Cost-utility studies in upper limb orthopaedic surgery: a systematic review of published literature

Cost Analysis of Intramedullary Screw versus Plate Osteosynthesis for Phalangeal and Metacarpal Fractures: An Observational Study

Background: To compare the observed healthcare and societal costs of intramedullary screw (IMS) and plate fixation of extra-articular metacarpal and phalangeal fractures in a contemporary Australian context. Methods: A retrospective analysis, based on previously published data, was performed utilising information from Australian public and private hospitals, the Medicare Benefits Schedule (MBS) and the Australian Bureau of Statistics. Results: Plate fixation demonstrated longer surgical lengths (32 minutes, compared to 25 minutes), greater hardware costs (AUD 1,088 vs. AUD 355), more extended follow-up requirements (6.3 months, compared to 5 months) and higher rates of subsequent hardware removal (24% compared to 4.6%), resulting in an increased healthcare expenditure of AUD 1,519.41 in the public system, and AUD 1,698.59 in the private sector. Wage losses were estimated at AUD 15,515.78 when the fracture cohort is fixed by a plate, and AUD 13,542.43 when using an IMS - a differential of AUD 1,973.35. Conclusions: There is a substantial saving to both the health system and the patient when using IMS fixation over dorsal plating for the fixation of extra-articular metacarpal and phalangeal fractures. Level of Evidence: Level III (Cost Utility).

Economic evaluation of operative versus nonoperative treatment of a humeral shaft fracture: economic analyses alongside a multicenter prospective cohort study (HUMMER)

PURPOSE

Operative treatment of a humeral shaft fracture results in faster recovery than nonoperative treatment. The cost-effectiveness, in terms of costs per Quality-Adjusted Life Year (QALY) gained (Dutch threshold €20,000-€80,000) or minimal important change (MIC) in disability reduced (DASH 6.7), is unknown. The aim of this study was to determine cost-utility and cost-effectiveness of operative versus nonoperative treatment in adults with a humeral shaft fracture type 12A or 12B.

METHODS

This study was performed alongside a multicenter prospective cohort study. Costs for health care and lost productivity until one year after trauma were calculated. The incremental cost-utility ratio (ICUR) was reported in costs per QALY (based on the EuroQoL-5D-3L (EQ-5D)) gained. The incremental cost-effectiveness ratio (ICER) was reported in costs per MIC (based on the DASH score at three months) reduced.

RESULTS

Overall, 245 patients were treated operatively and 145 nonoperatively. In the operative group, the mean total costs per patient (€11,925 versus €8793; p < 0.001) and QALYs (0.806 versus 0.778; p < 0.001) were higher. The ICUR of operative treatment was €111,860 per QALY gained (i.e., €3132/0.028). The DASH was 7.3 points (p < 0.001) lower in the operative group. The ICER of operative treatment was €2880 per MIC in disability reduced (i.e., €3132/7.3*6.7).

CONCLUSION

Due to the limited effect of treatment on quality of life measured with the EQ-5D, the ICUR of operative treatment (€111,860 per QALY gained) exceeds the threshold. However, the incremental costs of €2880 per clinically meaningful difference in DASH are much lower and suggest that operative treatment for a humeral shaft fracture is cost-effective.

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.

Understanding cost-utility analysis studies in the trauma and orthopaedic surgery literature

Cost-utility analysis (CUA) studies are becoming increasingly important due to the need to reduce healthcare spending, especially in the field of trauma and orthopaedics.

There is an increasing need for trauma and orthopaedic surgeons to understand these economic evaluations to ensure informed cost-effective decisions can be made to benefit the patient and funding body.

This review discusses the fundamental principles required to understand CUA studies in the literature, including a discussion of the different methods employed to assess the health outcomes associated with different management options and the various approaches used to calculate the costs involved.

Different types of model design may be used to conduct a CUA which can be broadly categorized into real-life clinical studies and computer-simulated modelling. We discuss the main types of study designs used within each category. We also cover the different types of sensitivity analysis used to quantify uncertainty in these studies and the commonly employed instruments used to assess the quality of CUAs. Finally, we discuss some of the important limitations of CUAs that need to be considered.

This review outlines the main concepts required to understand the CUA literature and provides a basic framework for their future conduct.

Cite this article: EFORT Open Rev 2021;6:305-315. DOI: 10.1302/2058-5241.6.200115

Cost-Effectiveness of Hip Arthroscopy for Treatment of Femoroacetabular Impingement Syndrome and Labral Tears: A Systematic Review

Background:

Hip arthroscopy has frequently been shown to produce successful outcomes as a treatment for femoroacetabular impingement (FAI) and labral tears. However, there is less literature on whether the favorable results of hip arthroscopy can justify the costs, especially when compared with a nonoperative treatment.

Purpose:

To systematically review the cost-effectiveness of hip arthroscopy for treating FAI and labral tears.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

PubMed/MEDLINE, Embase, and Cochrane Library databases, and the Tufts University Cost-Effectiveness Analysis Registry were searched to identify articles that reported the cost per quality-adjusted life-year (QALY) generated by hip arthroscopy. The key terms used were “hip arthroscopy,” “cost,” “utility,” and “economic evaluation.” The threshold for cost-effectiveness was set at $50,000/QALY. The Methodological Index for Non-Randomized Studies instrument and Quality of Health Economic Studies (QHES) score were used to determine the quality of the studies. This study was prospectively registered on PROSPERO (CRD42020172991).

Results:

Six studies that reported the cost-effectiveness of hip arthroscopy were identified, and 5 of these studies compared hip arthroscopy to a nonoperative comparator. These studies were found to have a mean QHES score of 85.2 and a mean cohort age that ranged from 33-37 years. From both a health care system perspective and a societal perspective, 4 studies reported that hip arthroscopy was more costly but resulted in far greater gains than did nonoperative treatment. The preferred treatment strategy was most sensitive to duration of benefit, preoperative osteoarthritis, cost of the arthroscopy, and the improvement in QALYs with hip arthroscopy.

Conclusion:

In the majority of the studies, hip arthroscopy had a higher initial cost but provided greater gain in QALYs than did a nonoperative treatment. In certain cases, hip arthroscopy can be cost-effective given a long enough duration of benefit and appropriate patient selection. However, there is further need for literature to analyze willingness-to-pay thresholds.

Modelling the cost-effectiveness of total knee arthroplasty: A systematic review

Objective

Osteoarthritis causes a significant healthcare burden and the number of total knee arthroplasty (TKA) procedures is predicted to increase significantly in the coming years. We conducted a systematic review to assess the scope and quality of all current TKA cost-effectiveness analysis (CEA) studies, identify trends, and identify areas for improvement.

Methods

An electronic database search of MEDLINE, Embase, the CEA registry and Scopus was used to identify all CEA studies where TKA was used with a comparator. Studies were included from January 1, 1997 to February 2, 2020. The Quality of Health Economic Analysis Studies (QHES) instrument was used to assess their quality. Thirty-three studies were included that offered both a QALY and cost calculation. The main findings, incremental-cost effectiveness ratios and other important study characteristics were then ascertained, and trends identified.

Results

Certain surgical interventions were suggested to be more cost-effective than TKA. This included unicompartmental knee arthroplasty for unicompartmental osteoarthritis, computer-assisted TKA compared to conventional TKA, and resurfacing the patella compared to no resurfacing. TKA was more cost-effective compared to non-operative management regardless of specific patient variables.

Conclusions

The analyses of the CEAs included in the study have to be interpreted with caution. Overall, certain surgical methods within TKA and alternative methods to TKA appear to be favoured for treating particular knee osteoarthritic conditions due to their suggested greater cost-effectiveness but this should be interpreted within local contexts. Our results should help guide future policy-making as healthcare associated costs continue to rise.