Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese

McLawhorn, Alexander S.; Southren, Daniel L.; Wang, Y. Claire; Marx, Robert G.; Dodwell, Emily

doi:10.2106/jbjs.n.00416

Cited by 49 publications

(39 citation statements)

References 53 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…We therefore included 13 papers in this review. 86,[97][98][99][100][101][102][103][104][105][106]109,110 Table 14 summarises the characteristics of the 13 studies. Five studies included both hip and knee replacement patients, [97][98][99]101,109 five included only hip replacement patients 100,[102][103][104]106 and three included only knee replacement patients.…”

Section: Results Of the Systematic Reviewmentioning

confidence: 99%

“…Five studies included both hip and knee replacement patients, [97][98][99]101,109 five included only hip replacement patients 100,[102][103][104]106 and three included only knee replacement patients. 86,105,110 Two papers evaluated an entire ERP 98,109 and the remainder evaluated components of a pathway, such as optimisation of comorbidities (specifically morbid obesity), 110 measures to reduce allogenic blood transfusion, 99,100 local infiltration of anaesthetic, 101 prophylactic antibiotics and other infection prevention measures, 97,[102][103][104] and physical therapy. 86,105 The final study 106 concerned the optimal timing of follow-up post surgery.…”

Section: Results Of the Systematic Reviewmentioning

confidence: 99%

“…We identified 11 studies presenting cost-utility data for components of an ERP. 86,97,[99][100][101][102][103][104][105][106]110 However, these cover only a few of the potential ERP components and the available evidence was mostly based on single studies. These studies covered a variety of interventions, across different health-care systems, and used different cost perspectives.…”

Section: Discussionmentioning

confidence: 99%

“…McLawhorn et al 110 used a Markov model to assess the cost-effectiveness of bariatric surgery 2 years before total knee arthroplasty for morbidly obese (BMI ≥ 35 kg/m 2 ) patients who were candidates for both operations because of end-stage knee osteoarthritis and failed non-operative weight loss interventions. The strategy including bariatric surgery was cost-effective at the stated willingness-to-pay threshold of US$100,000 per QALY in 98.8% of probabilistic simulations.…”

Section: Preoperative Components Of the Enhanced Recovery Pathwaymentioning

confidence: 99%

See 3 more Smart Citations

The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

Judge

Carr

Price

et al. 2020

Health Serv Deliv Res

View full text Add to dashboard Cite

Background There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system. Objectives To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement. Design (1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness. Setting Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England. Participants Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement. Interventions Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation). Main outcome measures Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years. Results Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole. Limitations Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors. Conclusion No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts. Future work There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals. Study registration This study is registered as PROSPERO CRD42017059473. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

show abstract

Section: Results Of the Systematic Reviewmentioning

confidence: 99%

Section: Results Of the Systematic Reviewmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Preoperative Components Of the Enhanced Recovery Pathwaymentioning

confidence: 99%

See 2 more Smart Citations

The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

Judge

Carr

Price

et al. 2020

Health Serv Deliv Res

View full text Add to dashboard Cite

show abstract

“…9 Further demonstrating this dynamic association, weight loss with bariatric surgery has been shown to significantly improve OA symptoms 10 and is estimated to be cost-effective prior to TKA. 11 Although greater BMI is significantly associated with the likelihood of requiring TKA, 12 outcomes for obese patients are broadly regarded as inferior to those of nonobese patients. [13][14][15] In an increasingly fiscally constrained healthcare environment, the value an intervention provides patients and society will continue to be scrutinized.…”

mentioning

confidence: 99%

Body Mass Index Classification Is Independently Associated with Health-Related Quality of Life after Primary Total Knee Arthroplasty: An Institutional Registry-Based Study

et al. 2019

Self Cite

View full text Add to dashboard Cite

The purpose of this study was to compare the health-related quality of life (HRQoL) before and after successful total knee arthroplasty (TKA) across World Health Organization (WHO) body mass index (BMI) classifications. Through an institutional registry, patients with end-stage knee osteoarthritis who received elective primary unilateral TKA were identified and categorized based on WHO BMI classification. Age, gender, laterality, year of surgery, and Charlson–Deyo comorbidity index were recorded. The primary outcome was the EQ-5D-3L index and visual analog scale (VAS) at 2 years postoperatively. Inferential statistics and regression analyses were performed to determine associations between BMI classification and HRQoL. EQ-5D-3L index and VAS scores were significantly different across BMI classes, with higher scores in patients with lower BMI at baseline and at 2 years. There was no difference observed for the 2-year change in EQ-VAS scores between groups, but there was a statistically greater increase in index scores for more obese patients. In the regression analyses, there were statistically significant negative effect estimates for EQ-VAS and index scores associated with increasing BMI class, particularly for class III obesity. Higher BMI classification is independently associated with lower HRQoL scores 2 years after uncomplicated primary TKA, although obese patients experienced greater benefits in EQ-5D index scores following TKA. These results detail the relationship between BMI and HRQoL following TKA and suggest that preoperative weight loss may lead to improved outcomes following TKA, but also that obesity, alone, should not be a contraindication to TKA.

show abstract

Cost‐Effectiveness of Surgical Weight‐Loss Interventions for Patients With Knee Osteoarthritis and Class III Obesity

Kostic

Leifer

Gong

et al. 2022

Arthritis Care & Research

View full text Add to dashboard Cite

Objective. Class III obesity (body mass index [BMI] ≥40 kg/m 2 ) is associated with worse knee pain and total knee replacement (TKR) outcomes. Because bariatric surgery yields sustainable weight loss for individuals with BMI ≥40 kg/m 2 , our objective was to establish the value of Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) in conjunction with usual care for knee osteoarthritis (OA) patients with BMI ≥40 kg/m 2 .Methods. We used the Osteoarthritis Policy model to assess long-term clinical benefits, costs, and costeffectiveness of RYGB and LSG. We derived model inputs for efficacy, costs, and complications associated with these treatments from published data. Primary outcomes included quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs), all discounted at 3%/year. This analysis was conducted from a health care sector perspective. We performed sensitivity analyses to evaluate uncertainty in input parameters.Results. The usual care + RYGB strategy increased the quality-adjusted life expectancy by 1.35 years and lifetime costs by $7,209, compared to usual care alone (ICER = $5,300/QALY). The usual care + LSG strategy yielded less benefit than usual care + RYGB and was dominated. Relative to usual care alone, both usual care + RYGB and usual care + LSG reduced opioid use from 13% to 4%, and increased TKR usage from 30% to 50% and 41%, respectively. For cohorts with BMI between 38 and 41 kg/m 2 , usual care + LSG dominated usual care + RYGB. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $50,000/QALY, usual care + RYGB and usual care + LSG were cost-effective in 70% and 30% of iterations, respectively.Conclusion. RYGB offers good value among knee OA patients with BMI ≥40 kg/m 2 , while LSG may provide good value among those with BMI between 35 and 41 kg/m 2 .

show abstract

Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese

Abstract: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Cited by 49 publications

References 53 publications

The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

Body Mass Index Classification Is Independently Associated with Health-Related Quality of Life after Primary Total Knee Arthroplasty: An Institutional Registry-Based Study

Cost‐Effectiveness of Surgical Weight‐Loss Interventions for Patients With Knee Osteoarthritis and Class III Obesity

Contact Info

Product

Resources

About