Value Propositions - June 2017

VBCR - June 2017, Vol 6, No 2 - Value Propositions

In This Article

  • Total Knee Replacement Beneficial for Quality of Life but Economically Unattractive

Total knee replacements have minimal effects on the quality of life of patients with knee osteoarthritis, and would be more effective if they were restricted to severely affected patients, assert the investigators of a recent cost-effectiveness analysis of this intervention.

Seeking to assess the effects that total knee replacement have on the quality of life of patients with knee osteoarthritis, and to evaluate the related differences in lifetime costs and quality-adjusted life-years (QALYs) by symptom level, Bart S. Ferket, MD, PhD, Assistant Professor, Department of Population Health Science and Policy, Icahn School of Medicine, Mount Sinai, NY, and colleagues used population-based cohort data to carry out marginal structural modeling and a cost-effective analysis.

Dr Ferket and colleagues noted that the potential benefit of total knee replacement in this population should outweigh associated costs.

“It is estimated, however, that up to a third of recipients of total knee replacement experience chronic pain postoperatively, and the health benefits of the procedure are assumed to be higher in those with poor physical functioning before surgery. This would imply that patients undergoing the procedure because of the recently expanded practice in the US might show less significant improvement in symptoms,” they reported.

Cohort data were gleaned from the Osteoarthritis Initiative (OAI) database, a multicenter cohort study of 4796 US patients who either have or are at risk for knee osteoarthritis. Patients were followed up for 9 years, and received interventions ranging from a current practice (ie, total knee replacement practice as performed in the OAI) to a practice that is restricted to patients with severe symptoms, and to no surgery.

Dr Ferket and colleagues measured generic and osteoarthritis-specific quality of life over the course of 8 years, and used models to assess QALYs, costs, and incremental cost-effectiveness over the course of a lifetime horizon.

Quality-of-life improvements were small when averaged across levels of confounding variables among patients who received total knee replacement through the OAI; SF-12 physical component summary, 1.70 (95% uncertainty interval, 0.26-3.57); Western Ontario and McMaster Universities Osteoarthritis Index, −10.69 (−13.39 to −8.01); and knee injury and osteoarthritis outcome score, 9.16 (6.35-12.49). Improvements in these areas grew with decreasing functional status at baseline. Per the investigators, an optimal scenario entailed giving total knee replacements to patients with SF-12 physical component summary scores <35, which offered a cost-effectiveness threshold of $200,000 per QALY, with cost-savings of $6974 ($5789-$8269) and a minimal loss of 0.008 (−0.056-0.043) QALYs versus current practice.

“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,” Dr Ferket and colleagues concluded. Ferket BS, et al. BMJ. 2017;356:j1131.

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  • Adherence to DMARD Treatment Correlates with Healthcare Cost-Savings, Better Outcomes

Among patients with arthritis, medication nonadherence is associated with healthcare costs during the first year of treatment, suggesting that improved adherence correlates not only with better outcomes, but with cost-savings, according to researchers of a recent multicohort study.

Seeking to investigate the relationship between disease-modifying antirheumatic drug (DMARD) nonadherence and healthcare costs, Annelieke Pasma, Junior Researcher, Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands, and colleagues followed up with 206 patients for 1 year, measuring their nonadherence via electronic monitored medication jars.

Patients newly diagnosed with rheumatoid arthritis, psoriatic arthritis, or undifferentiated arthritis who were receiving DMARD therapy for the first time were recruited from 11 hospitals throughout the southwest of The Netherlands. Ms Pasma and colleagues defined nonadherence as the number of days when a negative difference was observed between the expected and actual opening medication jars. Cost measurement (ie, hospital costs in the first year) included consultations, emergency department visits, drug costs, and laboratory tests.

Ms Pasma and colleagues used multivariate regression analyses to determine the relationship between nonadherence and cost, and other variables (eg, age, sex, socioeconomic status) and cost.

Of the patients involved in the study, 23.7% had a nonadherence rate of >20% for the duration of the follow-up period. Although healthcare consumption varied among these patients, nonadherence was positively related to costs, as well as to anxiety at baseline.

“Our findings address the need to improve adherence, because money is being wasted and potentially beneficial medication is discarded. It is important to study which patients are at risk for non-adherence, so that interventions to improve adherence can be targeted,” Ms Pasma and colleagues reported. Pasma A, et al. PLoS One. 2017;12:e0171070.

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  • Costs for Joint Replacement Increase Over 11-Year Time Frame, but Inpatient Length of Stay Is Shorter

In the past decade, use of total knee and hip arthroplasties have increased greatly in the United States, and are among the most expensive procedures for patients with Medicare. Results of a recent study, however, show that, although hospital costs for joint replacement increased from 2002 to 2013, inpatient length of stays have been reduced.

Citing medical advances that decrease length of hospital stay (eg, surgical techniques, anesthesia, and care pathways), Ilda B. Molloy, MD, Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, and colleagues sought to examine how trends in hospital costs were altered by length-of-stay diminutions.

Using data from the Agency for Healthcare Research and Quality National (Nationwide) Inpatient Sample, a component of the Healthcare Cost and Utilization Project, Dr Molloy and colleagues gathered procedure, demographic, and economic information on 6.4 million patients admitted for total knee arthroplasties and 2.8 million patients admitted for total hip arthroplasties from 2002 to 2013.

They used inflation-adjusted, survey-weighted, generalized linear regression models that were controlled for patient demographics and comorbidity to project trends in mean hospital costs and their relationship to length of stay.

The mean cost of a total knee arthroplasty increased from $14,988 in 2002 to $22,837 in 2013, denoting an overall increase of $7849 (52.4%), whereas the mean cost of a total hip arthroplasty increased from $15,792 in 2002 to $23,650 in 2013, denoting an increase of $7858 (49.8%). During the same time frame of 11 years, length of stays decreased from a mean time of 4.06 days to 2.97 days for total knee arthroplasty and from 4.06 days to 2.75 days for total hip arthroplasty.

According to Dr Molloy and her colleagues, the cost increase for a total knee arthroplasty would have been 70.8% instead of 52.4%, and for a total hip arthroplasty it would have been 67.4% instead of 49.8%, had the length of stay been set at the 2002 mean.

They assert that, per the findings of their study, hospital costs for joint replacements experienced growth from 2002 to 2013, but were tempered by a reduction in inpatient length of stay.

“Continued efforts to reduce episode-of-care costs, particularly in the context of bundled payment reimbursements, might be sought through implant standardization, utilization of outpatient arthroplasties, improved risk identification, and coordination with post-acute care facilities,” Dr Molloy and colleagues concluded. Molloy IB, et al. J Bone Joint Surg Am. 2017;99:402-407.

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Last modified: July 24, 2017
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