Cost-Utility Study of the Economics of Bunion Correction Surgery

A cost-utility study of elective haemorrhoidectomies in Canada

AIM

The aim was to estimate the 10-year cost-utility of haemorrhoidectomy surgery with preference-based measures of health using Canadian health utility measures and costs.

METHODS

Patients undergoing elective haemorrhoidectomies by general and colorectal surgeons in British Columbia, Vancouver, between September 2015 and November 2022, completed preoperatively and postoperatively the EuroQol five-dimension five-level health-related quality of life questionnaire (EQ-5D-5L). Quality-adjusted life years (QALYs) attributable to surgery were calculated by discounting preoperative and postoperative health utility values derived from the EQ-5D-5L. Costs were measured from a health system perspective which incorporated costs of hospital stay and specialists' fees. Results are presented in 2021 Canadian dollars.

RESULTS

Of 94 (47%) patients who completed both the preoperative and postoperative questionnaires, the mean gain in QALYs 10 years after surgery was 1.0609, assuming a 3.5% annual discounting rate. The average cost of the surgery was $3166. The average cost per QALY was $2985 when benefits of the surgery were assumed to accrue for 10 years. The cost per QALY was higher for women ($3821) compared with men ($2485). Participants over the age of 70 had the highest cost per QALY ($8079/QALY).

CONCLUSIONS

Haemorrhoidectomies have been associated with significant gains in health status and are inexpensive relative to the associated gains in quality of life based on patients' perspectives of their improvement in health and well-being.

Anatomical reconstruction of first ray instability hallux valgus with a medial anatomical TMTJ1 plate

BACKGROUND

First tarsometatarsal joint (TMTJ1) arthrodesis is a powerful tool for hallux valgus correction. Past criticism of the TMTJ1 arthrodesis has focused on high non-union rates, and consequent need for delayed weightbearing as prevention. In this study we present a selection and treatment protocol to minimise non-union while allowing early weightbearing.

METHODS

All TMTJ1 arthrodesis procedures for hallux valgus performed by the senior surgeon over the period June, 2016 to July, 2019 were included. An anatomically-designed, medial TMTJ1 plate and screw compression was utilised for TMTJ1 arthrodesis. The construct was augmented with synthetic intermetatarsal stabilisation. All patients were kept non-weightbearing for 2 weeks, followed by progressive weightbearing as tolerated for 4 weeks. Minimum follow-up was 1 year.

RESULTS

300 modified Lapidus procedures were performed for hallux valgus with mean IMA 17° (Range: 14-29). Mean age was 58 years, with 93% female. 284 (94%) had an Akin osteotomy, while 222 cases (74%) were associated with another forefoot procedure. Patients began progressive weight bearing as tolerated from 2 weeks. All were fully weight bearing by 8 weeks post-operatively. There was a 100% union rate in this group. Mean AOFAS Hallux MTP-IP scores rose from 59 pre-operatively to 97 post-operatively. One plate was removed due to tibialis anterior impingement. There were no recurrences at final follow-up.

CONCLUSIONS

We describe a selection and treatment protocol for TMTJ1 arthrodesis for hallux valgus. This yields high union rates while allowing early weight bearing.

LEVEL OF EVIDENCE

4.

A Clinician-Free Method Using Top-View Photography for Screening and Monitoring Hallux Valgus

BACKGROUND

Hallux valgus is a progressive foot deformity that commonly affects middle-aged women. The aim of this study was to develop a novel method using only top-view photographs to assess hallux valgus severity.

METHODS

A top-view digital photograph was taken of each foot of 70 female participants. Two straight lines were drawn along the medial edge of the great toe and forefoot, and the included angle (termed bunion angle) was measured using a free software program. Each foot was also assessed by a clinician using the Manchester scale as no (grade 1), mild (grade 2), moderate (grade 3), or severe (grade 4) deformity.

RESULTS

The mean bunion angles of the 140 feet were 6.7°, 13.5°, and 16.2° for Manchester grades 1, 2, and 3, respectively (no foot was in grade 4). The reliability was excellent for both intrarater (intraclass correlation coefficient [ICC] = 0.93-0.95) and interrater (ICC = 0.90) assessments. Receiver operating characteristic curves determined the optimal bunion angle cutoff value for screening hallux valgus to be 9°, which gives 89.2% sensitivity and 74.2% specificity.

CONCLUSIONS

The bunion angle is a reliable, clinician-free method that can potentially be integrated into a smartphone app for easy and inexpensive self-assessment of hallux valgus.

Measuring the impact of delayed access to elective cholecystectomy through patient's cost-utility: an observational cohort study

Background

Deferral of surgeries due to COVID-19 has negatively affected access to elective surgery and may have deleterious consequences for patient’s health. Delays in access to elective surgery are not uniform in their impact on patients with different attributes. The objective of this study is to measure the change in patient’s cost utility due to delayed elective cholecystectomy.

Methods

This study is based on retrospective analysis of a longitudinal sample of participants who have had elective cholecystectomy and completed the EQ-5D(3L) measuring health status preoperatively and postoperatively. Emergent cases were excluded. Patients younger than 19 years of age, unable to communicate in English or residing in a long-term care facility were ineligible. Quality-adjusted life years attributable to cholecystectomy were calculated by comparing health state utility values between the pre- and postoperative time points. The loss in quality-adjusted life years due to delayed access was calculated under four assumed scenarios regarding the length of the delay. The mean cost per quality-adjusted life years are shown for the overall sample and by sex and age categories.

Results

Among the 646 eligible patients, 30.1% of participants (N = 195) completed their preoperative and postoperative EQ-5D(3L). A delay of 12 months resulted in a mean loss of 6.4%, or 0.117, of the quality-adjusted life years expected without the delay. Among patients older than 70 years of age, a 12-month delay in their surgery corresponded with a 25.1% increase in the cost per quality-adjusted life years, from $10 758 to $13 463.

Conclusions

There is a need to focus on minimizing loss of quality of life for patients affected by delayed surgeries. Faced with equal delayed access to elective surgery, triage may need to prioritize older patients to maximize their health over their remaining life years.

Validating the Foot and Ankle Outcome score for measuring foot dysfunction among hallux valgus surgery patients using item response theory

BACKGROUND

There is an absence of high quality research validating instruments that measure foot and ankle related quality of life among hallux valgus (bunion) patients' perspectives. The Foot and Ankle Outcome Scale is a patient-reported outcome instrument, that when administered to patients with symptomatic hallux valgus, provides a patient-centric perspective of their foot function. The aim of this study is to assess the psychometric properties of the instrument's five subscales among preoperative bunion surgery patients.

METHODS

The Foot and Ankle Outcome Scale instrument measures Pain, Symptoms, Activities of Daily Living, Sport and Recreational Activities and Foot/Ankle Related Quality of Life. Preoperative data is collected from a sample of patients scheduled for surgical treatment of their condition in Vancouver, Canada. Classical and item response theory methods are used to report on reliability, validity and differential item functioning among subgroups.

RESULTS

This study included 249 surveys, representing an overall response rate of 44.1% among 564 eligible patients. The instrument demonstrated high reliability for all subscales, though 18 items across subscales, exhibited poor discrimination between item levels. Four items score differently according to patients' sex and one item scored differently by age.

CONCLUSIONS

The instrument measures five domains of health important to bunion patients. These findings suggest that the current instrument can be used with an understanding of its limitations, including redundant questions and sex-based differences. Future research should revise a number of items. The results highlight the importance of the psychometric analyses of instruments in specific patient populations.

Cost-effectiveness of interventions for musculoskeletal foot and ankle conditions: a systematic review

OBJECTIVE

Musculoskeletal conditions of the foot and ankle are common, yet the cost-effectiveness of the variety of treatments available is not well defined. The aim of this systematic review was therefore to identify, appraise and synthesise the literature pertaining to the cost-effectiveness of interventions for musculoskeletal foot and ankle conditions.

METHODS

Electronic databases were searched for studies presenting economic evaluations of non-surgical and surgical treatments for acute or chronic musculoskeletal conditions of the foot and ankle. Data on cost, incremental cost-effectiveness and quality-adjusted life years for each intervention and comparison were extracted. Risk of bias was assessed using the Drummond checklist for economic studies (range 0-35).

RESULTS

Thirty-six studies were identified reporting non-surgical interventions (n=10), non-surgical versus surgical interventions (n=14) and surgical interventions (n=12). The most common conditions were osteoarthritis, ankle fracture and Achilles tendon rupture. The strongest economic evaluations were for interventions managing end-stage ankle osteoarthritis, ankle sprain, ankle fracture, calcaneal fracture, and Achilles tendon rupture. Total ankle replacement and ankle arthrodesis for end-stage ankle osteoarthritis, in particular, have been demonstrated through high-quality studies to be cost-effective compared to the non-surgical alternative.

CONCLUSION

Selected interventions for musculoskeletal foot and ankle conditions dominate comparators, whereas others require thoughtful consideration as they provide better clinical improvements, but at an increased cost. Researchers should consider measuring and reporting costs alongside clinical outcome to provide context when determining the appropriateness of interventions for other foot and ankle complaints to best inform future clinical practice guidelines.

Cost-Effectiveness of Surgical Techniques in Hallux Valgus

Health care costs are increasing. Funding is not increasing at a commensurate rate. Demonstrable cost-effectiveness is critical when selecting operation and implant type. Clinicians must justify their decision on surgery and implant type, providing patient-reported outcome measures (PROM). Providing such data on cost and PROM forms the basis of future cost-effectiveness analysis (CEA). Such analysis is complex. Future research should analyze cost variables individually. Day case surgery, multimodal analgesia, and simultaneous surgery for bilateral cases show promise in reducing cost. With evidence of increased recurrence, requirement for additional equipment and more expensive implants it is unlikely to demonstrate superior cost-effectiveness.