Clinical benefit and cost effectiveness of total knee arthroplasty in the older patient

Abstract

PurposeTotal knee arthroplasty (TKA) is an effective, but also cost-intensive health care procedure for the elderly. Furthermore, bearing demographic changes in Western Europe in mind, TKA-associated financial investment for health care insurers will increase notably and thereby catalyze discussions on ressource allocation to Orthopedic surgery. To derive a quantitative rationale for such discussions within Western Europe's health care systems, a prospective assessment of both the benefit of TKA from a patient's perspective as well as its cost effectiveness from a health care insurer's perspective was implemented.MethodsA prospective cost effectiveness trial recruited a total of 65 patients (60% females), who underwent TKA in 2006; median age of patients was 66 years (interquartile range 61 - 74 years). Before and three months after surgery patients were interviewed by means of the EuroQol-5D and the WOMAC questionnaires to assess their individual benefit due to TKA and the subsequent inpatient rehabilitation. Both questionnaires' benefit estimates were transformed into the number of gained quality adjusted life years [QALYs]. Total direct cost estimates for the overall care were based on German DRG and rehabilitation cost rates [€]. The primary clinical endpoint of the investigation was the individual number of QALYs gained by TKA based on the WOMAC interview; the primary health economic endpoint was the marginal cost effectiveness ratio (MCER) relating the costs to the associated gain in quality of life [€/QALY].ResultsTotal direct costs for the overall procedure were estimed 9549 € in median. The WOMAC based interview revealed an overall gain of 4.59 QALYs (interquartile range 2.39 - 6.21 QALYs), resulting in marginal costs of 1795 €/QALY (1488 - 3288 €/QALY). The corresponding EuroQol based estimates were 2.93 QALYs (1.75 - 5.59 QALYs) and 3063 €/QALY (1613 - 5291 €/QALY). Logistic regression modelling identified the patients' age as the primary determinant of cost effectiveness (Likelihood Ratio p = 0.006): patients younger than 60 years showed a median gain of 6.45 QALYs and median marginal costs of 1463 €/QALY, patients between 60 - 70 years 5.47 QALYs and 1744 €/QALY, patients older than 70 years 2.76 QALYs and 3186 €/QALY.ConclusionTKA was proven to be cost effective from a health care insurer's perspective, although its marginal costs notably increased with increasing age. Note, however, that this age-related gradient in marginal cost effectiveness is of comparable order as the changes in cost effectiveness due to variation of the underlying assessment instrument.

International survey of primary and revision total knee replacement

“…National registries have been established in certain European countries, Canada, Australia, and New Zealand, to monitor the rates of revision replacement surgery [1]. Although primary and revision total knee replacement surgery is widely recognized as highly cost effective procedures [2][3][4][5][6], the utilization of joint arthroplasty has come under increased administrative scrutiny in an era of concern over limited healthcare resources [3].…”

Could a disruptive out patient healthcare delivery model reduce escalating in-hospital healthcare costs in knee osteoarthritis

“…These patients refused TKR and opted for IPGFE. Costs of TKR in Germany were obtained from a paper that also used the WOMAC knee outcome scores9 as used in patients in this article. The post-treatment follow-up WOMAC score was longer for patients treated with IPGFE (5–6 months) compared to the follow-up WOMAC score post-TKR (3 months).…”

“…Costs and quality adjusted life years (QALY) from TKR surgery were derived from previously published data from an article that used WOMAC function scores to calculate QALY 9. This was compared to data from this study where QALYs were calculated as the improvement in WOMAC knee function divided over a 10-year period.…”

Assessing the value of a total joint replacement

“…Krummenauer et al conducted a prospective CUA of TKA from the payer's perspective [22]. Their study population consisted of 65 patients with a median age of 66 years; follow-up was only 3 months.…”