Cost utility modeling of early vs late total knee replacement in osteoarthritis patients

The cost-effectiveness of guideline-recommended treatments for osteoarthritis: A systematic review

OBJECTIVE

To critically appraise the literature on the cost-effectiveness of guideline-recommended treatments for osteoarthritis (OA).

DESIGN

Electronic databases were searched for studies that provided incremental cost-effectiveness ratios (ICER) for treatments recommended by key international guidelines to manage OA in adults. Treatments were grouped as lifestyle and rehabilitative therapies, pharmacological, injection, or surgical. Primary outcome was ICERs, converted to 2023 US dollars for comparability across studies. Risk of bias was assessed using the Consensus on Health Economic Criteria checklist for trials and the Drummond checklist for modelling studies. Studies were deemed cost-effective based on established country-specific thresholds per quality-adjusted life-year.

RESULTS

There were 110 studies that included 33 lifestyle and rehabilitative therapies, 25 pharmacological, 11 injection and 42 surgical studies. Most studies (95%) were conducted in high-income countries. Time horizons varied from 8 weeks to a lifetime. Risk of bias domains were frequently scored poorly related to cost methods. Overall, the cost-effectiveness of lifestyle and rehabilitative therapies and non-steroidal anti-inflammatory drugs (NSAIDs) was mixed. Hyaluronic acid injection was cost-effective in knee OA compared to placebo, usual care and paracetamol but not to corticosteroid injections and NSAIDs. Total hip or knee replacement was cost-effective compared to usual care or no surgery, with early access to replacement cost-effective compared to delaying surgery.

CONCLUSIONS

There was a diversity of analytical perspectives and clinical heterogeneity of interventions. Policymakers should consider their local context when deciding clinical care and resource allocation.

Economic Benefits of Reduced Waiting Times for Elective Surgeries: A Systematic Literature Review

This systematic literature review aims to explore studies that assess the cost-effectiveness of reducing waiting times in elective surgeries. We conducted a systematic search of the MEDLINE/PubMed and Embase/Scopus electronic databases on March 12, 2024. Eligibility criteria included elective surgery and economic evaluation of waiting times, while transplantation surgery procedures were excluded. Due to the anticipated heterogeneity of the studies, the review was presented in a narrative synthesis format. Nine articles met the inclusion criteria, covering elective surgery procedures in the musculoskeletal system (four articles), cardiovascular system (two articles), ophthalmic system (one article), and gastrointestinal tract (two articles). The evidence from this review suggests that reducing waiting times in elective surgery is highly cost-effective and often cost-saving. While it may be argued that accounting for specific elective surgeries and specific countries limits the generalizability of the findings, the review provides quantitative evidence that supports the value of reducing waiting times.

Costs and models used in the economic analysis of Total Knee Replacement (TKR): A systematic review

OBJECTIVES

The main objective of this review is to summarize the evidence on the core modelling specifications and methodology on the cost-effectiveness of TKR compared to non-surgical management. Another objective of this study is to synthesize evidence of TKR cost and compare it across countries using purchasing power parity (PPP).

METHODOLOGY

The electronic databases used for this review were MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), HTAIn repository, Cost effectiveness Analysis (CEA) registry, and Google Scholar. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) was used to assess the validity of the methods and transparency in reporting the results. The Quality of Health Economic Studies (QHES) was used to check the quality of economic evaluation models of the studies included. The cost of TKR surgery from high income and low- or middle-income countries were extracted and converted to single USD ($) using purchasing power parities (PPP) method.

RESULT

Thirty-two studies were included in this review, out of which eight studies used Markov model, five used regression model, one each reported Marginal structure model, discrete simulation model, decision tree and Osteoarthritis Policy Model (OAPol) respectively to assess the cost-effectiveness of TKR. For PPP, twenty-six studies were included in the analysis of TKR cost. The average cost of TKR surgery was the lowest in developing country-India ($3457) and highest in USA ($19568).

CONCLUSION

The findings of this review showed that the Markov model was most widely used in the analysis of the cost effectiveness of TKR. Our review also concluded that the cost of TKR was higher in the developed countries as compared to the developing countries.

Impact of time to revision total knee arthroplasty on outcomes following aseptic failure

INTRODUCTION

Prior studies have demonstrated an association between time to revision total knee arthroplasty (rTKA) and indication; however, the impact of early versus late revision on post-operative outcomes has not been reported.

MATERIALS AND METHODS

A retrospective, observational study examined patients who underwent unilateral, aseptic rTKA at an academic orthopedic hospital between 6/2011 and 4/2020 with > 1-year of follow-up. Patients were early revisions if they were revised within 2 years of primary TKA (pTKA) or late revisions if revised after greater than 2 years. Patient demographics, surgical factors, and post-operative outcomes were compared.

RESULTS

470 rTKA were included (199 early, 271 late). Early rTKA patients were younger by 2.5 years (p = 0.002). The predominant indications for early rTKA were instability (28.6%) and arthrofibrosis/stiffness (26.6%), and the predominant indications for late rTKA were aseptic loosening (45.8%) and instability (26.2%; p < 0.001). Late rTKA had longer operative times (119.20 ± 51.94 vs. 103.93 ± 44.66 min; p < 0.001). There were no differences in rTKA type, disposition, hospital length of stay, all-cause 90-day emergency department visits and readmissions, reoperations, and number of re-revisions.

CONCLUSIONS

Aseptic rTKA performed before 2 years had different indications but demonstrated similar outcomes to those performed later. Early revisions had shorter surgical times, which could be attributed to differences in rTKA indication.

LEVEL OF EVIDENCE

III, retrospective observational analysis.

Is It Worth Delaying Total Knee Replacement as Late as Possible? A Cost-Effectiveness Analysis Using a Markov Model in the Indian Setting

BACKGROUND

Total knee replacement (TKR) is often delayed in younger patients in an attempt to prolong the longevity of the prosthesis and avoid the risk of revision. But delaying a TKR might compromise the quality of life of young patients who are otherwise active and healthy.

METHODS

We built a Markov decision model to study the simulated clinical course of a 50-year-old patient with severe unilateral knee osteoarthritis who could be either treated with conservative therapies or with a TKR at some point in time. An Indian healthcare payer perspective model was used, and lifetime costs (in Indian rupees), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were calculated.

RESULTS

In the base case scenario, patients who did not receive a TKR had a total lifetime cost of ₹216 709 and accumulated 13.59 QALYS in their lifetime. Those who received a TKR without delay (at age 50) accumulated 16.71 QALYS in their lifetime with an ICER of ₹9789 per QALY. When TKR was delayed, the total QALYs decreased, and ICER increased with each year of delay. But the cumulative risk of revision decreased from 27.4% when TKR was performed at 50 years to 10.0% when TKR was done at 70 years.

CONCLUSION

Our analysis found that TKR is a cost-effective procedure when the healthcare payer is willing to pay at least ₹9789 ($132) per QALY. The results also suggested that an early TKR is preferred to a delayed TKR despite the higher incidence of revisions.

Cost-of-illness of knee osteoarthritis: potential cost savings by not undergoing arthroplasty within the first 2 years

Purpose

Although knee arthroplasty (KA) is the largest source of hospitalization costs for knee osteoarthritis (OA), some studies have suggested reducing the use of “low-value” interventions, such as intra-articular hyaluronic acid (HA), to lower health care costs. However, those studies fail to consider that HA has demonstrated benefits in extending time to more costly KA or avoiding KA altogether. We evaluated 1) the overall knee OA costs (direct) within a 2-year period; 2) the relative contribution of HA and KA costs; 3) the direct cost savings from HA patients not undergoing KA.

Patients and methods

Knee OA patients were identified from the Optum Clinformatics data set, which includes physician, facility, and pharmacy claims data from privately insured patients of all ages. Patients were stratified in the no HA, non-hylan G-F 20, and hylan G-F 20 cohorts. The cumulative costs (payer perspective) were evaluated for all knee OA-related claims (adjusted to Consumer Price Index Jan 2017$) for patients who had at least 2 years follow-up. Costs were stratified into various clinical categories.

Results

The study cohort included 2,030,497 knee OA patients, of which 65,144 patients (3.2%) underwent KA. The cost of treating knee OA within the 2-year follow-up period was estimated to be $4.99 billion (B). The majority of the costs (69%) were attributed to KA patients (3.2% of patients). In all, 15.9% of the HA patients underwent KA within 2 years, but HA only contributed 1.7% to the total costs for these patients. The remaining 84.1% of HA patients did not undergo KA, which saved an estimated total of $1.54B (average $20,740 per patient) or 83.9%, after accounting for their non-KA therapies.

Conclusion

Our study estimated substantial cost savings through a large percentage of HA patients not undergoing KA. Although a fraction of patients moved on from their conservative therapy to undergo KA within the 2-year period, HA attributed to <2% of their total treatment costs.

The cost-effectiveness of osteochondral allograft transplantation in the knee

PURPOSE

Osteochondral allografts (OCA) consist of a layer of hyaline cartilage and a layer of underlying bone. They are used to repair combined defects of articular cartilage and bone. Such defects often occur in people far too young to have knee arthroplasty, for whom the main alternative to OCA is conservative symptomatic care, which will not prevent development of osteoarthritis. The aim of this report was to assess the cost-effectiveness of osteochondral allograft transplantation in the knee.

METHODS

Systematic review of evidence on clinical effectiveness and economic modelling.

RESULTS

The evidence on osteochondral allograft transplantation comes from observational studies, but often based on good quality prospective registries of all patients having such surgery. Without controlled trials, it was necessary to use historical cohorts to assess the effect of osteochondral grafts. There is good evidence that OCA are clinically effective with a high graft survival rate over 20 years. If an OCA graft fails, there is some evidence that revision with a second OCA is also effective, though less so than primary OCA. Economic modelling showed that osteochondral allograft transplantation was highly cost-effective, with costs per quality adjusted life year much lower than many other treatments considered cost effective.

CONCLUSIONS

Osteochondral allograft transplantation appears highly cost-effective though the cost per quality adjusted life year varies according to the widely varying costs of allografts. Based on one small study, revision OCA also appears very cost-effective, but more evidence is needed.

LEVEL OF EVIDENCE

II.

COST-UTILITY ANALYSIS OF PRIVATE CONTRACTING TO REDUCE PUBLIC WAITING TIMES FOR JOINT REPLACEMENT SURGERY

OBJECTIVES

Earlier treatment of publicly funded patients may achieve health gains that justify the additional costs of reducing waiting times. This study reports on the cost-effectiveness of implementing a private contracting model to meet alternative maximum waiting time targets for publicly funded patients undergoing total knee replacement surgery in Australia.

METHODS

A linked decision tree and cohort Markov model was developed and populated and validated using secondary data sources to represent the pathways, costs, and quality adjusted life-years (QALYs) gained of non-urgent patients with alternative waiting times for total knee replacement surgery to a maximum age of 100 years.

RESULTS

Assuming public waiting times are reduced through the purchase of private services, additional QALYs are gained at an incremental cost of less than $40,000. Value could be increased if lower private prices could be negotiated. Results are also sensitive to the rate of deterioration in function while waiting for surgery and the impact of functional status at the time of surgery on postsurgery outcomes.

CONCLUSIONS

More evidence on the value of expanded capacity or new models of care may inform new funding models to support such investments and reduced prices for new technologies, leading to more efficient and sustainable publicly funded healthcare systems.

Effect of joint mobilization techniques for primary total knee arthroplasty: Study protocol for a randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) has become the most preferred procedure by patients for the relief of pain caused by knee osteoarthritis. TKA patients aim a speedy recovery after the surgery. Joint mobilization techniques for rehabilitation have been widely used to relieve pain and improve joint mobility. However, relevant randomized controlled trials showing the curative effect of these techniques remain lacking to date. Accordingly, this study aims to investigate whether joint mobilization techniques are valid for primary TKA.

METHODS/DESIGN

We will manage a single-blind, prospective, randomized, controlled trial of 120 patients with unilateral TKA. Patients will be randomized into an intervention group, a physical modality therapy group, and a usual care group. The intervention group will undergo joint mobilization manipulation treatment once a day and regular training twice a day for a month. The physical modality therapy group will undergo physical therapy once a day and regular training twice a day for a month. The usual care group will perform regular training twice a day for a month. Primary outcome measures will be based on the visual analog scale, the knee joint Hospital for Special Surgery score, range of motion, surrounded degree, and adverse effect. Secondary indicators will include manual muscle testing, 36-Item Short Form Health Survey, Berg Balance Scale function evaluation, Pittsburgh Sleep Quality Index, proprioception, and muscle morphology. We will direct intention-to-treat analysis if a subject withdraws from the trial.

DISCUSSION

The important features of this trial for joint mobilization techniques in primary TKA are randomization procedures, single-blind, large sample size, and standardized protocol. This study aims to investigate whether joint mobilization techniques are effective for early TKA patients. The result of this study may serve as a guide for TKA patients, medical personnel, and healthcare decision makers.

TRIAL REGISTRATION

It has been registered at http://www.chictr.org.cn/showproj.aspx?proj=15262 (Identifier:ChiCTR-IOR-16009192), Registered 11 September 2016. We also could provide the correct URL of the online registry in the WHO Trial Registration. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-IOR-16009192.