The use of patient-reported outcome measures to guide referral for hip and knee arthroplasty

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Abstract

Aims

To assess how the cost-effectiveness of total hip arthroplasty (THA) and total knee arthroplasty (TKA) varies with age, sex, and preoperative Oxford Hip or Knee Score (OHS/OKS); and to identify the patient groups for whom THA/TKA is cost-effective.

Methods

We conducted a cost-effectiveness analysis using a Markov model from a United Kingdom NHS perspective, informed by published analyses of patient-level data. We assessed the cost-effectiveness of THA and TKA in adults with hip or knee osteoarthritis compared with having no arthroplasty surgery during the ten-year time horizon.

Results

THA and TKA cost < £7,000 per quality-adjusted life-year (QALY) gained at all preoperative scores below the absolute referral thresholds calculated previously (40 for OHS and 41 for OKS). Furthermore, THA cost < £20,000/QALY for patients with OHS of ≤ 45, while TKA was cost-effective for patients with OKS of ≤ 43, since the small improvements in quality of life outweighed the cost of surgery and any subsequent revisions. Probabilistic and one-way sensitivity analyses demonstrated that there is little uncertainty around the conclusions.

Conclusion

If society is willing to pay £20,000 per QALY gained, THA and TKA are cost-effective for nearly all patients who currently undergo surgery, including all patients at and above our calculated absolute referral thresholds.

Cite this article: Bone Joint J 2020;102-B(7):950–958.

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The estimation of a preference-based measure of health from the SF-36.

John Brazier, Jennifer Roberts, Mark Deverill (2002)

This paper reports on the findings of a study to derive a preference-based measure of health from the SF-36 for use in economic evaluation. The SF-36 was revised into a six-dimensional health state classification called the SF-6D. A sample of 249 states defined by the SF-6D have been valued by a representative sample of 611 members of the UK general population, using standard gamble. Models are estimated for predicting health state valuations for all 18,000 states defined by the SF-6D. The econometric modelling had to cope with the hierarchical nature of the data and its skewed distribution. The recommended models have produced significant coefficients for levels of the SF-6D, which are robust across model specification. However, there are concerns with some inconsistent estimates and over prediction of the value of the poorest health states. These problems must be weighed against the rich descriptive ability of the SF-6D, and the potential application of these models to existing and future SF-36 data set.

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Questionnaire on the perceptions of patients about total knee replacement

Jill Dawson, Ray Fitzpatrick, David Murray … (1998)

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Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative

Bart Ferket, Zachary Feldman, Jing Zhou … (2017)

Objectives To evaluate the impact of total knee replacement on quality of life in people with knee osteoarthritis and to estimate associated differences in lifetime costs and quality adjusted life years (QALYs) according to use by level of symptoms. Design Marginal structural modeling and cost effectiveness analysis based on lifetime predictions for total knee replacement and death from population based cohort data. Setting Data from two studies—Osteoarthritis Initiative (OAI) and the Multicenter Osteoarthritis Study (MOST)—within the US health system. Participants 4498 participants with or at high risk for knee osteoarthritis aged 45-79 from the OAI with no previous knee replacement (confirmed by baseline radiography) followed up for nine years. Validation cohort comprised 2907 patients from MOST with two year follow-up. Intervention Scenarios ranging from current practice, defined as total knee replacement practice as performed in the OAI (with procedural rates estimated by a prediction model), to practice limited to patients with severe symptoms to no surgery. Main outcome measures Generic (SF-12) and osteoarthritis specific quality of life measured over 96 months, model based QALYs, costs, and incremental cost effectiveness ratios over a lifetime horizon. Results In the OAI, total knee replacement showed improvements in quality of life with small absolute changes when averaged across levels of confounding variables: 1.70 (95% uncertainty interval 0.26 to 3.57) for SF-12 physical component summary (PCS); −10.69 (−13.39 to −8.01) for Western Ontario and McMaster Universities arthritis index (WOMAC); and 9.16 (6.35 to 12.49) for knee injury and osteoarthritis outcome score (KOOS) quality of life subscale. These improvements became larger with decreasing functional status at baseline. Provision of total knee replacement to patients with SF-12 PCS scores <35 was the optimal scenario given a cost effectiveness threshold of $200 000/QALY, with cost savings of $6974 ($5789 to $8269) and a minimal loss of 0.008 (−0.056 to 0.043) QALYs compared with current practice. These findings were reproduced among patients with knee osteoarthritis from the MOST cohort and were robust against various scenarios including increased rates of total knee replacement and mortality and inclusion of non-healthcare costs but were sensitive to increased deterioration in quality of life without surgery. In a threshold analysis, total knee replacement would become cost effective in patients with SF-12 PCS scores ≤40 if the associated hospital admission costs fell below $14 000 given a cost effectiveness threshold of $200 000/QALY. Conclusion Current practice of total knee replacement as performed in a recent US cohort of patients with knee osteoarthritis had minimal effects on quality of life and QALYs at the group level. If the procedure were restricted to more severely affected patients, its effectiveness would rise, with practice becoming economically more attractive than its current use.

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Author and article information

Contributors

H. Dakin: Role: Senior Researcher

P. Eibich: Role: Senior Researcher, Research Scientist

D. Beard: Role: Professor of Musculoskeletal Sciences

A. Gray: Role: Professor of Health Economics

A. Price: Role: Professor of Orthopaedic Surgery

Journal

Journal ID (nlm-ta): Bone Joint J

Journal ID (iso-abbrev): Bone Joint J

Journal ID (publisher-id): Bjj

Title: The Bone & Joint Journal

Publisher: The British Editorial Society of Bone & Joint Surgery (London )

ISSN (Print): 2049-4394

ISSN (Electronic): 2049-4408

Publication date (Print): 1 July 2020

Publication date (Electronic): 1 July 2020

Volume: 102-B

Issue: 7

Pages: 950-958

Affiliations

[1 ]org-divisionNuffield Department of Population Health, University of Oxford , Oxford, UK

[2 ]org-divisionMax Planck Institute for Demographic Research , Rostock, Germany

[3 ]org-divisionNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, NIHR Biomedical Research Unit, University of Oxford , Oxford, UK

Author notes

[*]

These authors contributed equally to the work.

Correspondence should be sent to H. Dakin. E-mail: helen.dakin@ 123456ndph.ox.ac.uk

Article

Publisher ID: BJJ-102B-950

DOI: 10.1302/0301-620X.102B7.BJJ-2019-0105.R2

PMC ID: 7376304

PubMed ID: 32600136

SO-VID: 979def0a-5a64-4e0c-ac75-55d39a3d5b46

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited

History

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odf2nlm-version $2.00

principal-institution Health Economics Research Centre, University of Oxford, Oxford, UK

article-type Arthroplasty

coi-statement All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author). H. Dakin reports personal fees from Halyard Health, outside the submitted work; D. Beard reports grants from Zimmer Biomet, outside the submitted work; A. Price reports personal fees from Zimmer Biomet and DePuy outside the submitted work; all declare that there are no other relationships or activities that could appear to have influenced the submitted work. The other authors declare that there are no relevant conflicts of interests.

Keywords: arthroplasty,joint arthroplasty,economic evaluation,cost-utility analysis,osteoarthritis,knee,hip

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Keywords: arthroplasty, joint arthroplasty, economic evaluation, cost-utility analysis, osteoarthritis, knee, hip

The use of patient-reported outcome measures to guide referral for hip and knee arthroplasty : part 2: a cost-effectiveness analysis

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SICOT-J (Orthopedic surgery and traumatology)

Most cited references 17

The estimation of a preference-based measure of health from the SF-36.

Questionnaire on the perceptions of patients about total knee replacement

Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative

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