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Losina E, Burbine SA, Suter LG, Hunter DJ, Solomon DH, Daigle ME, Dervan EE, Jordan JM, Katz JN. Pharmacologic regimens for knee osteoarthritis prevention: can they be cost-effective? Osteoarthritis Cartilage 2014; 22:415-30. [PMID: 24487044 PMCID: PMC4006219 DOI: 10.1016/j.joca.2014.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 12/20/2013] [Accepted: 01/17/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We sought to determine the target populations and drug efficacy, toxicity, cost, and initiation age thresholds under which a pharmacologic regimen for knee osteoarthritis (OA) prevention could be cost-effective. DESIGN We used the Osteoarthritis Policy (OAPol) Model, a validated state-transition simulation model of knee OA, to evaluate the cost-effectiveness of using disease-modifying OA drugs (DMOADs) as prophylaxis for the disease. We assessed four cohorts at varying risk for developing OA: (1) no risk factors, (2) obese, (3) history of knee injury, and (4) high-risk (obese with history of knee injury). The base case DMOAD was initiated at age 50 with 40% efficacy in the first year, 5% failure per subsequent year, 0.22% major toxicity, and annual cost of $1,000. Outcomes included costs, quality-adjusted life expectancy (QALE), and incremental cost-effectiveness ratios (ICERs). Key parameters were varied in sensitivity analyses. RESULTS For the high-risk cohort, base case prophylaxis increased quality-adjusted life-years (QALYs) by 0.04 and lifetime costs by $4,600, and produced an ICER of $118,000 per QALY gained. ICERs >$150,000/QALY were observed when comparing the base case DMOAD to the standard of care in the knee injury only cohort; for the obese only and no risk factors cohorts, the base case DMOAD was less cost-effective than the standard of care. Regimens priced at $3,000 per year and higher demonstrated ICERs above cost-effectiveness thresholds consistent with current US standards. CONCLUSIONS The cost-effectiveness of DMOADs for OA prevention for persons at high risk for incident OA may be comparable to other accepted preventive therapies.
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Affiliation(s)
- E Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Boston University School of Public Health, Boston, MA, USA.
| | - S A Burbine
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - L G Suter
- Yale University, New Haven, CT, USA.
| | - D J Hunter
- University of Sydney and Royal North Shore Hospital, Sydney, Australia.
| | - D H Solomon
- Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - M E Daigle
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - E E Dervan
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - J M Jordan
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA.
| | - J N Katz
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Losina E, Daigle ME, Reichmann WM, Suter LG, Hunter DJ, Solomon DH, Walensky RP, Jordan JM, Burbine SA, Paltiel AD, Katz JN. Disease-modifying drugs for knee osteoarthritis: can they be cost-effective? Osteoarthritis Cartilage 2013; 21:655-67. [PMID: 23380251 PMCID: PMC3670115 DOI: 10.1016/j.joca.2013.01.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 12/15/2012] [Accepted: 01/25/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Disease-modifying osteoarthritis drugs (DMOADs) are under development. Our goal was to determine efficacy, toxicity, and cost thresholds under which DMOADs would be a cost-effective knee OA treatment. DESIGN We used the Osteoarthritis Policy Model, a validated computer simulation of knee OA, to compare guideline-concordant care to strategies that insert DMOADs into the care sequence. The guideline-concordant care sequence included conservative pain management, corticosteroid injections, total knee replacement (TKR), and revision TKR. Base case DMOAD characteristics included: 50% chance of suspending progression in the first year (resumption rate of 10% thereafter) and 30% pain relief among those with suspended progression; 0.5%/year risk of major toxicity; and costs of $1,000/year. In sensitivity analyses, we varied suspended progression (20-100%), pain relief (10-100%), major toxicity (0.1-2%), and cost ($1,000-$7,000). Outcomes included costs, quality-adjusted life expectancy, incremental cost-effectiveness ratios (ICERs), and TKR utilization. RESULTS Base case DMOADs added 4.00 quality-adjusted life years (QALYs) and $230,000 per 100 persons, with an ICER of $57,500/QALY. DMOADs reduced need for TKR by 15%. Cost-effectiveness was most sensitive to likelihoods of suspended progression and pain relief. DMOADs costing $3,000/year achieved ICERs below $100,000/QALY if the likelihoods of suspended progression and pain relief were 20% and 70%. At a cost of $5,000, these ICERs were attained if the likelihoods of suspended progression and pain relief were both 60%. CONCLUSIONS Cost, suspended progression, and pain relief are key drivers of value for DMOADs. Plausible combinations of these factors could reduce need for TKR and satisfy commonly cited cost-effectiveness criteria.
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Affiliation(s)
- Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - Meghan E. Daigle
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - William M. Reichmann
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - Lisa G. Suter
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - David J. Hunter
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - Daniel H. Solomon
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - Rochelle P. Walensky
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - Joanne M. Jordan
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - Sara A. Burbine
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - A. David Paltiel
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
| | - Jeffrey N. Katz
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (EL, MED, SAB, WMR, JNK), Division of Infectious Disease (RPW), Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy (EL, DHS, JNK), Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA (EL, DHS, RPW, JNK); Boston University School of Public Health, Boston, MA (EL, WMR); Yale University, New Haven, CT (LGS, ADP); University of Sydney, Sydney Australia (DJH); Massachusetts General Hospital, Boston, MA (RPW); Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC (JMJ)
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Weinstein AM, Rome BN, Reichmann WM, Collins JE, Burbine SA, Thornhill TS, Wright J, Katz JN, Losina E. Estimating the burden of total knee replacement in the United States. J Bone Joint Surg Am 2013; 95:385-92. [PMID: 23344005 PMCID: PMC3748969 DOI: 10.2106/jbjs.l.00206] [Citation(s) in RCA: 297] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the last decade, the number of total knee replacements performed annually in the United States has doubled, with disproportionate increases among younger adults. While total knee replacement is a highly effective treatment for end-stage knee osteoarthritis, total knee replacement recipients can experience persistent pain and severe complications. We are aware of no current estimates of the prevalence of total knee replacement among adults in the U.S. METHODS We used the Osteoarthritis Policy Model, a validated computer simulation model of knee osteoarthritis, and data on annual total knee replacement utilization to estimate the prevalence of primary and revision total knee replacement among adults fifty years of age or older in the U.S. We combined these prevalence estimates with U.S. Census data to estimate the number of adults in the U.S. currently living with total knee replacement. The annual incidence of total knee replacement was derived from two longitudinal knee osteoarthritis cohorts and ranged from 1.6% to 11.9% in males and from 2.0% to 10.9% in females. RESULTS We estimated that 4.0 million (95% confidence interval [CI]: 3.6 million to 4.4 million) adults in the U.S. currently live with a total knee replacement, representing 4.2% (95% CI: 3.7% to 4.6%) of the population fifty years of age or older. The prevalence was higher among females (4.8%) than among males (3.4%) and increased with age. The lifetime risk of primary total knee replacement from the age of twenty-five years was 7.0% (95% CI: 6.1% to 7.8%) for males and 9.5% (95% CI: 8.5% to 10.5%) for females. Over half of adults in the U.S. diagnosed with knee osteoarthritis will undergo a total knee replacement. CONCLUSIONS Among older adults in the U.S., total knee replacement is considerably more prevalent than rheumatoid arthritis and nearly as prevalent as congestive heart failure. Nearly 1.5 million of those with a primary total knee replacement are fifty to sixty-nine years old, indicating that a large population is at risk for costly revision surgery as well as possible long-term complications of total knee replacement.
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Affiliation(s)
- Alexander M. Weinstein
- Orthopaedic and Arthritis Center for Outcomes Research (A.M.W., B.N.R., W.M.R., J.E.C., S.A.B., J.N.K., and E.L.) and Department of Orthopedic Surgery (T.S.T. and J.W.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for E. Losina:
| | - Benjamin N. Rome
- Orthopaedic and Arthritis Center for Outcomes Research (A.M.W., B.N.R., W.M.R., J.E.C., S.A.B., J.N.K., and E.L.) and Department of Orthopedic Surgery (T.S.T. and J.W.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for E. Losina:
| | - William M. Reichmann
- Orthopaedic and Arthritis Center for Outcomes Research (A.M.W., B.N.R., W.M.R., J.E.C., S.A.B., J.N.K., and E.L.) and Department of Orthopedic Surgery (T.S.T. and J.W.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for E. Losina:
| | - Jamie E. Collins
- Orthopaedic and Arthritis Center for Outcomes Research (A.M.W., B.N.R., W.M.R., J.E.C., S.A.B., J.N.K., and E.L.) and Department of Orthopedic Surgery (T.S.T. and J.W.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for E. Losina:
| | - Sara A. Burbine
- Orthopaedic and Arthritis Center for Outcomes Research (A.M.W., B.N.R., W.M.R., J.E.C., S.A.B., J.N.K., and E.L.) and Department of Orthopedic Surgery (T.S.T. and J.W.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for E. Losina:
| | - Thomas S. Thornhill
- Orthopaedic and Arthritis Center for Outcomes Research (A.M.W., B.N.R., W.M.R., J.E.C., S.A.B., J.N.K., and E.L.) and Department of Orthopedic Surgery (T.S.T. and J.W.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for E. Losina:
| | - John Wright
- Orthopaedic and Arthritis Center for Outcomes Research (A.M.W., B.N.R., W.M.R., J.E.C., S.A.B., J.N.K., and E.L.) and Department of Orthopedic Surgery (T.S.T. and J.W.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for E. Losina:
| | - Jeffrey N. Katz
- Orthopaedic and Arthritis Center for Outcomes Research (A.M.W., B.N.R., W.M.R., J.E.C., S.A.B., J.N.K., and E.L.) and Department of Orthopedic Surgery (T.S.T. and J.W.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for E. Losina:
| | - Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research (A.M.W., B.N.R., W.M.R., J.E.C., S.A.B., J.N.K., and E.L.) and Department of Orthopedic Surgery (T.S.T. and J.W.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for E. Losina:
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