Cost-effectiveness of timely versus delayed primary total hip replacement in Germany: A social health insurance perspective

Predicting the Risk of Total Hip Replacement by Using A Deep Learning Algorithm on Plain Pelvic Radiographs: Diagnostic Study

BACKGROUND

Total hip replacement (THR) is considered the gold standard of treatment for refractory degenerative hip disorders. Identifying patients who should receive THR in the short term is important. Some conservative treatments, such as intra-articular injection administered a few months before THR, may result in higher odds of arthroplasty infection. Delayed THR after functional deterioration may result in poorer outcomes and longer waiting times for those who have been flagged as needing THR. Deep learning (DL) in medical imaging applications has recently obtained significant breakthroughs. However, the use of DL in practical wayfinding, such as short-term THR prediction, is still lacking.

OBJECTIVE

In this study, we will propose a DL-based assistant system for patients with pelvic radiographs to identify the need for THR within 3 months.

METHODS

We developed a convolutional neural network-based DL algorithm to analyze pelvic radiographs, predict the hip region of interest (ROI), and determine whether or not THR is required. The data set was collected from August 2008 to December 2017. The images included 3013 surgical hip ROIs that had undergone THR and 1630 nonsurgical hip ROIs. The images were split, using split-sample validation, into training (n=3903, 80%), validation (n=476, 10%), and testing (n=475, 10%) sets to evaluate the algorithm performance.

RESULTS

The algorithm, called SurgHipNet, yielded an area under the receiver operating characteristic curve of 0.994 (95% CI 0.990-0.998). The accuracy, sensitivity, specificity, and F1-score of the model were 0.977, 0.920, 0932, and 0.944, respectively.

CONCLUSIONS

The proposed approach has demonstrated that SurgHipNet shows the ability and potential to provide efficient support in clinical decision-making; it can assist physicians in promptly determining the optimal timing for THR.

Long-term health-related quality of life of total hip arthroplasty patients and cost-effectiveness analysis in the Japanese universal health insurance system

AIM

Total hip arthroplasty can effectively improve patients' motility with end-stage osteoarthritis. This study aimed to: (1) compare gradual changes in utility values with total hip arthroplasty and estimated values without; (2) evaluate total hip arthroplasty cost-effectiveness; and (3) evaluate cost-effectiveness by age, diagnosis, and comorbidity.

METHODS

Patients who underwent total hip arthroplasty between January 2008 and December 2009 were included. Patients completed the EuroQol preoperatively and at 1, 3, 5 and 7 years postoperatively. To derive the quality-adjusted life years gained, a utility score was obtained from the EuroQol item scores and combined with 7 years, and estimates were obtained by discounting the postoperative 1-year utility value at an annual rate of 2%-4%. Mixed-effects regression models were used to compare the estimated and the measured utility values.

RESULTS

Mean total cost was 1,921,849 yen, and quality-adjusted life years gain score was 1.746 with per cost as 1,100,715 yen. Compared with actual measurements, the estimated values from 1 to 7 years post-surgery differed significantly, and interaction was observed. Regarding age, the older the patient, the higher the cost per quality-adjusted life years. Patients with lower preoperative physical function had higher quality-adjusted life years gains, while the cost per quality-adjusted life years was lower.

CONCLUSIONS

Total hip arthroplasty was cost-effective. Compared with actual measurements, the estimated utility values from 1 to 7 years post-surgery significantly differed. Even among older patients and those with impaired preoperative physical functions, its cost was lower than patients' willingness to pay in Japan.

Predicting whether patients will achieve minimal clinically important differences following hip or knee arthroplasty

Aims

A substantial fraction of patients undergoing knee arthroplasty (KA) or hip arthroplasty (HA) do not achieve an improvement as high as the minimal clinically important difference (MCID), i.e. do not achieve a meaningful improvement. Using three patient-reported outcome measures (PROMs), our aim was: 1) to assess machine learning (ML), the simple pre-surgery PROM score, and logistic-regression (LR)-derived performance in their prediction of whether patients undergoing HA or KA achieve an improvement as high or higher than a calculated MCID; and 2) to test whether ML is able to outperform LR or pre-surgery PROM scores in predictive performance.

Methods

MCIDs were derived using the change difference method in a sample of 1,843 HA and 1,546 KA patients. An artificial neural network, a gradient boosting machine, least absolute shrinkage and selection operator (LASSO) regression, ridge regression, elastic net, random forest, LR, and pre-surgery PROM scores were applied to predict MCID for the following PROMs: EuroQol five-dimension, five-level questionnaire (EQ-5D-5L), EQ visual analogue scale (EQ-VAS), Hip disability and Osteoarthritis Outcome Score-Physical Function Short-form (HOOS-PS), and Knee injury and Osteoarthritis Outcome Score-Physical Function Short-form (KOOS-PS).

Results

Predictive performance of the best models per outcome ranged from 0.71 for HOOS-PS to 0.84 for EQ-VAS (HA sample). ML statistically significantly outperformed LR and pre-surgery PROM scores in two out of six cases.

Conclusion

MCIDs can be predicted with reasonable performance. ML was able to outperform traditional methods, although only in a minority of cases.

Dedicated orthopaedic elective unit: our experience from a district general hospital

Introduction

The significance of ring-fencing orthopaedic beds and protected elective sites has recently been highlighted by the British Orthopaedic Association and the Royal College of Surgeons. During the pandemic, many such elective setups were established. This study aimed to compare the functioning and efficiency of an orthopaedic protected elective surgical unit (PESU) instituted during the pandemic with the pre-pandemic elective service at our hospital.

Methods

We retrospectively collected data of all patients who underwent elective orthopaedic procedures in PESU during the pandemic and a similar cohort of patients operated on via the routine elective service immediately prior to the pandemic. To minimise the effect of confounding factors, a secondary analysis was undertaken comparing total hip replacements by a single surgeon via PESU and pre-pandemic ward (PPW) over 5 months.

Results

A total of 192 cases were listed on PESU during the studied period whereas this number was 339 for PPW. However, more than half of those listed for a surgery on PPW were cancelled and only 162 cases were performed. PESU had a significantly better conversion rate with only 12.5% being cancelled. Forty-nine percent (87 out of 177) of the cases cancelled on PPW were due to a ‘bed unavailability’. A further 17% (30/177) and 16% (28/177) were cancelled due to ‘emergency case prioritisation’ and ‘patient deemed unfit’, respectively. In contrast, only 3 out of the 24 patients cancelled on PESU were due to bed unavailability. Single-surgeon total hip replacement showed similar demographic features for the 25 patients on PESU and 37 patients on PPW. The patients on PESU also demonstrated a decrease in length of hospital stay with an average of 3 days.

Preoperative Factors and Patient-Reported Outcomes After Total Hip Arthroplasty: Multivariable Prediction Modeling

BACKGROUND

Although total hip arthroplasty (THA) has been established as a cost-effective intervention, some patients experience ongoing pain and dissatisfaction. There is interest in predicting postoperative outcomes based on preoperative data, but the relative contribution of different preoperative factors is unclear. The study's aim was to develop multivariable prediction models for the assessment of patient-reported outcomes.

METHOD

Registry data on 1412 patients undergoing THA for osteoarthritis at two hospitals between 2013 and 2018 was used. Potential predictors included age, sex, body mass index, spoken language, education level, previous THA, American Society of Anaesthesiologists (ASA) score, lower back pain, depression/anxiety, other lower limb arthritis, number of other comorbidities, the preoperative expectation of pain and function, EuroQol Visual Analogue Scale (EQ-VAS) and preoperative OHS. Radiographic scores were also used: joint space narrowing (JSN), osteophytes, sclerosis, and an overall grade based on the Kellgren-Lawrence (KL) classification. Outcomes assessed were the patient-rated improvement, satisfaction, and OHS at six months.

RESULTS

JSN or overall KL scores were the most important predictors (P < .001) for all outcomes, with better radiographic scores associated with worse outcomes. Other predictors associated with poorer outcomes were lower back pain and lower expectation (predicting poor improvement), lower education and higher ASA (predicting lower satisfaction) and younger age, female sex, non-English speakers, lower preoperative EQ-VAS, lower education, back pain, and anxiety/depression (predicting lower OHS).

CONCLUSION

Preoperative radiological scores are an important predictor of patient-reported outcomes at six months postoperatively. Understanding the relative strengths and significance of different factors in predicting outcomes will help the clinician and patient decision-making for THA.

Assessing demographic access to hip replacement surgery in the United Kingdom: a systematic review

Persisting evidence suggests significant socioeconomic and sociodemographic inequalities in access to medical treatment in the UK. Consequently, a systematic review was undertaken to examine these access inequalities in relation to hip replacement surgery. Database searches were performed using MEDLINE, PubMed and Web of Science. Studies with a focus on surgical need, access, provision and outcome were of interest. Inequalities were explored in the context of sociodemographic characteristics, socioeconomic status (SES), geographical location and hospital-related variables. Only studies in the context of the UK were included. Screening of search and extraction of data were performed and 482 articles were identified in the database search, of which 16 were eligible. Eligible studies consisted of eight cross-sectional studies, seven ecological studies and one longitudinal study. Although socioeconomic inequality has somewhat decreased, lower SES patients and ethnic minority patients demonstrate increased surgical needs, reduced access and poor outcomes. Lower SES and Black minority patients were younger and had more comorbidities. Surgical need increased with age. Women had greater surgical need and provision than men. Geographical inequality had reduced in Scotland, but a north-south divide persists in England. Rural areas received greater provision relative to need, despite increased travel for care. In all, access inequalities remain widespread and policy change driven by research is needed.

Health and Economic Outcomes of Posterior Spinal Fusion for Children With Neuromuscular Scoliosis

OBJECTIVES

Neuromuscular scoliosis (NMS) can result in severe disability. Nonoperative management minimally slows scoliosis progression, but operative management with posterior spinal fusion (PSF) carries high risks of morbidity and mortality. In this study, we compare health and economic outcomes of PSF to nonoperative management for children with NMS to identify opportunities to improve care.

METHODS

We performed a cost-effectiveness analysis. Our decision analytic model included patients aged 5 to 20 years with NMS and a Cobb angle ≥50°, with a base case of 15-year-old patients. We estimated costs, life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness from published literature and conducted sensitivity analyses on all model inputs.

RESULTS

We estimated that PSF resulted in modestly decreased discounted life expectancy (10.8 years) but longer quality-adjusted life expectancy (4.84 QALYs) than nonoperative management (11.2 years; 3.21 QALYs). PSF costs $75 400 per patient. Under base-case assumptions, PSF costs $50 100 per QALY gained. Our findings were sensitive to quality of life (QoL) and life expectancy, with PSF favored if it significantly increased QoL.

CONCLUSIONS

In patients with NMS, whether PSF is cost-effective depends strongly on the degree to which QoL improved, with larger improvements when NMS is the primary cause of debility, but limited data on QoL and life expectancy preclude a definitive assessment. Improved patient-centered outcome assessments are essential to understanding the effectiveness of NMS treatment alternatives. Because the degree to which PSF influences QoL substantially impacts health outcomes and varies by patient, clinicians should consider shared decision-making during PSF-related consultations.

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.

Resuming elective hip and knee arthroplasty after the first phase of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates recommendations

PURPOSE

The Covid-19 pandemic has disrupted health care systems all over the world. Elective surgical procedures have been postponed and/or cancelled. Consensus is, therefore, required related to the factors that need to be in place before elective surgery, including hip and knee replacement surgery, which is restarted. Entirely new pathways and protocols need to be worked out.

METHODS

A panel of experts from the European Hip Society and European Knee Association have agreed to a consensus statement on how to reintroduce elective arthroplasty surgery safely. The recommendations are based on the best available evidence and have been validated in a separate survey.

RESULTS

The guidelines are based on five themes: modification and/or reorganisation of hospital wards. Restrictions on orthopaedic wards and in operation suite(s). Additional disinfection of the environment. The role of ultra-clean operation theatres. Personal protective equipment enhancement.

CONCLUSION

Apart from the following national and local guidance, protocols need to be put in place in the patient pathway for primary arthroplasty to allow for a safe return.

Systematic Review of the Evolution of Health-Economic Evaluation Models of Osteoarthritis

OBJECTIVE

To comprehensively synthesize the evolution of health-economic evaluation models (HEEMs) of all osteoarthritis (OA) interventions, including preventions, core treatments, adjunct nonpharmacologic interventions, pharmacologic interventions, and surgical treatments.

METHODS

The literature was searched within health-economic/biomedical databases. Data extracted included OA type, population characteristics, model setting/type/events, study perspective, and comparators; the reporting quality of the studies was also assessed. The review protocol was registered at the International Prospective Register of Systematic Reviews (CRD42018092937).

RESULTS

Eighty-eight studies were included. Pharmacologic and surgical interventions were the focus in 51% and 44% of studies, respectively. Twenty-four studies adopted a societal perspective (with increasing popularity after 2013), but most (63%) did not include indirect costs. Quality-adjusted life years was the most popular outcome measure since 2008. Markov models were used by 62% of studies, with increasing popularity since 2008. Until 2010, most studies used short-to-medium time horizons; subsequently, a lifetime horizon became popular. A total of 86% of studies reported discount rates (predominantly between 3% and 5%). Studies published after 2002 had a better coverage of OA-related adverse events (AEs). Reporting quality significantly improved after 2001.

CONCLUSION

OA HEEMs have evolved and improved substantially over time, with the focus shifting from short-to-medium-term pharmacologic decision-tree models to surgical-focused lifetime Markov models. Indirect costs of OA are frequently not considered, despite using a societal perspective. There was a lack of reporting sensitivity of model outcome to input parameters, including discount rate, OA definition, and population parameters. While the coverage of OA-related AEs has improved over time, it is still not comprehensive.