The Alberta Hip and Knee Replacement Project: a model for health technology assessment based on comparative effectiveness of clinical pathways

Economic and Humanistic Burden of Osteoarthritis: An Updated Systematic Review of Large Sample Studies

OBJECTIVE

A previous systematic literature review demonstrated a significant economic and humanistic burden on patients with osteoarthritis (OA). The aim of this study was to systematically review and update the burden of OA reported by large sample studies since 2016.

METHODS

We searched Medline (via Ovid) and Embase using the updated search strategy based on the previous review. Those studies with a sample size ≥ 1000 and measuring the cost (direct or indirect) or health-related quality of life (HRQL) of OA were included. Pairs of reviewers worked independently and in duplicate. An arbitrator was consulted to resolve discrepancies between reviewers. The Kappa value was calculated to examine the agreement between reviewers. All costs were converted to 2021 US dollars according to inflation rates and exchange rates.

RESULTS

A total of 1230 studies were screened by title and abstract and 159 by full text, and 54 studies were included in the review. The Kappa value for the full-text screening was 0.71. Total annual OA-related direct costs ranged from US$326 in Japan to US$19,530 in the US. Total annual all-cause direct costs varied from US$173 in Italy to US$41,433 in the US. The annual indirect costs ranged from US$736 in the US to US$18,884 in the Netherlands. Thirty-four studies reported HRQL, with EQ-5D (13, 38%) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (6, 18%) being the most frequently used instruments. The EQ-VAS and utility scores ranged from 41.5 to 81.7 and 0.3 to 0.9, respectively. The ranges of WOMAC pain (range 0-20, higher score for worse health), stiffness (range 0-8), and physical functioning (range 0-68) were 2.0-3.0, 1.0-5.0, and 5.8-42.8, respectively.

CONCLUSION

Since 2016, the ranges of direct costs of OA became wider, while the HRQL of patients remained poor. More countries outside the US have published OA-related disease burden using registry databases.

Annual incidence and assessment of risk factors for early-onset deep surgical site infection following primary total knee arthroplasty in osteoarthritis

Aims

This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection.

Methods

This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality.

Results

A total of 39,038 patients underwent primary TKA for osteoarthritis during the study period. Of these, 275 patients developed a deep SSI within 90 days of surgery, representing a cumulative incidence of 0.7%. The annual infection rate did not significantly decrease over the seven-year study period (p = 0.162). Overall, 13,885 (35.5%) cases were excluded from the risk analysis due to missing data. Risk factors associated with early-onset deep SSI included male sex, American Society of Anesthesiologists grade ≥ 3, blood transfusion, acute length of stay, and surgeon volume < 30 TKAs/year. Early-onset deep SSI was not associated with increased 90-day mortality.

Conclusion

This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis using robust Infection Prevention and Control surveillance data, and identifies several potentially modifiable risk factors.

Assessment of risk factors for early-onset deep surgical site infection following primary total hip arthroplasty for osteoarthritis

The aim of this study was to determine the incidence, annual trend, and perioperative outcomes and identify risk factors of early-onset (≤90 d) deep surgical site infection (SSI) following primary total hip arthroplasty (THA) for osteoarthritis. We performed a retrospective study using prospectively collected patient-level data from January 2013 to March 2020. The diagnosis of deep SSI was based on the published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definition. The Mann–Kendall trend test was used to detect monotonic trends. Secondary outcomes were 90 d mortality and 90 d readmission. A total of 22 685 patients underwent primary THA for osteoarthritis. A total of 46 patients had a confirmed deep SSI within 90 d of surgery representing a cumulative incidence of 0.2 %. The annual infection rate decreased over the 7-year study period (p=0.026). Risk analysis was performed on 15 466 patients. Risk factors associated with early-onset deep SSI included a BMI > 30 kg m-2 (odds ratio (OR) 3.42 [95 % CI 1.75–7.20]; p<0.001), chronic renal disease (OR, 3.52 [95 % CI 1.17–8.59]; p=0.011), and cardiac illness (OR, 2.47 [1.30–4.69]; p=0.005), as classified by the Canadian Institute for Health Information. Early-onset deep SSI was not associated with 90 d mortality (p=0.167) but was associated with an increased chance of 90 d readmission (p<0.001). This study establishes a reliable baseline infection rate for early-onset deep SSI after THA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable, and therefore targeted preoperative interventions of patients with these risk factors is encouraged.

The use of patient-reported outcome measures in hip and knee arthroplasty in Alberta

PROMs are part of routine measurement for hip and knee replacement in Alberta, Canada. We provide an overview of how PROMs are implemented in routine care, and how we use PROMs data for decision-making at different levels within the health system. The Alberta Bone and Joint Health Institute (ABJHI) ran a randomized controlled trial to determine the effectiveness and cost-effectiveness of an evidence-based care pathway for hip and knee arthroplasty in 2004. The study included several PROMs questionnaires: Western Ontario and McMaster Universities Osteoarthritis Index, Health Utility Index, Short Form 36 and the EQ-5D-3L. Subsequently, the focus shifted to spread and scale of the care pathway provincially. WOMAC and EQ-5D-3L and a patient experience survey were selected for provincial adoption – captured before surgery, three-months post-surgery, and 12-months post-surgery. These PROMs data were integrated into research and routine clinical practice at the micro, meso and macro levels. At the micro level, PROMs data are used at the individual patient and provider level for patients to provide input on their care and as a tool to communicate with their healthcare providers. We examined the relationship of appropriateness and patient reported outcomes in a prospective cohort study. We evaluated whether routinely collected PROMs could be integrated into a patient decision aid to better inform shared decision making. At the meso level, continuous quality improvement reports are provided routinely to individual health care providers, hospitals and clinics on their performance against the measurement framework and standard key performance indicators. At the macro level, PROMs data are used to evaluate system performance by comparing outcomes across different jurisdictions or over time and support health policy decision making. Combined with administrative databases, we have used simulation models to reflect transition through the continuum of care from disease onset through end-stage care regarding the burden of disease, healthcare resource requirements and associated healthcare costs. The addition of PROMs data in clinical repositories and analyses enables the system to identify and address issues of continuous quality improvement against a measurement framework of performance indicators and to explicitly recognize the trade-offs that are inherent in any resource-constrained system.

Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears

BACKGROUND AND OBJECTIVES

Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted.

METHODS

We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care.

RESULTS

A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management.

CONCLUSION

The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

Validation of a tool to assess patient satisfaction, waiting times, healthcare utilization, and cost

AIM

Patients' experience of the quality of care received throughout their continuum of care can be used to direct quality improvement efforts in areas where they are most needed. This study aims to establish validity and reliability of the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) - a tool that collects patients' experience that quantifies aspect of care used to make judgments about quality from the perspective of the Alberta Quality Matrix for Health (AQMH).

BACKGROUND

The AQMH is a framework that can be used to assess and compare the quality of care in different healthcare settings. The AQMH provides a common language, understanding, and approach to assessing quality. The HAPSQ is one tool that is able to assess quality of care according to five of six AQMH's dimensions.

METHODS

This was a prospective methodologic study. Between March and October 2015, a convenience sample of patients presenting with chronic full-thickness rotator cuff tears was recruited prospectively from the University of Calgary Sport Medicine Centre in Calgary, Alberta, Canada. Reliability of the HAPSQ was assessed using test-retest reliability [interclass correlation coefficient (ICC)>0.70]. Validity was assessed through content validity (patient interviews, floor and ceiling effects), criterion validity (percent agreement >70%), and construct validity (hypothesis testing).

FINDINGS

Reliability testing was completed on 70 patients; validity testing occurred on 96 patients. The mean duration of symptoms was three years (SD: 5.0, range: 0.1-29). Only out-of-pocket utilization possessed an ICC<0.70. Patients reported that items were relevant and appropriate to measuring quality of care. No floor or ceiling effects were present. Criterion validity was reached for all items assessed. A priori hypotheses were confirmed. The HAPSQ represents an inexpensive, reliable, and valid approach toward collecting clinical information across a patient's continuum of care.

Development of key performance indicators to evaluate centralized intake for patients with osteoarthritis and rheumatoid arthritis

Introduction

Centralized intake is integral to healthcare systems to support timely access to appropriate health services. The aim of this study was to develop key performance indicators (KPIs) to evaluate centralized intake systems for patients with osteoarthritis (OA) and rheumatoid arthritis (RA).

Methods

Phase 1 involved stakeholder meetings including healthcare providers, managers, researchers and patients to obtain input on candidate KPIs, aligned along six quality dimensions: appropriateness, accessibility, acceptability, efficiency, effectiveness, and safety. Phase 2 involved literature reviews to ensure KPIs were based on best practices and harmonized with existing measures. Phase 3 involved a three-round, online modified Delphi panel to finalize the KPIs. The panel consisted of two rounds of rating and a round of online and in-person discussions. KPIs rated as valid and important (≥7 on a 9-point Likert scale) were included in the final set.

Results

Twenty-five KPIs identified and substantiated during Phases 1 and 2 were submitted to 27 panellists including healthcare providers, managers, researchers, and patients in Phase 3. After the in-person meeting, three KPIs were removed and six were suggested. The final set includes 9 OA KPIs, 10 RA KPIs and 9 relating to centralized intake processes for both conditions. All 28 KPIs were rated as valid and important.

Conclusions

Arthritis stakeholders have proposed 28 KPIs that should be used in quality improvement efforts when evaluating centralized intake for OA and RA. The KPIs measure five of the six dimensions of quality and are relevant to patients, practitioners and health systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0843-7) contains supplementary material, which is available to authorized users.

Prevalence and Costs of Rehabilitation and Physical Therapy After Primary TJA

This study evaluated the trends in discharge patterns and the prevalence and cost of post-discharge PT. The 5% Medicare database (1997-2010) was used to identify 50,886 primary THA and 107,675 TKA patients. More than 50% of patients were discharged from hospital to an inpatient facility. There were an increase in discharges to skilled nursing units and a reduced rate to rehabilitation facilities. In contrast to hospital, surgeon reimbursement, and implant costs, the average annual PT cost per patient rose through the study period. Approximately 25% of PT costs were used on less common modalities. PT costs more than $648 million a year. With the increased pressure to control costs for primary TJA, these patterns may change unless PT effectiveness can be demonstrated.

Evaluating the primary-to-specialist referral system for elective hip and knee arthroplasty

RATIONALE, AIMS AND OBJECTIVES

Persistently long waiting times for hip and knee total joint arthroplasty (TJA) specialist consultations have been identified as a problem. This study described referral processes and practices, and their impact on the waiting time from referral to consultation for TJA.

METHODS

A mixed-methods retrospective study incorporating semi-structured interviews, patient chart reviews and observational studies was conducted at three clinic sites in Alberta, Canada. A total of 218 charts were selected for analysis. Standardized definitions were applied to key event dates. Performance measures included waiting times percentage of referrals initially accepted. Voluntary (patient-related) and involuntary (health system-related) waiting times were quantified.

RESULTS

All three clinics had defined, but differing, referral processing rules. The mean time from referral to consultation ranged from 51 to 139 business days. Choosing a specific surgeon for consultation rather than a next available surgeon lengthened waits by 10-47 business days. Involuntary waiting times accounted for at least 11% of total waiting time. Approximately 40-80% of the time patients with TJA wait for surgery was in the consultation period. Fifty-four per cent of new referrals were initially rejected, prolonging patient waits by 8-46 business days.

CONCLUSIONS

Our results suggest that variation in referral processing led to increased waiting times for patients. The large proportion of total wait attributable to waiting for a surgical consultation makes failure to measure and evaluate this period a significant omission. Improving referral processes and decreasing variation between clinics would improve patient access to these specialist referrals in Alberta.

Where is the patient in models of patient-centred care: a grounded theory study of total joint replacement patients

Background

Patient-centered care ideally considers patient preferences, values and needs. However, it is unclear if policies such as wait time strategies for hip and knee replacement surgery (TJR) are patient-centred as they focus on an isolated episode of care. This paper describes the accounts of people scheduled to undergo TJR, focusing on their experience of (OA) as a chronic disease that has considerable impact on their everyday lives.

Methods

Semi-structured qualitative interviews were conducted with participants scheduled to undergo TJR who were recruited from the practices of two orthopaedic surgeons. We first used maximum variation and then theoretical sampling based on age, sex and joint replaced. 33 participants (age 38-79 years; 17 female) were included in the analysis. 20 were scheduled for hip replacement and 13 for knee replacement. A constructivist approach to grounded theory guided sampling, data collection and analysis.

Results

While a specific hip or knee was the target for surgery, individuals experienced multiple-joint symptoms and comorbidities. Management of their health and daily lives was impacted by these combined experiences. Over time, they struggled to manage symptoms with varying degrees of access to and acceptance of pain medication, which was a source of constant concern. This was a multi-faceted issue with physicians reluctant to prescribe and many patients reluctant to take prescription pain medications due to their side effects.

Conclusions

For patients, TJR surgery is an acute intervention in the experience of chronic disease, OA and other comorbidities. While policy has focused on wait time as patient/surgeon decision for surgery to surgery date, the patient’s experience does not begin or end with surgery as they struggle to manage their pain. Our findings suggest that further work is needed to align the medical treatment of OA with the current policy emphasis on patient-centeredness. Patient-centred care may require a paradigm shift that is not always evident in current policy and strategies.

Cost-utility of metal-on-metal hip resurfacing compared to conventional total hip replacement in young active patients with osteoarthritis

BACKGROUND

Metal-on-metal hip resurfacing arthroplasty (MoM HRA) has emerged as an alternative to total hip arthroplasty (THA) for younger active patients with osteoarthritis (OA). Birmingham hip resurfacing is the most common MoM HRA in Alberta, and is therefore compared with conventional THA.

OBJECTIVE

The objective of this study was to estimate the expected cost-utility of MoM HRA versus THA, in younger patients with OA, using a decision analytic model with a 15-year time horizon.

METHODS

A probabilistic Markov decision analytic model was constructed to estimate the expected cost per quality-adjusted life-year (QALY) of MoM HRA versus THA from a health care payer perspective. The base case considered patients with OA aged 50 years; men comprised 65.9% of the cohort. Sensitivity analyses evaluated cohort age, utility values, failure probabilities, and treatment costs. Data were derived from the Hip Improvement Project and the Hip and Knee Replacement Pilot databases in Alberta, the 2010 National Joint Replacement Registry of the Australian Orthopaedic Association, and the literature.

RESULTS

In the base case, THA was dominated by MoM HRA (incremental mean costs of -$583 and incremental mean QALYs of 0.079). In subgroup analyses, THA remained dominated when cohort age was 40 years instead of 50 years or when only men were assessed. THA dominated when the cohort age was 60 years or when only women were assessed. Results were sensitive to utilities, surgery costs, and MoM HRA revision and conversion probabilities. At a willingness-to-pay of Can $50,000/QALY, there was a 58% probability that MoM HRA is cost-effective.

CONCLUSIONS

The results show that, on average, MoM HRA was preferred to THA for younger and male patients, but THA is still a reasonable option if the patient or clinician prefers given the small absolute differences between the options and the confidence ellipses around the cost-effectiveness estimates.

Healthcare technology: physician collaboration in reducing the surgical cost

BACKGROUND

The increasing cost of providing health care is a national concern. Healthcare spending related to providing hospital care is one of the primary drivers of healthcare spending in the United States. Adoption of advanced medical technologies accounts for the largest percentage of growth in healthcare spending in the United States when compared with other developed countries. Within the specialty of orthopaedic surgery, a variety of implants can result in similar outcomes for patients in several areas of clinical care. However, surgeons often do not know the cost of implants used in a specific procedure or how the use of an implant or technology affects the overall cost of the episode of care.

QUESTIONS/PURPOSES

The purposes of this study were (1) to describe physician-led processes for introduction of new surgical products and technologies; and (2) to inform physicians of potential cost savings of physician-led product contract negotiations and approval of new technology.

METHODS

We performed a detailed review of the steps taken by two centers that have implemented surgeon-led programs to demonstrate responsibility in technology acquisition and product procurement decision-making.

RESULTS

Each program has developed a physician peer review process in technology and new product acquisition that has resulted in a substantial reduction in spending for the respective hospitals in regard to surgical implants. Implant costs have decreased between 3% and 38% using different negotiating strategies. At the same time, new product requests by physicians have been approved in greater than 90% of instances.

CONCLUSIONS

Hospitals need physicians to be engaged and informed in discussions concerning current and new technology and products. Surgeons can provide leadership for these efforts to reduce the cost of high-quality care.

Patterns of care after magnetic resonance imaging of the spine in primary care

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To examine health care services use after a magnetic resonance imaging (MRI) scan of the lumbosacral or cervical spine ordered by a primary care physician.

SUMMARY OF BACKGROUND DATA

The use of MRI of the spine in the primary care setting is increasing, yet little is known about the relationship between MRI scan findings and subsequent patterns of health care utilization.

METHODS

Linkage of records from an audit of outpatient MRI scans of the spine performed in Ontario, Canada, to administrative databases.

RESULTS

Of the 647 patients who had a lumbosacral spine MRI scan ordered by a primary care physician, 288 (44.5%) were seen in consultation by an orthopedic surgeon or neurosurgeon, and 42 (6.5%) received spine surgery during 3 years of follow-up. Of the 373 patients who had a cervical spine MRI scan ordered by a primary care physician, 164 (44.0%) were seen in consultation by an orthopedic surgeon or neurosurgeon, and none had spine surgery during 3 years of follow-up. Patients with severe disc herniation (likelihood ratio, 5.62, 95% confidence interval, 2.64-12.00) or severe spinal stenosis (likelihood ratio, 2.34; 95% confidence interval, 1.13-4.85) on lumbosacral spine MRI were more likely to undergo subsequent surgery. However, many patients with these MRI abnormalities did not receive surgery, and the absence of these MRI findings did not significantly lower the likelihood of subsequent surgery.

CONCLUSION

Patients receiving MRI scans of the spine in the primary care setting are frequently referred for surgical assessment and most do not receive subsequent surgery. MRI scan results do not discriminate very well between those who will and will not undergo surgery, suggesting that alternative models for the assessment of patients with spinal complaints in primary care should be explored, particularly in jurisdictions with long wait times for elective spinal surgery consultation.

Comparative effectiveness of alternative clinical pathways for primary hip and knee joint replacement patients: a pragmatic randomized, controlled trial

OBJECTIVE

Total hip replacement (THR) and total knee replacement (TKR) (arthroplasty) surgery for end-stage osteoarthritis (OA) are ideal candidates for optimization through an algorithmic care pathway. Using a comparative effectiveness study design, we compared the effectiveness of a new clinical pathway (NCP) featuring central intake clinics, dedicated inpatient resources, care guidelines and efficiency benchmarks vs. the standard of care (SOC) for THR or TKR.

METHODS

We compared patients undergoing primary THR and TKR who received surgery in NCP vs. SOC in a randomised controlled trial within the trial timeframe. 1,570 patients (1,066 SOC and 504 NCP patients) that underwent surgery within the study timeframe from urban and rural practice settings were included. The primary endpoint was improvement in Western Ontario and McMaster University osteoarthritis index (WOMAC) overall score over 12 months post-surgery. Secondary endpoints were improvements in the physical function (PF) and bodily pain (BP) domains of the Short Form 36 (SF-36).

RESULTS

NCP patients had significantly greater improvements from baseline WOMAC scores compared to SOC patients after adjusting for covariates (treatment effect=2.56; 95% confidence interval (CI) [1.10-4.01]). SF-36 BP scores were significantly improved for both hip and knee patients in the NCP (treatment effect=3.01, 95% CI [0.70-5.32]), but SF-36 PF scores were not. Effects of the NCP were more pronounced in knee patients.

CONCLUSION

While effect sizes were small compared with major effects of the surgery itself, an evidence-informed clinical pathway can improve health related quality of life (HRQoL) of hip and knee arthroplasty patients with degenerative joint disorder in routine clinical practice for up to 12 months post-operatively. CLINICALTRIALS.GOV IDENTIFIER: NCT00277186.

Comparison of arthroplasty trial publications after registration in ClinicalTrials.gov

In 2005, the International Committee of Medical Journal Editors established a mandatory trial registration before study enrollment for publication in member journals. Our primary objective was to evaluate the publication rates of arthroplasty trials registered with ClinicalTrials.gov (CTG). We further aimed to examine the consistency of registration summaries with that of final publications. We searched CTG for all trials related to joint arthroplasty and conducted a thorough search for publications resulting from registered closed trials. Of 101 closed and completed trials, we found 23 publications, for an overall publication rate of 22.8%. Registration of arthroplasty trials in CTG does not consistently result in publication or disclosure of results. In addition, changes are frequently made to the final presentation of the data that are not reflected in the trial registry.

Functional outcomes for 2 years comparing hip resurfacing and total hip arthroplasty

This prospective observational study of 499 patients with hip resurfacing and 255 patients with total hip arthroplasty compared outcomes for 2 years. We used propensity scores to identify matched cohorts of 118 patients with hip resurfacing and 118 patients with total hip arthroplasty. We used these cohorts to compare improvements in the Western Ontario and McMaster University (WOMAC) osteoarthritis index and Medical Outcomes Short-Form 36 physical function component (SF-36 PF) scores at 3 months and at 1 and 2 years postsurgery. Both groups demonstrated significant improvements from baseline in WOMAC and SF-36 PF. Improvements in SF-36 PF were greater for patients with hip resurfacing than for patients with total hip arthroplasty 1 and 2 years postsurgery; improvements in WOMAC were similar for both groups. The clinical significance of this observation needs further investigation.

Measuring the value of total hip and knee arthroplasty: considering costs over the continuum of care

BACKGROUND

Controlling escalating costs of hip (THA) and knee arthroplasty (TKA) without compromising quality of care has created the need for innovative system reorganization to inform sustainable solutions.

QUESTIONS/PURPOSES

The purpose of this study was to inform estimates of the value of THA and TKA by determining: (1) the data sources data required to obtain costs across the care continuum; (2) the data required for different analytical perspectives; and (3) the relative costs across the continuum of care.

METHODS

Within the context of a pragmatic randomized controlled trial comparing alternative care pathways, we captured healthcare resource use: (1) 12 months before surgery; (2) inpatient; (3) acute recovery; and (4) long-term recovery 3 and 12 months postsurgery. We established a standardized costing model to reflect both the healthcare payer and patient perspectives.

RESULTS

Multiple data sources from regional health authorities, administrative databases, and patient questionnaire were required to estimate costs across the care continuum. Inpatient and acute care costs were approximately 60% of the total with the remaining 40% incurred 12 months presurgery and 12 months postsurgery. Regional health authorities bear close to 60%, and patient costs are approximately 30% of the mean total costs, most of which were incurred after the acute inpatient stay.

CONCLUSIONS

To fully understand the value of an orthopaedic intervention such as THA and TKA, a broader perspective than one limited to the payer should be considered using a standardized measurement framework over a relevant time horizon and from multiple viewpoints to reflect the substantial patient burden and support sustainable improvement over the care continuum.

LEVEL OF EVIDENCE

Level III, economic and decision analyses study. See Guidelines for Authors for a complete description of levels of evidence.