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TKA and THA are cost-effective interventions

A systematic review finds that total knee arthroplasty (TKA) and total hip arthroplasty (THA) are cost-effective interventions, especially when not delayed, compared with non-operative strategies for the management of knee and hip osteoarthritis (OA).

A review of 23 studies determined that the incremental cost-effectiveness ratio (ICER) was generally well below $100,000 per quality-adjusted life-year gained for each operation, but cost-effectiveness and improvement in life "depended on the population that was considered and the interventions that they were compared to," according to UK researchers.

"TKA and THA were found to be cost-effective for patients with severe or end-stage knee or hip OA across all age groups and when compared to nonoperative strategies," wrote Hanin Kamaruzaman, from the University of Birmingham and colleagues. "Regardless of perspective adopted, TKA and THA remain among the most effective interventions in terms of improvements in quality of life of OA patients."

Although delaying arthroplasty has often been advocated to realize cost savings, "studies included in this review concluded that delaying arthroplasty (both knee and hip) was not a cost-effective option and that the health-related quality of life lost as a result of the delay is greater than the savings in costs that may occur from delaying the procedure." The researchers also noted that clinical guidelines by the National Institute for Health and Care Excellence in the UK do not include economic analyses of surgical treatments, limiting cost analyses to pharmacologic and conventional treatments, but should incorporate suggestions for the use of surgical intervention.

Kamaruzaman and co-investigators searched for economic evaluations associated with clinical trials or cohort-based trials that assessed all types of treatment modalities (pharmacologic, non-pharmacologic, surgical) for all types of OA. A total of 23 studies met the inclusion criteria, which included study populations with knee or hip OA, surgery as an intervention, any comparators (no interventions, usual care, and other surgical modalities), and outcomes for economic evaluations (ICER).

Six studies were categorised as "good quality," and 14 others were considered as "moderate quality" based on the Quality of Health Economic Studies. Four studies compared TKA with non-operative/non-surgical strategies, and all concluded that TKA is a cost-effective intervention. Three of these studies assessed total economic costs to society, and found cost-effectiveness from a societal perspective as well as a healthcare perspective.

Five studies compared TKA with uni-compartmental knee arthroplasty (UKA) to determine the most cost-effective option. Results were widely variable, with one set of authors concluding that UKA was associated with significantly poorer long-term survival than TKA with not even a theoretical cost benefit over TKA, while another group concluded that UKA has the potential to be a cost-effective alternative to TKA, depending on the cost as well as the durability and function of a UKA; another determined that "UKA yields clear advantages in terms of costs and marginal advantages in terms of health effects, in comparison with TKA."

TKA was found to be cost effective compared with no intervention in an Australian population. Another study compared early and delayed TKA and found that TKA without delay is the preferred cost-effective strategy from a societal perspective, and that TKA "without delay may be an overall cost-saving healthcare delivery strategy."

In a comparison of THA with metal-on-metal hip resurfacing (MoM-HRA), the latter was preferable in younger patients and THA was better in older patients and MoM-HRA was more preferable in men and THA in women.

The authors made a plea for considering the societal perspective, since "a large proportion of the economic burden of OA is related to indirect costs and productivity losses," and therefore has the "potential to capture all important impacts on the whole society." Yet, about one third of the studies limited the analysis to a healthcare perspective.

Additional studies should be undertaken to compare the various types of THA surgeries to maximise benefits from the available resources, the researchers recommended. Among the limitations are the inclusion of studies considered to be of poor quality and grading of quality assessment by only one reviewer. In addition, studies were conducted across nine countries, which may limit the generalisability and transferability of the findings.

Background: The primary purpose of this study is to assess the existing evidence on the cost-effectiveness of surgical interventions for the management of knee and hip osteoarthritis by systematically reviewing published economic evaluation studies.
Methods: A systematic review was conducted for the period 2004 to 2016. Electronic databases were searched to identify both trial and model based economic evaluation studies that evaluated surgical interventions for knee and hip osteoarthritis.
Results: A total of 23 studies met the inclusion criteria and an assessment of these studies showed that total knee arthroplasty (TKA), and total hip arthroplasty (THA) showed evidence of cost-effectiveness and improvement in quality of life of the patients when compared to non-operative and non-surgical procedures. On the other hand, even though delaying TKA and THA may lead to some cost savings in the short-run, the results from the study showed that this was not a cost-effective option.
Conclusions: TKA and THA are cost-effective and should be recommended for the management of patients with end stage/severe knee and hip OA. However, there needs to be additional studies to assess the cost-effectiveness of other surgical interventions in order for definite conclusions to be reached.

Hanin Kamaruzaman, Philip Kinghorn, Raymond Oppong

[link url=""]Med Page Today report[/link]
[link url=""]BMC Musculoskeletal Disorders abstract[/link]

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