Determining the cost-effectiveness requirements of an exoskeleton preventing second hip fractures using value of information

Balancing ability of patients with lumbar spinal canal stenosis

PURPOSE

To determine the relationship between postural sway and the severity of lumbar spinal canal stenosis as well as the effect on postoperative improvement.

METHODS

Stabilometry was performed before and 6 months after surgery in 52 patients (29 men and 23 women; mean age, 74.1 ± 7.8 years) who underwent decompression surgery for lumbar spinal canal stenosis. The environmental area (EA; the area surrounding the circumference of the stabilogram) and locus length per EA (L/EA) were evaluated. The patients were divided into moderate (n = 22) and severe (n = 30) groups according to the severity of canal stenosis. Patient characteristics and parameters were compared between the groups before and after surgery, including the visual analog scale (VAS) score for leg pain, Oswestry Disability Index (ODI), EA, and L/EA. In addition, factors affecting EA and L/EA were evaluated using multiple regression analysis.

RESULTS

Age (p = 0.031), preoperative EA (p < 0.001), preoperative L/EA (p = 0.032), and sagittal vertical axis (p = 0.033) were significantly different between groups. The VAS score and ODI significantly improved postoperatively in both groups (p < 0.001). The EA significantly improved postoperatively only in the severe group (p < 0.001), whereas the L/EA did not significantly improve in either group. Multiple regression analysis showed that only the severity of canal stenosis was significantly associated with preoperative EA (p = 0.030), whereas age (p = 0.040) and severity of canal stenosis (p = 0.030) were significantly associated with preoperative L/EA. Diabetes was significantly associated with postoperative EA (p = 0.046) and L/EA (p = 0.030).

CONCLUSION

The severity of canal stenosis affected abnormal postural sway, which improved after decompression surgery.

Cost-effectiveness analysis of surgical proximal femur fracture prevention in elderly: a Markov cohort simulation model

BACKGROUND

Hip fractures are a common and costly health problem, resulting in significant morbidity and mortality, as well as high costs for healthcare systems, especially for the elderly. Implementing surgical preventive strategies has the potential to improve the quality of life and reduce the burden on healthcare resources, particularly in the long term. However, there are currently limited guidelines for standardizing hip fracture prophylaxis practices.

METHODS

This study used a cost-effectiveness analysis with a finite-state Markov model and cohort simulation to evaluate the primary and secondary surgical prevention of hip fractures in the elderly. Patients aged 60 to 90 years were simulated in two different models (A and B) to assess prevention at different levels. Model A assumed prophylaxis was performed during the fracture operation on the contralateral side, while Model B included individuals with high fracture risk factors. Costs were obtained from the Centers for Medicare & Medicaid Services, and transition probabilities and health state utilities were derived from available literature. The baseline assumption was a 10% reduction in fracture risk after prophylaxis. A sensitivity analysis was also conducted to assess the reliability and variability of the results.

RESULTS

With a 10% fracture risk reduction, model A costs between $8,850 and $46,940 per quality-adjusted life-year ($/QALY). Additionally, it proved most cost-effective in the age range between 61 and 81 years. The sensitivity analysis established that a reduction of ≥ 2.8% is needed for prophylaxis to be definitely cost-effective. The cost-effectiveness at the secondary prevention level was most sensitive to the cost of the contralateral side's prophylaxis, the patient's age, and fracture treatment cost. For high-risk patients with no fracture history, the cost-effectiveness of a preventive strategy depends on their risk profile. In the baseline analysis, the incremental cost-effectiveness ratio at the primary prevention level varied between $11,000/QALY and $74,000/QALY, which is below the defined willingness to pay threshold.

CONCLUSION

Due to the high cost of hip fracture treatment and its increased morbidity, surgical prophylaxis strategies have demonstrated that they can significantly relieve the healthcare system. Various key assumptions facilitated the modeling, allowing for adequate room for uncertainty. Further research is needed to evaluate health-state-associated risks.

Risk of hip fracture in meat-eaters, pescatarians, and vegetarians: a prospective cohort study of 413,914 UK Biobank participants

BACKGROUND

Meat-free diets may be associated with a higher risk of hip fracture, but prospective evidence is limited. We aimed to investigate the risk of hip fracture in occasional meat-eaters, pescatarians, and vegetarians compared to regular meat-eaters in the UK Biobank, and to explore the role of potential mediators of any observed risk differences.

METHODS

Middle-aged UK adults were classified as regular meat-eaters (n = 258,765), occasional meat-eaters (n = 137,954), pescatarians (n = 9557), or vegetarians (n = 7638) based on dietary and lifestyle information at recruitment (2006-2010). Incident hip fractures were identified by record linkage to Hospital Episode Statistics up to September 2021. Multivariable Cox regression models were used to estimate associations between each diet group and hip fracture risk, with regular meat-eaters as the reference group, over a median follow-up time of 12.5 years.

RESULTS

Among 413,914 women, 3503 hip fractures were observed. After adjustment for confounders, vegetarians (HR (95% CI): 1.50 (1.18, 1.91)) but not occasional meat-eaters (0.99 (0.93, 1.07)) or pescatarians (1.08 (0.86, 1.35)) had a greater risk of hip fracture than regular meat-eaters. This is equivalent to an adjusted absolute risk difference of 3.2 (1.2, 5.8) more hip fractures per 1000 people over 10 years in vegetarians. There was limited evidence of effect modification by BMI on hip fracture risk across diet groups (p_interaction = 0.08), and no clear evidence of effect modification by age or sex (p_interaction = 0.9 and 0.3, respectively). Mediation analyses suggest that BMI explained 28% of the observed risk difference between vegetarians and regular meat-eaters (95% CI: 1.1%, 69.8%).

DISCUSSION

Vegetarian men and women had a higher risk of hip fracture than regular meat-eaters, and this was partly explained by their lower BMI. Ensuring adequate nutrient intake and weight management are therefore particularly important in vegetarians in the context of hip fracture prevention.

TRIAL REGISTRATION

NCT05554549, registered retrospectively.

Assessing the Social and Environmental Impact of Healthcare Technologies: Towards an Extended Social Return on Investment

Stroke is the third leading cause of death and disability overall worldwide. Upper limb impairment is a common consequence for stroke survivors, having negative impact on their quality of life. Robotic rehabilitation, through repetitive and monitored movements, can improve their status. Developed by a team of researchers at Politecnico di Milano, AGREE is an exoskeleton for upper limb rehabilitation at the stage gate between translational research and clinical validation. Since the cost of this device is particularly high, the present study aimed to provide a framework for assessing its value. The Social Return on Investment (SROI) method, able to grasp the economic, social and environmental impact of an activity, was applied, using expert opinions of a pool of clinical engineers and healthcare professionals from different Italian hospitals to obtain information. Environmental impacts were estimated through Life Cycle Assessment in terms of CO₂ emissions and incorporated in the analysis. Considering a 5-year period, the SROI for a single exoskeleton was 3.75:1, and the SROI for the number of exoskeletons projected to be sold was 2.868:1, thus resulting largely in value for money. This study provides a model for combining economic, social and environmental outcomes that, besides contributing to theory, could be useful for decision-making.

Foods, nutrients and hip fracture risk: A prospective study of middle-aged women

BACKGROUND AND AIMS

Hip fracture affects 1.6 million people globally each year, and increases morbidity and mortality. There is potential for risk reduction through diet modification, but prospective evidence for associations between intake of several foods and nutrients and hip fracture risk is limited. This study aimed to investigate associations between food and nutrient intakes and hip fracture risk in the UK Women's Cohort Study, and to determine the role of body mass index (BMI) as a potential effect modifier.

METHODS

Dietary, lifestyle, anthropometric, and socio-economic information of UK women, ages 35-69 years, were collected in a survey at recruitment (1995-1998), and included a validated 217-item food frequency questionnaire. Hip fracture cases were identified by linking participant data at recruitment with their Hospital Episode Statistics (HES) up to March 2019. Cox regression models were used to estimate associations between standard portions of food and nutrient intakes and hip fracture risk over a median follow-up time of 22.3 years.

RESULTS

Among 26,318 women linked to HES data (556,331 person-years), 822 hip fracture cases were identified. After adjustment for confounders, every additional cup of tea or coffee per day was associated with a 4% lower risk of hip fracture (HR (95% CI): 0.96 (0.92, 1.00)). A 25 g/day increment of dietary protein intake was also associated with a 14% lower risk of hip fracture (0.86 (0.73, 1.00)). In subgroup analyses, BMI modified linear associations between dietary intakes of protein, calcium, total dairy, milk, and tea and hip fracture risk (p_interaction = 0.02, 0.002, 0.003, 0.001, and 0.003, respectively); these foods and nutrients were associated with a reduced risk of hip fracture in underweight but not healthy or overweight participants. In particular, risk of hip fracture in underweight participants (28 cases, 545 participants) was 45% lower for every 25 g/day protein consumed (0.55 (0.38, 0.78)).

CONCLUSIONS

This is the first prospective cohort study internationally of multiple food and nutrient intakes in relation to hip fracture risk by BMI using linkage to hospital records. Results suggest that the potential roles of some foods and nutrients in hip fracture prevention, particularly protein, tea and coffee in underweight women, merit confirmation.

PROTOCOL REGISTRATION

Clinicaltrials.gov NCT05081466.

Correction to: Determining the cost-effectiveness requirements of an exoskeleton preventing second hip fractures using value of information

An amendment to this paper has been published and can be accessed via the original article.