A prospective study of lumbar facet arthroplasty in the treatment of degenerative spondylolisthesis and stenosis: cost-effective assessment from the Total Posterior Spine system (TOPSTM) IDE Study: 2-year model revision and sensitivity analyses based on 305 subjects

BACKGROUND CONTEXT

A previous cost-effectiveness analysis published in 2022 found that the Total Posterior Spine (TOPSTM) system was dominant over transforaminal lumbar interbody fusion (TLIF). This analysis required updating to reflect a more complete dataset and pricing considerations.

PURPOSE

To evaluate the cost-effectiveness of TOPSTM system as compared with TLIF based on an updated and complete FDA investigational device exemption (IDE) data set.

STUDY DESIGN/SETTING

Cost-utility analysis of the TOPSTM system compared to TLIF.

PATIENT SAMPLE

A multicenter, FDA IDE, randomized control trial (RCT) investigated the efficacy of TOPSTM compared to TLIF with a current population of n=305 enrolled and n=168 with complete 2-year follow-up.

OUTCOME MEASURES

Cost and quality adjusted life years (QALYs) were calculated to determine our primary outcome measure, the incremental cost-effectiveness ratio. Secondary outcome measures included: net monetary benefit as well at willingness-to-pay (WTP) thresholds.

METHODS

The primary outcome of cost-effectiveness is determined by incremental cost-effectiveness ratio. A Markov model was used to simulate the health outcomes and costs of patients undergoing TOPSTM or TLIF over a 2-year period. alternative scenario sensitivity analysis, one-way sensitivity analysis, and probabilistic sensitivity analysis were conducted to assess the robustness of the model results.

RESULTS

The updated base case result demonstrated that TOPSTM was immediately and longitudinally dominant compared with the control with an incremental cost-effectiveness ratio of -9,637.37 $/QALY. The net monetary benefit was correspondingly $2,237, both from the health system's perspective and at a WTP threshold of 50,000 $/QALY at the 2-year time point. This remained true in all scenarios tested. The Alternative Scenario Sensitivity Analysis suggested cost-effectiveness irrespective of payer type and surgical setting. To remain cost-effective, the cost difference between TOPSTM and TLIF should be no greater than $1,875 and $3,750 at WTP thresholds of $50,000 and 100,000 $/QALY, respectively.

CONCLUSIONS

This updated analysis confirms that the TOPSTM device is a cost-effective and economically dominant surgical treatment option for patients with lumbar stenosis and degenerative spondylolisthesis compared to TLIF in all scenarios examined.

The Association Between Provider Price and Complication Rates for Outpatient Surgical Services

BACKGROUND

Wide variations exist in price and quality for health-care services, but the link between price and quality remains uncertain.

OBJECTIVE

This paper used claims data from a large commercially insured population to assess the association between both procedure- and provider-level prices and complication rates for three common outpatient surgical services.

DESIGN

This is a retrospective cohort study.

SETTING

The study used medical claims data from commercial health plans between 2009 and 2013 for three outpatient surgical services-joint arthroscopy, cataract surgery, and colonoscopy.

MAIN MEASURES

For each procedure, price was assessed as the sum of patient, employer, and insurer spending. Complications were identified using existing algorithms specific to each service. Multivariate regressions were used to risk-adjust prices and complication rates. Provider-level price and complication rates were compared by calculating standardized differences that compared provider risk-adjusted price and complication rates with other providers within the same geographic market. The association between provider-level risk-adjusted price and complication rates was estimated using a linear regression.

KEY RESULTS

Across the three services, there was an inverse association between both procedure- and provider-level prices and complication rates. For joint arthroscopy, cataract surgery, and colonoscopy, a one standard deviation increase in procedure-level price was associated with 1.06 (95% CI 1.05-1.08), 1.14 (95% CI 1.11-1.16), and 1.07 (95% CI 1.06-1.07) odds increases in the rate of procedural complications, respectively. A one standard deviation increase in risk-adjusted provider price was associated with 0.09 (95% CI 0.07 to 0.11), 0.02 (95% CI 0.003 to 0.05), and 0.32 (95% CI 0.29 to 0.34) standard deviation increases in the rate of provider risk-adjusted complication rates, respectively.

LIMITATIONS

Results may be due to unobserved factors. Only three surgical services were examined, and the results may not generalize to other services and procedures. Quality measurements did not include patient satisfaction or experience measures.

CONCLUSIONS

For three common outpatient surgical services, procedure- and provider-level prices are associated with modest increased rates of complication rates.

Surgery for hip fracture yields societal benefits that exceed the direct medical costs

BACKGROUND

A hip fracture is a debilitating condition that consumes significant resources in the United States. Surgical treatment of hip fractures can achieve better survival and functional outcomes than nonoperative treatment, but less is known about its economic benefits.

QUESTIONS/PURPOSES

We asked: (1) Are the societal benefits of hip fracture surgery enough to offset the direct medical costs? (2) Nationally, what are the total lifetime benefits of hip fracture surgery for a cohort of patients and to whom do these benefits accrue?

METHODS

We estimated the effects of surgical treatment for displaced hip fractures through a Markov cohort analysis of patients 65 years and older. Assumptions were obtained from a systematic literature review, analysis of Medicare claims data, and clinical experts. We conducted a series sensitivity analyses to assess the effect of uncertainty in model parameters on our estimates. We compared costs for medical care, home modification, and long-term nursing home use for surgical and nonoperative treatment of hip fractures to estimate total societal savings.

RESULTS

Estimated average lifetime societal benefits per patient exceeded the direct medical costs of hip fracture surgery by USD 65,000 to USD 68,000 for displaced hip fractures. With the exception of the assumption of nursing home use, the sensitivity analyses show that surgery produces positive net societal savings with significant deviations of 50% from the base model assumptions. For an 80-year-old patient, the breakeven point for the assumption on the percent of patients with hip fractures who would require long-term nursing home use with nonoperative treatment is 37% to 39%, compared with 24% for surgical patients. Nationally, we estimate that hip fracture surgery for the cohort of patients in 2009 yields lifetime societal savings of USD 16 billion in our base model, with benefits and direct costs of USD 21 billion and USD 5 billion, respectively. For an 80-year-old, societal benefits ranged from USD 2 billion to USD 32 billion, using our range of estimates for nursing home use among nonoperatively treated patients who are immobile after the fracture.

CONCLUSIONS

Surgical treatment of hip fractures produces societal savings. Although the magnitude of these savings depends on model assumptions, the finding of societal savings is robust to a range of parameter values.

LEVEL OF EVIDENCE

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

Cost analysis of converting from single-bundle to double-bundle anterior cruciate ligament reconstruction

BACKGROUND

Recent studies comparing double-bundle anterior cruciate ligament reconstruction to single-bundle anterior cruciate ligament reconstruction have reported some biomechanical advantages but little or no short-term clinical benefit from the double-bundle technique. In the current healthcare environment, the potential economic implications of widespread conversion to a double-bundle anterior cruciate ligament reconstruction are an important consideration.

PURPOSE

To determine the economic implications of widespread use of the double-bundle technique for anterior cruciate ligament reconstruction.

STUDY DESIGN

Economic analysis; Level of evidence, 2.

METHODS

A cost model to assess the effect of double-bundle anterior cruciate ligament reconstruction was constructed using standard accounting methodology. The model was based on actual 2008 cost figures (in US dollars) for ligamentous allografts, fixation implants, and operating room time. Revision rate (4%) and time to revision surgery (mean, 4 years) for single-bundle anterior cruciate ligament reconstruction was based on the available literature. Assumptions about the prevalence of double-bundle versus single-bundle anterior cruciate ligament reconstruction, the number of grafts used, and the revision rate for double-bundle reconstruction were varied to assess their effect on cost.

RESULTS

The potential additional cost for widespread conversion to the double-bundle technique for anterior cruciate ligament reconstruction ranges from $36 million to $792 million per year in the United States alone. To offset this increased cost, the double-bundle technique would have to reduce the revision rate at a minimum from 4% to 1.5% and potentially from 24.1% to 0%.

CONCLUSION

Double-bundle anterior cruciate ligament reconstruction has the potential of adding considerable cost to the health-care system.

CLINICAL RELEVANCE

While further research is warranted to determine if there are other benefits from this technique, widespread adoption of a double-bundle anterior cruciate ligament reconstruction does not appear to be cost-effective at this time.

Single-level cervical radiculopathy: clinical outcome and cost-effectiveness of four techniques of anterior cervical discectomy and fusion and disc arthroplasty

Although there are several accepted methods of surgical treatment for single-level cervical radiculopathy, the choice depend on the surgeon's preference. The techniques may vary in peri-operative morbidity, short- and long-term outcome, but no study so far has analyzed their cost-effectiveness. This study might give some insight in balancing cost and effectiveness and deciding the right technique. Sixty consecutive patients (15 each group), mean age 36 (range 24-76 years) with single-level cervical disc disease underwent surgical treatment with four different techniques in two centers over the period of 1999-2005. The four groups were--(1) plate and tricortical autograft, (2) plate, cage, and bone substitute, (3) cage only, and (4) disc arthroplasty. The data was collected prospectively according to our protocol and subsequently analyzed. The clinical outcome was assessed comparing visual analog scale (VAS) of neck pain and, short form 12 (SF12) questionnaire both pre- and postoperatively. The radiological assessment was done for fusion rate and postoperative related possible complications at 3 months, 6 months, 1 year, and final follow-up. The cost analysis was done calculating the operative time, hospital stay, implant cost together. The mean follow-up period was 31 months (range 28-43 months). The clinical outcome in terms of VAS of neck and arm pain and SF12 physical and mental score improvement (P=0.001) were comparable with all four techniques. The radiological fusion rate was comparable to current available data. As the hospital stay was longer (average 5 days) with plate and autograft group, the total cost was maximum (average 2,920 pound sterling) with this group. There was satisfactory clinical and radiological outcome with all four techniques. Using the cage alone was the most cost-effective technique, but the disc arthroplasty was comparable to the use of cage and plate. Anterior cervical discectomy and fusion is an established surgical treatment for cervical radiculopathy. Single-level cervical radiculopathy was treated with four different techniques. The clinical outcome and cost-effectiveness were compared in this study.

Advances in orthopaedic outcomes research

As the field of orthopaedic surgery continues to expand in terms of indications and technologies, there has been increasing emphasis placed on validated patient-derived outcome measures in clinical orthopaedic research. As concerns mount regarding rising health care costs, declining quality, and variability in clinical practice patterns, outcome measures become important tools in assessing quality. Furthermore, outcome measures can be utilized to justify the clinical benefits of existing and new diagnostic modalities and surgical interventions. This review provides a brief overview of traditional outcomes approaches in orthopaedics followed by a discussion of the current trend toward patient-centered outcomes research and its role in the emerging field of cost-effectiveness analysis in orthopaedics.

An economic model of one-level lumbar arthroplasty versus fusion

BACKGROUND CONTEXT

Degenerative disc disease (DDD) is a cause of low back pain commonly requiring surgical intervention. The option of lumbar total disc replacement (TDR) represents an advance in the surgical treatment of DDD. However, new treatments, particularly those that include the use of new implants, may lead to increased costs to both hospitals and payers. Therefore, it is both necessary and appropriate to examine the potential costs associated with a new procedure such as total disc replacement compared with traditional treatments for a specific pathology.

PURPOSE

To perform an economic analysis of lumbar TDR versus three different techniques for lumbar fusion.

STUDY DESIGN/SETTING

A cost-minimization model.

METHODS

An economic model examining hospital and payer cost perspectives was developed to compare costs of TDR with the CHARITE Artificial Disc to three spinal fusion procedures: anterior lumbar interbody fusion (ALIF) with iliac crest bone graft (ICBG); ALIF with INFUSE Bone Graft and LT-Cages, and instrumented posterior lumbar interbody fusion (IPLIF) with ICBG. The hospital perspective compares direct medical costs during the index hospitalization. The payer perspective considers direct medical costs of the index hospitalization and those incurred in the following two-year period. The model contains a Diagnostic Related Group (DRG) arm based strictly on DRG coding and payment, and a per-diem arm that includes a device carve-out cost and payment.

RESULTS

In the DRG and per-diem arms of the model, compared with TDR, hospital costs are 12.0% higher for ALIF with ICBG, 36.5% higher for ALIF with INFUSE, and 36.5% higher for IPLIF. For payers, in the per-diem arm compared with TDR, ALIF with ICBG has 4.4% lower cost, whereas ALIF with INFUSE and IPLIF have costs of 16.1% and 27.1% higher, respectively. In the DRG arm compared with TDR, payer cost is 87.1% higher for ALIF with ICBG, 82.8% higher for ALIF with INFUSE, and 99.0% higher for IPLIF.

CONCLUSIONS

The model shows that the overall economic effect of one-level TDR procedures on hospitals and payers is likely to be less than or at worse equivalent to one-level lumbar fusion procedures.

[The tele-visit as a telemedical technique in daily clinical practice. First results for elbow joint arthrolysis]

Technologies in telecommunication and information are being increasingly applied in the public health system of the western world. Also responsible for this development is the cost factor in the field of financing and maintenance of such a system of superior medical supply, as well as the concurrent patient' demand for optimized medical "24 h care and treatment". Pioneers in the use of telematic projects have, up until now, been large states such as the USA, Canada, Norway or Australia. Such projects have been used to provide, guarantee and maintain medical care in geographically remote regions with few medical facilities. After breaking the obstacle of geographic distance, telemedical solutions in general, and especially the tele-visit, represent a new form of treatment for patient care after discharge from hospital. In the year 2002, a prospective randomized two-armed study was initiated including patients after surgical intervention by arthroplasty in posttraumatic contracture of the elbow. The system of the tele-visit was used for 6 weeks after discharge and the patients were controlled as outpatients after 6 months, including a physical examination. The functional outcome, duration of stay in hospital and the costs for treatment arising were determined. A standardized questionnaire was developed and the degree of satisfaction of the patients surveyed. A shorter stay in hospital was found together with lowered costs in medical treatment, while no differences in functional outcome could be found in comparison to the control group, although there was an additionally high grade of satisfaction with the new system.

Cost-effectiveness of unicompartmental and total knee arthroplasty in elderly low-demand patients. A Markov decision analysis

BACKGROUND

Interest in unicompartmental knee arthroplasty has recently increased in the United States, making a firm understanding of the indications for this procedure important. The purpose of this study was to examine the cost-effectiveness of unicompartmental knee arthroplasty compared with total knee arthroplasty in elderly low-demand patients.

METHODS

A Markov decision model was used to evaluate the cost-effectiveness of unicompartmental knee arthroplasty as compared with total knee arthroplasty in the elderly population. Transition probabilities were estimated from the Norwegian Arthroplasty Register and the arthroplasty literature, and costs were based on the average Medicare reimbursement for unicompartmental, tricompartmental, and revision knee arthroplasties. Outcomes were measured in quality-adjusted life-years.

RESULTS

Our model showed unicompartmental knee arthroplasty to be a cost-effective strategy for this population as long as the annual probability of revision is <4%. The cost of unicompartmental knee arthroplasty must be greater than $13,500 or the cost of total knee arthroplasty must be less than $8500 before total knee arthroplasty becomes more cost-effective.

CONCLUSIONS

Our model suggests that, on the basis of currently available cost and outcomes data, unicompartmental knee arthroplasty and total knee arthroplasty have similar cost-effectiveness profiles in the elderly low-demand patient population. However, several important parameters that could alter the cost-effectiveness analysis were identified; these included implant survival rates, costs, perioperative mortality and infection rates, and utility values achieved with each procedure. The thresholds identified in this study may help decision-makers to evaluate the cost-effectiveness of each strategy as further research characterizes the variables associate with unicompartmental and total knee arthroplasties and may be helpful for designing future appropriate clinical trials.

Surgeon experience and clinical and economic outcomes for shoulder arthroplasty

BACKGROUND

Previous studies have demonstrated that a high surgical volume for certain surgical procedures reduces morbidity and improves economic outcome; however, to our knowledge, no study has demonstrated a similar relationship between volume and outcome for total shoulder arthroplasty and hemiarthroplasty. The objective of this study was to determine whether increased surgeon experience was associated with improved clinical and economic outcomes for patients undergoing total shoulder arthroplasty or hemiarthroplasty.

METHODS

We analyzed discharge data on patients treated between 1994 and 2000 from the Maryland Health Services Cost Review Commission, which has a statewide hospital discharge database of all patients in the state of Maryland. The database included all patients undergoing total shoulder arthroplasty and hemiarthroplasty. We assessed the relationship between surgeon volume (low, medium, and high) and the risk of complications, length of stay, and total charges. The statistics were adjusted for procedure, age, gender, race, marital status, comorbidity, diagnosis, insurance type, income, and hospital volume.

RESULTS

For the 1868 discrete total shoulder arthroplasties and hemiarthroplasties done in the state of Maryland, the risk of at least one complication associated with the procedures done by the high-volume surgeon group was nearly half that associated with the procedures done by the low-volume surgeon group (adjusted odds ratio, 0.6; 95% confidence interval, 0.4 to 0.9). High-volume surgeons were three times more likely than were low-volume surgeons to have patients with a hospital stay of less than six days (odds ratio, 0.3; 95% confidence interval, 0.2 to 0.6). Although the average cost of hospitalization was $1000 less in the high-volume surgeon group compared with the low-volume surgeon group, this reduction did not reach significance after adjustment for multiple variables (odds ratio, 0.8; 95% confidence interval, 0.5 to 1.4).

CONCLUSIONS

This study indicates that the patients of surgeons with higher average annual caseloads of total shoulder arthroplasties and hemiarthroplasties have decreased complication rates and hospital lengths of stay compared with the patients of surgeons who perform fewer of these procedures. These analyses of hospital discharge data are limited because of a lack of prospective data, operative details, and patient outcomes data. However, this study emphasizes the importance of continued education for orthopaedic surgeons who perform shoulder arthroplasty.

Prozessoptimierung in der primären Hüftarthroplastik - ressourcenschonende Operationstechnik?

PURPOSE

Development of a standardized surgical technique for total hip replacement thereby saving manpower (one assistant) by using a retractor system.

METHOD

Total hip replacement is performed with the patient in a true lateral position on a tunnel cushion. By means of a direct lateral approach the pelvitrochanteric muscles are partially detached using an omega-shaped cut. The Bookwalter retractor is fixed dorsally on the operating table. The ring is centered keeping the greater trochanter in the middle. The Hohmann retractors are fixed to the ring to sufficiently expose the acetabulum. To insert the femoral stem the ring needs to be opened dorsally and the patient's leg is bent 90 degrees in the hip and the knee over the tunnel cushion. The muscles inserting at the greater trochanter are retracted by a separate Hohmann retractor with weight. In a case control study with matched pairs the patients treated with this technique were compared with those treated in supine position with the transgluteal approach. The number of assistants required and the operating time were assessed.

RESULTS

All the hip replacements with the patient in side position were performed with one assistant, in supine position with two assistants. The operating time did not differ significantly (supine position 110 min/side position 112 min). The complication rate in both groups was comparable (one secondary wound healing, one transient ischalgia).

CONCLUSION

The process of total hip replacement can be optimized. The described technique allows to spare one surgical assistant without prolonging the operating time.

On reducing the need for arthroplasty: benefits for patients and budgets

The need for arthroplasty, especially in the hip, arises primarily because of failure to replace damaged structural proteins as a result of improper balance in essential nutrients. The principal failure is an inadequate production of elastin resulting in cartilage consisting primarily of a collagen that may be flexible but is not elastic. In spite of the fact that an excess of protein, with adequate lysine, is commonly consumed by the affluent societies, this lysine is not utilized because of the inadequate intake of ascorbic acid necessary for virtually every step of the structural protein synthetic reactions. Experiments in animals support these conclusions. It is anticipated that dietary correction in candidates for total hip replacement will be able to restore normal hip cartilage (with corresponding improvements of other structural protein deficits throughout the body) in less than a year. Adoption of this regimen should result in: (1) a greatly decreased need for arthroplasties; and (2) better results in those that are performed, with less failures and less need for revisions. The benefits include much less suffering for patients and far lower medical costs.

Hip fracture treatment: outcome and socio-economic aspects. A one-year survey in a Belgian University Hospital

Between October 1, 1997 and September 30, 1998, 201 consecutive hip fractures in patients over the age of 50 were registered according to the SAHFE (Standardised Audit of Hip Fractures in Europe) protocol. The mean age was 81.3 years; 75% were females, more than 40% were admitted from an institution and fewer than 10% were completely fit. Almost 60% of the fractures occurred in the trochanteric region while less than 40% were intracapsular. All fractures but one were operated on, according to a standardised protocol. More than half the patients were treated with a dynamic hip screw, more than 30% with a cemented biarticulated hemiarthroplasty and fewer than 15% with cannulated screws. The mean admission time in the orthopedic department was 18.7 days and was poorly correlated with the type of surgery or with the place to which the patients were discharged. After hospitalisation, most patients admitted from an institution went back to that institution. More than one-third of the patients admitted from their home went back home but over 40% used rehabilitation facilities. After four months, 32 patients had died, 27 were lost to follow-up and six had been reoperated. Of the independent patients, at least 24% were institutionalised and more than 60% lived at home. Although hip fractures in the elderly are expensive and debilitating, adequate operative treatment and rehabilitation can reduce costs by limiting the hospital stay, lowering reoperation rates and by favouring reintegration into their prefracture surroundings.

Orthopaedic malpractice claims in the VA medical system

This study was undertaken to delineate the outcome of orthopaedic malpractice claims in the Veterans Affairs Medical Center (VAMC) system compared with the private sector. All orthopaedic administrative tort (malpractice) claims handled by the Office of Regional Counsel in Nashville, Tennessee during the 5-year period (8/93-7/98) were analyzed. Attention was directed at: 1) the number and type of claims, 2) the disposition of the claims, 3) the average award or settlement and range in size of awards (indemnity), and 4) the length of time required to process and dispose of each claim. These data were compared to those compiled in that segment of the private sector represented in the database of Physician Insurers Association of America (PIAA) for a similar five years (1/90-12/94). Twenty-six claims were filed in the 5-year study period and 22 were adjudicated by December 1999. Fourteen of 22 (64%) were defended successfully and eight (36%) resulted in an award to the claimant plaintiff. In the private sector those figures were 69% and 31%, respectively. The VAMC average indemnity was 20,404 dollars (range, 3500-100,000 dollars) versus 145,200 dollars in the private sector. Approximately 1% of all awards in the private sector were greater than 1,000,000 dollars. The length of time required by the VAMC to process and dispose of each claim ranged from 6 to 59 months and averaged 15.2 months. The settlement rate of orthopaedic medical malpractice claims involving the VAMC and the private sector is similar. It appears that the average award is greater in the private sector. This may reflect more claims and lesser awards in the VAMC. In both systems, most claims do not result in an indemnity.

The rheumatoid hand: a predictable disease with unpredictable surgical practice patterns

OBJECTIVES

To evaluate variation in fusion, arthroplasty, and tenosynovectomy rates among rheumatoid arthritis (RA) patients across states; to evaluate associations between surgery rates and the density of hand surgeons; and to evaluate differences in treatment by sex of the patient.

METHODS

Data were obtained from the 1996 and 1997 Healthcare Cost and Utilization Project database. The procedure codes for fusion, arthroplasty, and tenosynovectomy were matched to patients with the diagnostic code of RA, which provided the total number of procedures performed in each state. The smoothed estimates of the RA population for each state were derived from age/sex strata in the 1995 US census using age/sex-adjusted RA prevalence data from the Third National Health and Nutrition Examination Survey. The number of hand surgeons was from the 1996 American Society for Surgery of the Hand.

RESULTS

Procedure rates across states varied from 9-fold to 12-fold for all 3 procedures. The rates of the reconstructive procedures-fusion and arthroplasty-were highly correlated in each state, but these 2 procedures were only moderately correlated with tenosynovectomy. Surgeon density and procedure rates were minimally correlated. Procedure rates differed by patient sex, with significantly more arthroplasty and fusion procedures performed in women. More tenosynovectomy procedures were performed in men, and they were also performed at a younger age in men.

CONCLUSIONS

Significant large area variations are present in the surgical management of the rheumatoid hand, but the correlations between reconstructive and early intervention procedures are modest. These rate differences are not explained by the number of hand surgeons, disease prevalence, or demographic composition of the states. However, men are more likely to receive more aggressive early surgical interventions, and women are more likely to receive end-stage reconstructive surgery.

Hemiarthroplasty in hip fracture care: effects of surgical volume on short-term outcome

In 1992, the Agency of Health Care Administration in Tallahassee, Florida started releasing, as part of the discharge information, the names of the treating physician along with the clinical data. This information was used to assess the effects of volume on the short-term outcome of hemiarthroplasty surgery in hip fracture care as a function of surgeons and hospitals in the state of Florida, during the year 1992. A total of 5,604 cases were available for study. Analysis of the data showed that the average inhospital mortality rate was 4.3%. The average length of stay was 11.2 days. After arbitrarily dividing the doctors into three case volume groups (low, medium, high), results showed that surgeons with a low volume of arthroplasty cases (less than 10 per year) had a statistically significant higher average length of stay and inhospital charges when compared with the other two case volume groups.

[Acromioclavicular joint injuries: efficient therapy from the economic viewpoint]

The results of surgical treatment with tension band wiring versus conservative therapy with bandages are described in a retrospective study. Operative therapy is associated with complications in 32.3% and two occasions of hospitalisation. The advantages of conservative therapy are obvious: it is easy and comfortable for the patient; there are no complications and low costs, and it is associated with a shorter temporary disablement. Therefore, conservative therapy is our standard, and surgery is performed only for Rockwood IV-VI lesions and in exceptional cases.

Cost analysis of the American College of Chest Physicians guidelines for deep vein thrombosis prophylaxis in patients undergoing orthopedic arthroplastic surgery

Guidelines for prophylaxis of deep vein thrombosis secondary to orthopedic surgery have been developed. In selecting a specific drug for formulary inclusion, it is ideal for an individual institution to determine the cost of therapy, as well as the frequency of adverse events and the cost of treating them for each agent undergoing consideration. Cost-effectiveness analysis using incremental cost-effectiveness ratios and sensitivity analyses are useful for determining which drug may be most cost effective.

Modular shoulder arthroplasty

One hundred consecutive Biomet modular shoulder arthroplasties were studied prospectively and were evaluated with a minimum 2-year follow-up (average 41 months). Fifty-seven women and 43 men with an average age of 64 years were evaluated for pain, activities of daily living, range of motion, cost, and complications. Fourteen patients had undergone previous surgery to the shoulder. Seventy patients underwent total shoulder arthroplasty, and thirty underwent hemiarthroplasty. Pain and range of motion demonstrated statistically significant improvement. Eight activities of daily living were rated on a 0 to 3 scale, and all were significantly improved. Complications were noted in 18 patients and included urinary retention, pulmonary embolus, rotator cuff tear, titanium synovitis, subluxation, and dislocation. Twelve shoulders underwent secondary procedures for rotator cuff repair, open reduction, and component revision for instability. Lucent lines were present in 62.5% of glenoids, 92.3% of cemented stems, and 0% of cementless stems on postoperative radiographs. No patients underwent revision surgery for component loosening, and no cases of humeral head-stem dissociation were seen. Ninety-five shoulders were rated by the patients as improved, and five were made worse.

Cost effectiveness of the prevention and treatment of deep vein thrombosis and pulmonary embolism

The purpose of this article is to review and critically appraise the cost-effectiveness analyses that have compared various modalities for the prevention and treatment of deep vein thrombosis (DVT) and pulmonary embolism. Studies were identified by MEDLINE search and review of bibliographies of retrieved articles. Original economic analyses for the prevention or treatment of venous thromboembolism published in the English language literature were included in the analysis. In addition to collecting clinical and economic data, the methodological quality of the studies was evaluated using predefined criteria. Separate analyses were performed for studies of the prevention, and of the treatment, of venous thromboembolism following general surgery and following total hip arthroplasty. Fourteen cost-effectiveness analyses involving thromboembolic prophylaxis following total hip arthroplasty and 7 following general surgery met the eligibility criteria for this analysis. Each of the total hip arthroplasty studies containing a 'no intervention arm' determined that effective forms of prophylaxis not only reduced the rates of venous thromboembolic complications, but were less costly than a strategy of not providing venous thromboembolic prophylaxis. Six of 7 studies found low-molecular-weight (LMW) heparin to be more effective, and 4 of 7 found it to be less costly, than either unfractionated heparin or warfarin for the prevention of venous thrombosis following total hip arthroplasty. Following general surgical procedures, 6 of 7 studies found prophylaxis to be both more effective and less costly than no prophylaxis. Two studies also concluded that LMW heparin was more effective and less costly than unfractionated heparin for the prevention of DVT after general surgery. In general, the studies included in this overview were of high methodological quality with 11 of 15 studies fulfilling 4 or more of the 6 criteria for sound cost-effectiveness analyses. Effective venous thromboembolic prophylaxis results in fewer complications and is less costly than no prophylaxis following general surgery and total hip arthroplasty. LMW heparin was reported to be more efficacious and cost effective than unfractionated heparin following general surgery, and unfractionated heparin and warfarin following total hip arthroplasty. However, these findings must be regarded with caution in view of recent clinical trials and a meta-analysis reporting that the efficacy of LMW heparin and unfractionated heparin are similar following general surgery, and the efficacy of LMW heparin and warfarin are similar following total hip arthroplasty. Conclusions about the most cost-effective treatment for DVT await the publication of cost analyses from clinical trials comparing outpatient subcutaneous LMW heparin with inpatient therapy with intravenous unfractionated heparin.

Functional improvement and costs of hip and knee arthroplasty in destructive rheumatoid arthritis

Functional improvement and costs were analysed in 54 patients after 23 hip and 31 knee arthroplasties. All patients had destructive RA (ARA criteria 5-8). Mean stay at the surgical department was 15 and 26 days respectively, regardless of preoperative locomotion status, sex, or age, but additional in-patient rehabilitation was significantly longer after knee than hip arthroplasty (11 days and 4 days, respectively). Subjective and objective status as evaluated with total locomotion score showed significant improvement 6 months after operation. The degree of over-all improvement was equal for men and women, for all age groups, and for the different score groups. Quality of life improved with pain relief, improved sleep, and improved walking ability. The mean total costs were 34,902 SEK for hip and 56,200 SEK for knee replacement, including in-patient rehabilitation. Costs for home help were reduced from 693,600 SEK to 479,400 SEK. Severely disabled patients showed satisfactory improvement, but did not reach the functional level achieved by patients who were less disabled at the time of operation. Costs were not significantly higher for the former category.

Trends in temporomandibular joint surgery: economic implications and complications

A 5-year retrospective study of 103 patient records was undertaken. It analyzed the trend toward outpatient surgical management of patients requiring temporomandibular joint arthroplasties and determined the relative economic value and complication rate associated with this trend. Complication rates were not significantly different during the 5-year study interval, and comparative costs to the patient showed a 26% reduction for the 5-year interval.

Rates of total hip arthroplasty; a population-based study

Three hundred eighty-one total hip arthroplasties were performed on residents of Olmsted County, Minnesota, during the period from 1969 to 1980, for a rate (adjusted for sex and age) of 44.6 per 100,000 person-years. Rates rose with age, were higher for women than men, and were higher among urban than rural residents of the county. If we assume that the Olmsted County experience is medically optimal and apply it to the 1980 United States population, we calculate a national requirement of over 100,000 total hip arthroplasties per year, well above the current actual figure. If this calculated number of total hip arthroplasties were actually performed each year, over 1.4 million hospital days would be required, and direct medical costs would probably exceed $1 billion annually.