A cost-effectiveness analysis of the arthroplasty options for displaced femoral neck fractures in the active, healthy, elderly population

What Are the Differences in Hospital Cost Associated With the Use of Cemented Versus Cementless Femoral Stems in Hemiarthroplasty and Total Hip Arthroplasty for the Treatment of Femoral Neck Fracture?

BACKGROUND

The purpose of this study was to determine if there is a difference in hospital costs associated with the use of cemented versus cementless femoral stems in hemiarthroplasty (HA) and total hip arthroplasty (THA) for the treatment of femoral neck fracture (FNF).

METHODS

This retrospective cohort study utilizes the 2019 Medicare Provider Analysis and Review Limited Data Set. Patients undergoing arthroplasty for the treatment of FNF were identified. Patients were grouped by cemented or cementless femoral stem fixation. There were 16,148 patients who underwent arthroplasty for FNF available: 4,913 THAs (3,705 patients who had cementless femoral stems and 1,208 patients who had cemented femoral stems) and 11,235 HAs (6,099 patients who had cementless femoral stems and 5,136 who had cemented femoral stems). Index hospital costs were estimated by multiplying total charges by cost-to-charge ratios. Costs were analyzed using univariable and multivariable generalized linear models.

RESULTS

Cemented femoral stem THA generated 1.080 times (95% confidence interval, 1.06 to 1.10; P < .001), or 8.0%, greater index hospital costs than cementless femoral stem THA, and cemented femoral stem HA generated 1.042 times (95% confidence interval, 1.03 to 1.05; P < .001), or 4.2%, greater index hospital costs than cementless femoral stem HA.

CONCLUSIONS

Cemented femoral stems for FNF treated with either THA or HA are associated with only a small portion of increased cost compared to cementless femoral stems. Providers may choose the method of arthroplasty stem fixation for the treatment of FNF based on what they deem most appropriate for the specific patient.

The comparison of femoral neck system and cancellous screws internal fixation for femoral neck fracture

BACKGROUND

The clinical efficacy of cancellous screws (CS) and femoral neck system (FNS) internal fixation in the treatment of femoral neck fracture (FNF) was compared in this research.

METHODS

Ninety-six patients with FNF were enrolled in this study. There were 47 cases in FNS group and 49 cases in CS group. The data of operation time, intraoperative bleeding, bed days and complication were recorded. Patients' joint function was evaluated by Harris score. At the last follow-up, the cost-effectiveness analysis of the two methods was analyzed according to the total cost of patients and hip function.

RESULTS

The intraoperative blood loss of the patients in FNS group was significantly higher than that in the CS group, but the length of hospitalization was significantly lower. There was no significant difference in the incidence of complications between FNS and CS. The joint function of FNS group was significantly better than that of CS group at 3 months after operation. There was no significant difference in Harris score between the two groups at the last follow-up. The overall medical cost of FNS group in 1 year is high. Cost-effectiveness analysis showed that compared with CS group, FNS group needs to pay 5761.1 yuan more for each additional Harris score.

CONCLUSION

FNS and CS internal fixation can achieve satisfactory clinical results in the treatment of FNF. FNS treatment is helpful to the early functional recovery of patients, but the overall medical cost is high.

Stratified cost-utility analysis of total hip arthroplasty in displaced femoral neck fracture

OBJECTIVE

To conduct a stratified cost-utility analysis of total versus partial hip arthroplasty as a function of clinical subtype.

METHOD

All cases of this type of intervention were analysed between 2010 and 2016 in the Basque Health Service, gathering data on clinical outcomes and resource use to calculate the cost and utility in quality-adjusted life years (QALYs) at individual level. The statistical analysis included applying the propensity score to balance the groups, and seemingly unrelated regression models to calculate the incremental cost-utility ratio and plot the cost-effectiveness plane. The interaction between age group and American Society of Anesthesiologists (ASA) risk class was assessed in the multivariate analysis.

RESULTS

The study identified 5867 patients diagnosed with femoral neck fracture, of whom 1307 and 4560 were treated with total and partial hip arthroplasty, respectively. In the cost-utility analysis based on the seemingly unrelated regression, total hip arthroplasty was found to have a higher cost and higher utility (2465€ and 0.42 QALYs). Considering a willingness-to-pay threshold of €22,000 per QALY, total hip arthroplasty was cost-effective in the under-80-year-old subgroup. Among patients above this age, hemiarthroplasty was cost-effective in ASA class I-II patients and dominant in ASA class III-IV patients.

CONCLUSIONS

Subgroup analysis supports current daily clinical practice in displaced femoral neck fractures, namely, using partial replacement in most patients and reserving total replacement for younger patients.

Is Total Hip Arthroplasty a Cost-Effective Option for Management of Displaced Femoral Neck Fractures? A Trial-Based Analysis of the HEALTH Study

BACKGROUND

Displaced femoral neck fractures are a significant source of morbidity and mortality and can be treated with either hemiarthroplasty (HA) or total hip arthroplasty (THA). Proponents of THA have argued THA offers lower risk of revision, with improved functional outcomes when compared to HA. To evaluate cost effectiveness of THA compared with HA, a trial-based economic analysis of the HEALTH study was undertaken.

METHODS

Health care resource utilization (HRU) and health-related quality of life (HRQoL) data were collected postoperatively and costed using publicly available databases. Using EuroQol-5 Dimensions (EQ-5D) scores, we derived quality adjusted life years (QALYs). A 1.5% discount rate to both costs and QALYs was applied. Age analyses per age group were conducted. All costs are reported in 2019 Canadian dollars.

RESULTS

When compared with HA, THA was not cost-effective for all patients with displaced femoral neck fractures ($150,000/QALY gained). If decision makers were willing to spend $50,000 or $100,000 to gain one QALY, the probability of THA being cost-effective was 12.8% and 32.8%, respectively. In a subgroup of patients younger than 73 (first quartile), THA was both more effective and less costly. Otherwise, THA was more expensive and yielded marginal HRQoL gains.

CONCLUSIONS

Our results suggest that for most patients, THA is not a cost-effective treatment for displaced femoral neck fracture management versus HA. However, THA may be cost effective for younger patients. These patients experience more meaningful improvements in quality of life with less associated cost because of shorter hospital stay and fewer postoperative complications.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in the Elderly: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost-effectiveness of screw fixation versus hemiarthroplasty for nondisplaced femoral neck fractures in low-demand elderly patients.

METHODS

We constructed a Markov decision model using a low-demand, 80-year-old patient as the base case. Costs, health-state utilities, mortality rates, and transition probabilities were obtained from published literature. The simulation model was cycled until all patients were deceased to estimate lifetime costs and quality-adjusted life years (QALYs). The primary outcome was the incremental cost-effectiveness ratio with a willingness-to-pay threshold set at $100,000 per QALY. We performed sensitivity analyses to assess our parameter assumptions.

RESULTS

For the base case, hemiarthroplasty was associated with greater quality of life (2.96 QALYs) compared with screw fixation (2.73 QALYs) with lower cost ($23,467 vs. $25,356). Cost per QALY for hemiarthroplasty was $7925 compared with $9303 in screw fixation. Hemiarthroplasty provided better outcomes at lower cost, indicating dominance over screw fixation.

CONCLUSIONS

Hemiarthroplasty is a cost-effective option compared with screw fixation for the treatment of nondisplaced femoral neck fractures in the low-demand elderly. Medical comorbidities and other factors that impact perioperative mortality should also be considered in the treatment decision.

LEVEL OF EVIDENCE

Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost-utility analysis of total knee arthroplasty for osteoarthritis in a regional medical center in China

BACKGROUND

To analyze the cost-effective ratio of total knee arthroplasty (TKA) in the osteoarthritis (OA) treatment of at a regional medical center in China.

METHODS

One hundred thirty-nine patients with osteoarthritis who underwent TKA at the Department of Osteoarthritis in Luhe hospital (Tongzhou, Beijing) from January 2011 to January 2012 were followed up. Their health-related quality of life (HRQoL) was evaluated using Short-Form Health Survey (SF) -36 Chinese version, and compared with those of the normal population to assess quality-adjusted life years (QALYs) gained after surgery for its effectiveness of the treatment. The total expense was the cost of patient hospitalization. The cost per QALY was calculated. The cost-benefit ratio (CBR) was expressed as a ratio of each QALY's expenditure to per capita gross domestic product (GDP). Factors affecting the cost, including age, gender, length of stay, and ICU experience, were also considered.

RESULTS

The total hospitalization fee was Ұ8,053,736.68, Ұ57,940.55 in average, of which, 81.59% constituted out-of-pocket expenses. The SF-36 scores were as follows: Physical Function: 25.14, Role Physical: 7.12, Bodily Pain: 9.60, Role emotional: 5.58, Vitality: 19.9, Mental Health: 25.84, Social Function: 9.86 and General Health: 21.15. Compared with normal people of the same age and sex, a total of Ұ2487.74 QALYs and Ұ3237.37/QALY were gained, 10% less than the regional GDP per capita. The cost-effective ratio of TKA for osteoarthritis in China was 1: 10.78. The main cost of the patient was the cost of prosthesis (61.78%). The average cost afforded by patients' themselves was Ұ47,242.64 after the deduction of government subsidies. There were Ұ31,306.64 difference compared with the annual average income of the local people. The cost might be affected by length of stay and ICU experience. Longer stay caused more cost of treatment. Patients who remained in ICU after surgery had higher overall costs and blood transfusion costs.

CONCLUSION

The factors that affect TKA cost are hospital and postsurgical ICU stay. It is cost-effective for regional medical care center to treat osteoarthritis using TKA economically. However, considering the average income of patients in the area, it is necessary to reduce the cost of the treatment.

Hemiarthroplasty for Femoral Neck Fracture

Hemiarthroplasty is a common treatment for femoral neck fractures in the elderly population. The main complications are periprosthetic dislocation and infection, which potentially impact morbidity and quality of life and may contribute to mortality. This procedure can be technically demanding, and adequate closure of the capsule and soft tissue cannot be emphasized enough. One advantage of a bipolar prosthesis is that it can be easily converted to a total hip arthroplasty without replacing the femoral component and with approximately the same complication rates as a revision total hip arthroplasty. Cement should be used when the patient is osteoporotic or has a Dorr type-C canal because there is a significant reduction in risk of fracture. The addition of a collared stem is helpful if there is a crack in the calcar extending from the fracture. The procedure is as follows. (1) The patient is placed in the lateral decubitus position. (2) The surgical site is prepared and draped to above the iliac crest and mid-sacrum. (3) A posterior approach is utilized. (4) The hip is dislocated. (5) A cut is made at the femoral neck. (6) The implant is templated with the femoral head. (7) The femur is broached. (8) The trial implant is placed. (9) The femur is cemented. (10) Trial implants are removed and cement is placed. (11) The final stem implant is placed in 5° to 10° of anteversion. (12) The final head and neck implants are trialed and then placed. (13) Implant position and range of motion are tested. (14) The surgical wound is irrigated. (15) Short external rotators are repaired. The posterior approach, which is often used, is known for increased rates of dislocation. The rate of dislocation can be minimized with repair of the posterior capsule and posterior soft tissue. Proper placement of the implants is of the utmost importance to minimize complications. Other contributing factors that lead to dislocation are implant malpositioning and patient factors.

The effect of time to surgery on outcomes and complication rates following total hip arthroplasty for fractured neck of femur

INTRODUCTION

Total hip arthroplasty is recommended for elderly patients with fractured neck of femur who are independently mobile, have few co-morbidities and are not cognitively impaired. Providing a daily total hip arthroplasty service is challenging for some units in the UK and considering that these patients may be physiologically distinct from the average hip fracture patient, loss of the best practice tariff as a result of surgical delay may be unjustified. The aim of this study was to determine whether time to surgical intervention for patients eligible for total hip arthroplasty had a negative impact on patient complications, length of stay and functional outcomes.

METHODS

All patients undergoing total hip arthroplasty for fractured neck of femur at our institution over a ten-year period were identified. Complications and functional outcomes were compared between patients receiving total hip arthroplasty before and after 36 hours.

RESULTS

Of 112 consecutive patients undergoing total hip arthroplasty, 70 responded to a questionnaire or telephone consultation. Four patients were excluded owing to delayed presentation, the presence of advanced rheumatoid arthritis or a pathological fracture. Two-thirds (64%) of the remaining 66 patients underwent surgery within 36 hours of presentation. There were no significant differences between the groups of patients receiving surgery before or after 36 hours with regard to postoperative length of stay, complications, Oxford hip scores or visual analogue scale scores for state of health.

CONCLUSIONS

Delaying surgery for patients eligible for total hip arthroplasty as per the National Institute for Health and Care Excellence guidelines is justified and should not incur loss of the best practice tariff.

Choice of Prosthetic Implant Combinations in Total Hip Replacement: Cost-Effectiveness Analysis Using UK and Swedish Hip Joint Registries Data

BACKGROUND

Prosthetic implants used in total hip replacements (THR) have a range of bearing surface combinations (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, and metal-on-metal), head sizes (small [<36 mm in diameter] and large [≥36 mm in diameter]), and fixation techniques (cemented, uncemented, hybrid, and reverse hybrid). These can influence prosthesis survival, patients' quality of life, and healthcare costs.

OBJECTIVES

To compare the lifetime cost-effectiveness of implants for patients of different age and sex profiles.

METHODS

We developed a Markov model to compare the cost-effectiveness of various implants against small-head cemented metal-on-polyethylene implants. The probability that patients required 1 or more revision surgeries was estimated from analyses of more than 1 million patients in the UK and Swedish hip joint registries, for men and women younger than 55, 55 to 64, 65 to 74, 75 to 84, and 85 years and older. Implant and healthcare costs were estimated from local procurement prices, national tariffs, and the literature. Quality-adjusted life-years were calculated using published utility estimates for patients undergoing THR in the United Kingdom.

RESULTS

Small-head cemented metal-on-polyethylene implants were the most cost-effective for men and women older than 65 years. These findings were robust to sensitivity analyses. Small-head cemented ceramic-on-polyethylene implants were most cost-effective in men and women younger than 65 years, but these results were more uncertain.

CONCLUSIONS

The older the patient group, the more likely that the cheapest implants, small-head cemented metal-on-polyethylene implants, were cost-effective. We found no evidence that uncemented, hybrid, or reverse hybrid implants were the most cost-effective option for any patient group. Our findings can influence clinical practice and procurement decisions for healthcare payers worldwide.

Pharmacologic Hemostatic Agents in Total Joint Arthroplasty-A Cost-Effectiveness Analysis

BACKGROUND

Total knee and hip arthroplasties can be associated with substantial blood loss, affecting morbidity and even mortality. Two pharmacological antifibrinolytics, ε-aminocaproic acid (EACA) and tranexamic acid (TXA) have been used to minimize perioperative blood loss, but both have associated morbidity. Given the added cost of these medications and the risks associated with then, a cost-effectiveness analysis was undertaken to ascertain the best strategy.

METHODS

A cost-effectiveness model was constructed using the payoffs of cost (in United States dollars) and effectiveness (quality-adjusted life expectancy, in days). The medical literature was used to ascertain various complications, their probabilities, utility values, and direct medical costs associated with various health states. A time horizon of 10 years and a willingness to pay threshold of $100,000 was used.

RESULTS

The total cost and effectiveness (quality-adjusted life expectancy, in days) was $459.77, $951.22, and $1174.87 and 3411.19, 3248.02, and 3342.69 for TXA, no pharmacologic hemostatic agent, and EACA, respectively. Because TXA is less expensive and more effective than the competing alternatives, it was the favored strategy. One-way sensitivity analyses for probability of transfusion and myocardial infarction for all 3 strategies revealed that TXA remains the dominant strategy across all clinically plausible values.

CONCLUSION

TXA, when compared with no pharmacologic hemostatic agent and with EACA, is the most cost-effective strategy to minimize intraoperative blood loss in hip and knee total joint arthroplasties. These findings are robust to sensitivity analyses using clinically plausible probabilities.

Cost-utility analysis in orthopaedic trauma; what pays? A systematic review

BACKGROUND

As healthcare systems come under ever-increasing pressure to provide more care with fewer resources, emphasis is being placed on value-based systems that maximise quality and minimize cost. The aim of this study was to determine which interventions in fracture care have been demonstrated to be cost effective.

METHODS

A systemic review of cost-utility studies on the management of fractures from 1976 to 2015 was carried out using a search of the Cost-Effectiveness Analysis Registry, National Health Service Economic Evaluation Database (NHS EED) and MEDLINE.

RESULTS

20 studies were included with 15 (75%) studies assessing interventions in lower limb trauma and 8 (25%) studies assessing interventions in upper limb trauma. 50% of studies used a decision tree model and 50% used collected data alongside a randomised clinical trial. Interventions which were shown to be cost effective in lower limb trauma were total hip replacement in displaced femoral neck fractures, the SHS in stable (A1 and A2) fractures and IM nailing for unstable (A3) fractures, salvage treatment for grade IIIB and IIIC open tibial fractures and operative treatment of ankle and calcaneal fractures. For systems-based strategies, there is evidence demonstrating cost effectiveness to treating hip fractures in high volume centres and to having resources in place to facilitate fractures being treated within 48 h of injury. In upper limb trauma there was evidence showing operative treatment of displaced proximal humerus fractures to be neither clinically nor cost effective. There was evidence supporting the operative treatment of non-displaced scaphoid fractures. Overall the quality of the studies was poor with only 50% (10) of studies able to make a treatment recommendation. Reasons for this included poor quality primary source data and poor reporting methodological practices.

CONCLUSION

Certain aspects of fracture management have been shown to be cost effective. However, there is a paucity of evidence in this area and further research is required so that value-based interventions are chosen by healthcare providers engaged in orthopaedic trauma care.

Clinical Outcomes and 90-Day Costs Following Hemiarthroplasty or Total Hip Arthroplasty for Hip Fracture

BACKGROUND

In the era of bundled payments, many hospitals are responsible for costs from admission through 90 days postdischarge. Although bundled episodes for hip fracture will have a separate target price for the bundle, little is known about the 90-day resource use burden for this patient population.

METHODS

Using Medicare 100% Standard Analytic Files (2010-2014), we identified patients undergoing hemiarthroplasty or total hip arthroplasty (THA). Patients were aged 65 and older with admitting diagnosis of closed hip fracture, no concurrent fractures of the lower limb, and no history of hip surgery in the prior 12 months baseline. Continuous Medicare-only enrollment was required. Complications, resource use, and mortality from admission through 90 days following discharge (follow-up) were summarized.

RESULTS

Four cohorts met selection criteria for analysis: (1) hemiarthroplasty diagnosis-related group (DRG) 469 (N = 19,634), (2) hemiarthroplasty DRG 470 (N = 77,744), (3) THA DRG 469 (N = 1686), and (4) THA DRG 470 (N = 9314). All-cause mortality during the study period was 51.6%, 29.5%, 48.1%, and 24.9% with mean 90-day costs of $28,952, $19,243, $29,763, and $18,561, respectively. Most of the patients waited 1 day from admission to surgery (41%-51%). Incidence of an all-cause complication was approximately 70% in each DRG 469 cohort and 14%-16% in each DRG 470 cohort.

CONCLUSION

This study confirms patients with hip fracture are a costly subpopulation. Tailored care pathways to minimize post-acute care resource use are warranted for these patients.

Disparities in Total Hip Arthroplasty Versus Hemiarthroplasty in the Management of Geriatric Femoral Neck Fractures

Introduction:

Recent clinical evidence suggests that total hip arthroplasty (THA) provides improved clinical outcomes as compared to hemiarthroplasty (HA) for displaced femoral neck fractures in elderly individuals. However, THA is still utilized relatively infrequently. Few studies have evaluated the factors affecting utilization and the role socioeconomics plays in THA versus HA.

Methods:

In the United States, the National Inpatient Sample (NIS) database was used to identify patients treated surgically for femoral neck fracture, between 2009 and 2010. Patients were identified using International Classification of Diseases, Ninth Revision, codes for closed, transcervical femoral neck fractures and closed fractures at unspecified parts of the femoral neck. All candidate predictors of THA versus HA were entered into a multilevel mixed-effect regression model.

Results:

Older patient age, being Asian or Pacific Islander, and having Medicaid payer status were all associated with lower odds of receiving THA. Patients with private insurance including Health Maintenance organization (HMO) had higher odds of THA as did patients with other insurance. Odds of THA were significantly lower among patients in teaching hospitals and higher at hospitals with greater THA volume.

Discussion:

Ethnicity, payer status, hospital size, and institutional THA volume were all associated with the utilization of THA versus HA in the treatment of geriatric femoral neck fractures.

Level of Evidence:

Level III Retrospective Cohort study.

ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis

BACKGROUND

The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ≤65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario.

METHODS

A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis.

RESULTS

THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs.

CONCLUSIONS

Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group.

LEVEL OF EVIDENCE

Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Contemporary Trends in Femoral Neck Fracture Management Reveals Discrepancies in Treatment

Background:

Recent evidence supports total hip arthroplasty (THA) as compared to hemiarthroplasty (HA) for the management of displaced femoral neck fractures in a significant subset of elderly patients. The purpose of this study was to examine trends in femoral neck fracture management over the last 12 years.

Methods:

Using the National Inpatient Sample database, we identified patients treated for femoral neck fractures between 1998 and 2010 with THA, HA, or internal fixation (IF). We examined treatment trends and demographic variables including patient age, gender, socioeconomic status, and payer and hospital characteristics.

Results:

We identified 362 127 femoral neck fracture patients treated between 1998 and 2010. Overall, there were statistically significant increases in rates of THA and HA, whereas rates of IF decreased. Total hip arthroplasty varied based on patient age, with significant increases occurring in age-groups 0 to 49 years, 50 to 59 years, 60 to 69 years, and 70 to 79 years. Utilization of THA varied significantly based on socioeconomic status and race. Patient sex, urban versus rural hospital location, and teaching versus nonteaching hospital status were not related to rates of THA.

Conclusion:

Rates of THA for femoral neck fractures increased between 1998 and 2010 in patients younger than 80 years, suggesting that surgeons are responding to clinical evidence supporting THA for the treatment of elderly femoral neck fractures. This is the first study to demonstrate this change and expose disparities in practice patterns over time in response to this evidence in the United States. Further research is indicated to explore the effect of socioeconomic status and race on femoral neck fracture management.

Total medical costs of treating femoral neck fracture patients with hemi- or total hip arthroplasty: a cost analysis of a multicenter prospective study

The aim of this study was to determine the total medical costs for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. The mean total costs per patient at 2 years of follow-up were €26,399. These results contribute to cost awareness.

INTRODUCTION

The absolute number of hip fractures is rising and increases the already significant burden on society. The aim of this study was to determine the mean total medical costs per patient for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients.

METHODS

The population was the Dutch sample of an international randomized controlled trial consisting of femoral neck fracture patients treated with hemi- or total hip arthroplasty. Patient data and health care utilization were prospectively collected during a total follow-up period of 2 years. Costs were separated into costs for hospital care during primary stay, hospital costs for clinical follow-up, and costs generated outside the hospital during rehabilitation. Multiple imputations were used to account for missing data.

RESULTS

Data of 141 participants (mean age 81 years) were included in the analysis. The 2-year mortality rate was 19 %. The mean total cost per patient after 10 weeks of follow-up was €15,216. After 1 and 2 years of follow-up the mean total costs were €23,869 and €26,399, respectively. Rehabilitation was the main cost determinant, and accounted for 46 % of total costs. Primary hospital admission days accounted for 22 % of the total costs, index surgery for 11 %, and physical therapy for 7 %.

CONCLUSIONS

The main cost determinants for hemi- or total hip arthroplasty after treatment of displaced femoral neck fractures (€26,399 per patient until 2 years) were rehabilitation and nursing homes. Most of the costs were made in the first year. Reducing costs after hip fracture surgery should focus on improving the duration and efficiency of the rehabilitation phase.

The Cemented Unipolar Prosthesis for the Management of Displaced Femoral Neck Fractures in the Dependent Osteopenic Elderly

BACKGROUND

Significant variability exists across orthopedic surgeons in the management of the displaced femoral neck fracture in the elderly patient (>75 years old). These patients tend to be less healthy, have inferior bone quality, and gait instability leading to increased risk of periprosthetic fracture, compromised implant fixation, dislocation, and need for revision. The surgeon's goals should be to restore mobility while eliminating pain and need for reoperation.

METHODS

In this review article, we examine the best available evidence in the literature to determine which strategy achieves optimal outcomes. We examine outcome studies comparing use of hemiarthroplasty and total hip arthroplasty, unipolar and bipolar hemiarthroplasty, and cemented vs cementless fixation of femoral stems.

RESULTS AND CONCLUSIONS

For the active, healthy, and lucid patient, or one who has preexisting groin pain, who sustains a displaced femoral neck fracture, the literature supports a total hip arthroplasty. Patients sustaining a displaced femoral neck fracture and who are less active, have decreased bone mass, and are at increased risk of falls would benefit most from a device that optimally balances the need for revision surgery, restores ambulation, and eliminates pain. Thus, the current evidence favors cemented, unipolar hemiarthroplasty for the dependent osteopenic elderly patient with a displaced femoral neck fracture.

Total Hip Arthroplasty for Failed Internal Fixation After Femoral Neck Fracture Versus That for Acute Displaced Femoral Neck Fracture: A Comparative Study

The outcome of total hip arthroplasty (THA) for failed internal fixation after femoral neck fracture (FNF) versus that for acute displaced femoral neck fracture is still controversial. This study retrospectively analyzed a consecutive series of 130 THAs for acute displaced FNF (64, group I) and for failed internal fixation (66, group II). Results showed THAs in group II were more technically demanding procedures with longer operative time and larger amounts of drainage compared to that in group I. Furthermore, multivariate analysis revealed that the associations between THAs (group II) and hip complications were notable (OR=4.15, P=0.017). These increased risks should be paid much attention to, not only for choosing the appropriate treatment option, but also for providing effective perioperative care.

The Quality of Cost-Utility Analyses in Orthopedic Trauma

As health care in the United States transitions toward a value-based model, there is increasing interest in applying cost-effectiveness analysis within orthopedic surgery. Orthopedic trauma care has traditionally underemphasized economic analysis. The goals of this review were to identify US-based cost-utility analysis in orthopedic trauma, to assess the quality of the available evidence, and to identify cost-effective strategies within orthopedic trauma. Based on a review of 971 abstracts, 8 US-based cost-utility analyses evaluating operative strategies in orthopedic trauma were identified. Study findings were recorded, and the Quality of Health Economic Studies (QHES) instrument was used to grade the overall quality. Of the 8 studies included in this review, 4 studies evaluated hip and femur fractures, 3 studies analyzed upper extremity fractures, and 1 study assessed open tibial fracture management. Cost-effective interventions identified in this review include total hip arthroplasty (over hemiarthroplasty) for femoral neck fractures in the active elderly, open reduction and internal fixation (over nonoperative management) for distal radius and scaphoid fractures, limb salvage (over amputation) for complex open tibial fractures, and systems-based interventions to prevent delay in hip fracture surgery. The mean QHES score of the studies was 79.25 (range, 67-89). Overall, there is a paucity of cost-utility analyses in orthopedic trauma; however, the available evidence suggests that certain operative interventions can be cost-effective. The quality of these studies, however, is fair, based on QHES grading. More attention should be paid to evaluating the cost-effectiveness of operative intervention in orthopedic trauma.

Current status of cost utility analyses in total joint arthroplasty: a systematic review

BACKGROUND

Total joint arthroplasty (TJA), although considered to be highly beneficial, is associated with substantial costs to the US healthcare system. Cost utility analysis has become an increasingly important means to objectively evaluate the value of a healthcare intervention from the perspective of both extending the quantity and improving the quality of life. Relatively little is known about the overall cost utility analysis evidence base in TJA.

QUESTIONS/PURPOSES

The goals of this review were to (1) determine the cost utility of TJA interventions; (2) critically assess the quality of published US-based cost utility analyses using the Quality of Health Economic Studies instrument; and (3) determine what characteristics were common among studies receiving a high quality score.

METHODS

A systematic review of the literature using the MEDLINE database was performed to compile findings and critically appraise US-based cost utility analysis studies for total hip and knee arthroplasty. Based on review of 676 identified articles, 23 studies were included. We used the Quality of Health Economic Studies instrument to assess study quality and one-sided Fisher's exact tests were applied to analyze the predictors of high-quality cost utility analysis.

RESULTS

Very few studies compare the cost utility of TJA versus nonoperative intervention; however, the available evidence suggests that TJA can be cost-saving and is highly cost-effective compared with conservative management of end-stage arthritis. The majority of identified studies are focused on the cost utility of new implant technologies or comparisons among surgical alternatives. These studies suggest that the upfront costs associated with new technologies are cost-effective when there is a major reduction in a future cost. The quality of identified studies is quite high (Quality of Health Economic Studies Instrument score: mean 86.5; range, 63-100). National funding source (p = 0.095) and lifetime horizon for analysis (p = 0.07) correlate with high-quality evidence but do not reach significance.

CONCLUSIONS

Over the past 15 years, there has been a major increase in the volume of cost utility analyses published in total hip and knee arthroplasty. The quality of cost utility analyses published during that period is good. As increasing attention is paid to value in US health care, more attention should be paid to understanding the cost utility of TJA compared with nonoperative treatment modalities. Future studies may also look to incorporate patient willingness to pay.

Computer-assisted navigation in ACL reconstruction is attractive but not yet cost efficient

PURPOSE

Conventional reconstruction of the anterior cruciate ligament (ACL) has a high success rate. Computer-assisted navigation systems (CANSs) have been developed to further improve the accuracy of tunnel positioning. What is the economic impact from the hospital perspective?

METHODS

Patients having a first ACL reconstruction procedure were included in a prospective multicentre open controlled study comparing two groups: CANS versus conventional surgery. The primary clinical efficacy criterion was the objective International Knee Documentation Committee score at 1-2-year follow-up. Costs were collected retrospectively nationwide.

RESULTS

No significant differences were found for the clinical effectiveness between conventional surgery (100 patients) and CANS (114 patients) at follow-up: ORadjusted 1.01 [0.36-2.84] (n.s). Junior surgeons achieved a significant mean decrease in operating time during the study period: 30 % in the CANS group compared with 10 % in the control group (p < 0.01). The average cost of surgery was 704<euro> for the control group and 1,158<euro> for the CANS group (p < 0.01). The cost of the operating room accounts for >70 % of the total cost. The surgeon's status and the technical CANS learning effect influenced this cost. The cost differential between the two groups decreased with 'CANS' expertise: 238<euro> and 271<euro> in 'expert' centres versus 427<euro> to 731<euro> in other centres.

CONCLUSION

While our study demonstrates the feasibility and the potential interest of CANS for training in ACL reconstruction, from a hospital perspective it is not cost efficient at present.

LEVEL OF EVIDENCE

Economic and decision analysis-developing an economic or decision model, Level II.

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.

Economic evaluation of access to musculoskeletal care: the case of waiting for total knee arthroplasty

Background

The projected demand for total knee arthroplasty is staggering. At its root, the solution involves increasing supply or decreasing demand. Other developed nations have used rationing and wait times to distribute this service. However, economic impact and cost-effectiveness of waiting for TKA is unknown.

Methods

A Markov decision model was constructed for a cost-utility analysis of three treatment strategies for end-stage knee osteoarthritis: 1) TKA without delay, 2) a waiting period with no non-operative treatment and 3) a non-operative treatment bridge during that waiting period in a cohort of 60 year-old patients. Outcome probabilities and effectiveness were derived from the literature. Costs were estimated from the societal perspective with national average Medicare reimbursement. Effectiveness was expressed in quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, effectiveness, and quality-adjusted life years; and net health benefits.

Results

In the base case, a 2-year wait-time both with and without a non-operative treatment bridge resulted in a lower number of average QALYs gained (11.57 (no bridge) and 11.95 (bridge) vs. 12.14 (no delay). The average cost was $1,660 higher for TKA without delay than wait-time with no bridge, but $1,810 less than wait-time with non-operative bridge. The incremental cost-effectiveness ratio comparing wait-time with no bridge to TKA without delay was $2,901/QALY. When comparing TKA without delay to waiting with non-operative bridge, TKA without delay produced greater utility at a lower cost to society.

Conclusions

TKA without delay is the preferred cost-effective treatment strategy when compared to a waiting for TKA without non-operative bridge. TKA without delay is cost saving when a non-operative bridge is used during the waiting period. As it is unlikely that patients waiting for TKA would not receive non-operative treatment, TKA without delay may be an overall cost-saving health care delivery strategy. Policies aimed at increasing the supply of TKA should be considered as savings exist that could indirectly fund those strategies.

Modeling the indirect economic implications of musculoskeletal disorders and treatment

Background

Musculoskeletal disorders impose a substantial economic burden on American society, but few studies have examined the economic benefits associated with treating such disorders. The purpose of this research is to estimate the indirect economic implications of activity limitations associated with musculoskeletal disorders and to quantifying the potential economic gains from elective surgery to treat arthritis of the knee and hip.

Methods

Using regression analysis with the National Health Interview Survey (2004-2010 data, n=185,829 adults) we quantify the relationship between severity of activity limitations (walking, sitting, standing, etc.) and employment, household income, missed work days, and receipt of supplemental security income for disability. Activity limitations are combined to create an index similar to the Functional Ability Index from the Short Form 36 Health Questionnaire (SF-36) often used in clinical trials to measure patient functional mobility. This index is included in the regression analyses. We use data from published, prospective clinical trials to establish the improvement in patient functional ability following surgery to treat arthritis of the knee and hip.

Results

Improved physical function is associated with higher likelihood of employment, higher household income and fewer missed work days for those who are employed, and reduced likelihood of receiving supplemental security income for disability. The magnitude of the impact and statistical significance vary by activity limitation and severity. Each percentage point increase in the index value is associated with a 2-percentage-point increase in the odds of being employed, a 3-percentage-point-day decline in work days missed and an additional $180 in annual household income if employed, and a 2-percentage-point decline in the odds of receiving supplemental security income for disability. All estimates are statistically significant at the 0.05 level.

Conclusions

Using a large, representative sample of non-institutionalized adults in the U.S., we find that physical activity limitations are associated with worse economic outcomes across multiple economic metrics. Combined with estimates of improved functional ability following knee and hip surgery, we quantify some of the economic benefits of surgery for arthritis of the knee and hip. This information helps improve understanding of the societal benefits of medical treatment for musculoskeletal conditions.

Cost effectiveness analysis of graft options in spinal fusion surgery using a Markov model

STUDY DESIGN

Statistical decision model.

OBJECTIVE

To determine the most cost-effective graft option in spinal fusion.

SUMMARY OF BACKGROUND DATA

Spinal fusion has been shown to be an effective technique to treat lumbar degenerative spondylolisthesis. There have been significant advances in bone graft options to improve outcomes related to spinal fusion. RhBMP-2 (RhBMP), iliac crest bone graft (ICBG), local bone alone (LBG), demineralized bone matrix with local bone (DBM), local bone with corticocancellous allograft chips (CCA) have all been used as graft options. There has not been significant research in which graft option is most cost effective.

METHODS

A Markov decision model has been created to identify the most cost-effective graft option for use in spinal fusion to treat 1-level (L4-L5) degenerative spondylolisthesis in a cohort of 60-year-old patients. Costs and effectiveness of successful spinal fusion surgery and revision surgery associated with each graft option was estimated through published data. The quality adjusted life years (QALYs) from these surgeries were compared with the amount of QALYs associated with living with chronic back pain.

RESULTS

: In the base case, the incremental cost-effective ratio for each graft option when compared with living with chronic back pain was $21,308/QALY for ICBG, $16,595/QALY for RhBMP, $21,204/QALY for LBG, $21,287/QALY for DBM, and $28,153/QALY for CCA. Therefore, the most cost-effective graft option in the base case was RhBMP. Sensitivity analysis shows that RhBMP is not the most cost-effective option if the revision rate is significantly raised. If the cost of treatment with RhBMP rises >$42,250 then LBG becomes the likely cost-effective treatment.

CONCLUSIONS

RhBMP is the most cost-effective graft option for L4-L5 fusion for degenerative spondylolisthesis largely due to the reduced rate of revision spine surgery. The increased upfront cost and list of complications associated with RhBMP is offset by the reduced rate of revision surgery.

Is surgical fixation for stress-positive unstable ankle fractures cost effective? Results of a multicenter randomized control trial

OBJECTIVES

A recent multicenter randomized control trial demonstrated similar quality of life at 1 year after open reduction and internal fixation (ORIF) compared with nonoperative treatment for stress-positive unstable isolated lateral malleolar fractures. We sought to determine the cost-effectiveness of ORIF compared with nonoperative management of these isolated lateral malleolar fractures.

DESIGN

Cost-utility analysis using decision tree and Markov modeling based on data from a prospective randomized control trial and previously published literature. A single-payer perspective with 1-year and lifetime time horizons was adopted.

SETTING

Clinical trial data from 6 Canadian level I trauma hospitals.

INTERVENTION

Lateral malleolus ORIF versus nonoperative treatment.

MAIN OUTCOME MEASUREMENTS

Incremental cost-effectiveness ratio (ICER).

RESULTS

The base case 1-year ICER of the ORIF treatment was $205,090 per quality-adjusted life year gained, favoring nonoperative treatment. For the lifetime time horizon, ORIF becomes the preferred treatment with an ICER of $16,404 per quality-adjusted life year gained. This conclusion is stable provided ORIF lowers the lifetime incidence of ankle arthrosis by >3% compared with nonoperative treatment. Probabilistic sensitivity analysis demonstrated that 33% of model simulations favored ORIF in the 1-year time horizon and 65% of simulations in the lifetime time horizon.

CONCLUSIONS

From a single-payer governmental perspective, ORIF does not seem to be cost effective in the 1-year time horizon; however, if operative fixation decreases the lifetime incidence of posttraumatic ankle arthrosis by >3%, then ORIF becomes the economically preferred treatment.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Hip hemiarthroplasty after displaced femoral neck fracture: a survivorship analysis

The standard of care for displaced femoral neck fractures is not clear. We reviewed all patients 65 years or older with displaced femoral neck fracture who underwent hip hemiarthroplasty at our institution between 1997 and 2006. Women accounted for 70% of the patients. Mean patient age was 78 years, and most of the patients were community ambulators. Complete operative information was available for 226 (79%) of 285 patients. Follow-up was available for 126 patients (mean, 15.8 months; range, 1-97 months). Total mortality rate was 58%. Mean University of California, Los Angeles (UCLA) scores were 8.3 for pain, 6.7 for walking, 5.6 for function, and 3.5 for activity. Two patients had acetabular wear on radiography, but symptoms were not severe enough to warrant revision. Three patients (1.3%) underwent revision, 1 with acetabular wear and 2 for infection. Despite the limited follow-up, the rate of conversion to total hip arthroplasty (THA) was low. Longer, prospective studies are needed to delineate which patients will benefit from THA.