younger than 40 years, affected by sequelae of congenital diseases, operated by a who performed less than 400 total hip artroplasty in the period. Furthermore, cemented cups and stems (less expensive) have a higher risk of failure compared with uncemented ones (more expensive).

CONCLUSION

The only variable that affects survival and that can be modified by is the type of prosthesis: a lower cost is associated to a higher risk. Results concerning the risk associated with cemented components are partially in disagreement with studies performed in countries where cemented prostheses are used more often than uncemented ones.

Minimally invasive hip replacement: rationale, applied anatomy, and instrumentation

The term minimally invasive hip replacement encompasses a diverse range of surgical approaches through which hip replacement may be performed. These surgical approaches are technically demanding and are best performed using specially designed instruments that help to compensate for the reduced surgical exposure. The early results using these techniques are encouraging, although the literature is lacking evidence from well designed prospective trials comparing MIS techniques with standard approaches. The studies that exist suggest that patient satisfaction is high, bleeding may be reduced, recovery of function may be faster, and there may be the potential to reduce lengths of hospital stay, and all this may be achieved without increasing complication rates. These results,however, have been achieved by a small number of high-volume surgeons, and the authors feel it is essential that as these techniques are introduced into widespread practice the results be studied carefully.

Economic evaluation in total hip arthroplasty: analysis and review of the literature

We performed a bibliographic search of MEDLINE databases from January 1966 to July 2002 to identify English language articles that contained either "cost" or "economic" in combination with "total hip arthroplasty" (THA) in the abstract or title. Each study was then critically reviewed for content, technique, and adherence to established healthcare economic principles. Only 81 of the 153 studies retrieved contained actual economic data. Only 6% of studies adhered to established criteria for a comprehensive health care economic analysis. Although the number of publications regarding economic evaluation of THA is on the rise, the methodologic quality of many of these studies remains inadequate. Future studies should employ sound healthcare economic techniques to properly evaluate and assess the true social and economic value of THA.