Cost effectiveness analysis for commonly used human cell and tissue products in the management of diabetic foot ulcers.

Background and Aims: This study considers the cost-effectiveness of commonly used cellular, acellular, and matrix­like products (CAMPs) of human origin also known as human cell and tissue products (HCT/Ps) in the management of diabetic foot ulcers. Methods: We developed a 1-year economic model assessing six CAMPs [cryopreserved placental membrane with viable cells (vCPM), bioengineered bilayered living cellular construct (BLCC), human fibroblast dermal substitute (hFDS), dehydrated human amnion chorion membrane (dHACM), hypothermically stored amniotic membrane (HSAM) and human amnion membrane allograft (HAMA) which had randomized controlled trial evidence compared with standard of care (SoC). CAMPs were compared indirectly and ranked in order of cost-effectiveness using SoC as the baseline, from a CMS/Medicare's perspective. Results: The mean cost, healed wounds (hw) and QALYs per patient for vCPM is $10,907 (0.914 hw, 0.783 QALYs), for HAMA $11,470 (0.903 hw, 0.780 QALYs), for dHACM $15,862 (0.828 hw, 0.764 QALYs), for BLCC $18,430 (0.816 hw, 0.763 QALYs), for hFDS $19,498 (0.775 hw, 0.757 QALYs), for SoC $19,862 (0.601 hw, 0.732 QALYs) and $24, 214 (0.829, 0.763 QALYs) for HSAM respectively. Over 1 year, vCPM results in cheaper costs overall and better clinical outcomes compared to other CAMPs. Following probabilistic sensitivity analysis, vCPM has a 60%, HAMA 40% probability of being cost-effective then dHACM, hFDS, BLCC, and lastly HSAM using a $100,000/healed wound or QALY threshold. Conclusions: All CAMPs were shown to be cost-effective when compared to SoC in managing DFUs. However, vCPM appears to be the most cost-effective CAMP over the modelled 52 weeks followed by HAMA, dHACM, hFDS, BLCC, and HSAM. We urge caution in interpreting the results because we currently lack head-to-head evidence comparing all these CAMPs and therefore suggest that this analysis be updated when more direct evidence of CAMPs becomes available.

An All-Suture-Based Technique for Meniscal Repair Is Cost-Effective in Comparison to Partial Meniscectomy for Horizontal Cleavage Tears.

Purpose: To determine the cost-effectiveness of meniscal repair (MR) using an all-suture-based technique when compared to partial meniscectomy (PM) for horizontal cleavage tears (HCTs) from a payor's perspective in the United States. Methods: A state-transition model and cost-utility analysis were developed from a US payor's perspective to project treatment costs and quality-adjusted life-years (QALYs) in a cohort of 35-year-old patients without osteoarthritis at baseline and presenting with either a lateral or medial HCT. Two outpatient costing perspectives were used, namely ambulatory surgical centers (ASCs) and hospitals. The state-transition model had 7 health states with transition probabilities, costs, and utilities obtained from the existing literature. Cost-effectiveness was assessed using a willingness-to-pay threshold of $100,000/QALY, and sensitivity analysis considered the effects of parameter uncertainty on model results. MR failure rates were focused on an all-suture-based technique; however, in a separate scenario, this study considered effectiveness data from various MR techniques and devices. Results: MR dominated PM over a lifetime horizon, increasing QALYs by 0.43 per patient and decreasing the cost by $12,227 per patient within a hospital setting (and by $12,570 within an ASC). MR with an all-suture-based technique continued to be the dominant treatment when age at primary treatment was varied between 30 and 60 years. Sensitivity analysis showed that MR was not cost-effective in year 1, was cost-effective from year 2, and was cost-saving from year 6 onward from both ASC and hospital perspectives. Probabilistic sensitivity analysis found that MR was cost-effective over a lifetime horizon in 99% of 10,000 iterations on base-case analysis. Conclusions: Using a lifetime horizon, this study found that from a payor's perspective, MR is a cost-saving intervention when compared with PM in patients with an HCT. Level of Evidence: Level III, economic analysis.

Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy.

INTRODUCTION: Rotator cuff tear (RCT) is a painful, progressive condition resulting from damage to the rotator cuff tendons and is the leading cause of shoulder-related disability. Surgical repair of rotator cuff is an established standard of care (SOC); however, failure of the procedure can occur. In this context, the use of collagen-based bioinductive implant REGENETEN showed long-term improvements in clinical scores. The aim of the study was to assess the cost-effectiveness of REGENETEN combined with SOC (SOC + REGENETEN) compared to SOC alone from both National Healthcare Service (NHS) and societal perspectives in Italy. METHODS: A decision analytic model was developed to estimate the number of tears healed and costs for the two considered treatment strategies over 1 year. Clinical data were retrieved from the literature, and the clinical pathways for the management of patients with RCTs were retrieved from four key opinion leaders in Italy. RESULTS: Over a 1-year time horizon, healed lesions were 90.70% and 72.90% for surgical repair of RCTs with and without REGENETEN, respectively. Considering the NHS perspective, mean costs per patient were €7828 and €4650 for the two strategies, respectively, leading to an incremental cost-effectiveness ratio (ICER) of €17,857 per healed tear. From the societal perspective, the mean costs per patient were €12,659 for SOC and €11,784 for REGENETEN, thus showing savings of €4918 per healed tear when the bioinductive implant is used. The sensitivity analyses confirmed the robustness of the model results. CONCLUSION: In the context of paucity of cost-effectiveness studies, our findings provide additional evidence for clinicians and payers regarding the value of a new treatment option that supports a tailored approach for the management of patients with RCTs.

The rotator cuff refers to a group of four muscles, with tendons connected to the upper arm bone, which act together to allow lifting and rotating the shoulder. A tear of the rotator cuff can affect either a single tendon or multiple tendons. Typical first-line treatment includes conservative therapies, which aim to alleviate pain and reduce functional impairment, but are often ineffective. Persisting disease is usually managed through conventional surgical repair. Recently, REGENETEN, a collagen-based bioinductive implant derived from purified bovine Achilles tendon, positioned over the site of the damaged rotator cuff, achieved successful rotator cuff tendon repair with an increase in healed tears of 17.80% at 1 year compared to conventional surgery. Considering the National Healthcare Service perspective in Italy, the cost needed to achieve one additional healed tear using REGENETEN compared to conventional surgery is €17,857. From the societal perspective, which includes patients' productivity losses from hospital admission to return to work, the use of REGENETEN may be cost-saving compared to conventional surgery. The findings of our study provide evidence for clinicians and payers to support the value of a new treatment option for patients with rotator cuff lesions.

Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2040-2060.

Background: National projections of future joint arthroplasties are useful in understanding the changing burden of surgery and related outcomes on the health system. The aim of this study is to update the literature by producing Medicare projections for revision total joint arthroplasty procedures from 2040 through 2060. Methods: The study uses 2000-2019 data from the CMS Medicare Part-B National Summary and combines procedure counts using CPT codes for revision total joint arthroplasty procedures. In 2019, revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) procedures totaled 53,217 and 30,541, respectively, forming a baseline from which we generated point forecasts between 2020 and 2060 and 95% forecast intervals (FI). Results: On average, the model projects an annual growth rate of 1.77% for rTHAs and 4.67% for rTKAs. By 2040, rTHAs were projected to be 43,514 (95% FI = 37,429-50,589) and rTKAs were projected to be 115,147 (95% FI = 105,640-125,510). By 2060, rTHAs was projected to be 61,764 (95% FI = 49,927-76,408) and rTKAs were projected to be 286,740 (95% FI = 253,882-323,852). Conclusions: Based on 2019 total volume counts, the log-linear exponential model forecasts an increase in rTHA procedures of 42% by 2040 and 101% by 2060. Similarly, the estimated increase for rTKA is projected to be 149% by 2040 and 520% by 2060. An accurate projection of future revision procedure demands is important to understand future healthcare utilization and surgeon demand. This finding is only applicable to the Medicare population and demands further analysis for other population groups.

Resorbable Bioinductive Collagen Implant Is Cost Effective in the Treatment of Rotator Cuff Tears.

Purpose: This study was conducted to investigate whether the use of resorbable bioinductive collagen implant (RBI) in addition to conventional rotator cuff repair (conventional RCR) is cost-effective when compared to conventional RCR alone, in the treatment of full-thickness rotator cuff tears (FT RCT). Methods: We developed a decision analytic model to compare the expected incremental cost and clinical consequences for a cohort of patients with FT RCT. The probabilities for healing or failure to heal (retear) were estimated from the published literature. Implant and healthcare costs were estimated from a payor's perspective in 2021 U.S. prices. An additional analysis included indirect cost estimations (e.g., productivity losses). Sensitivity analyses explored the effect of tear size, as well as the impact of risk factors. Results: The base case analysis demonstrated that resorbable bioinductive collagen implant + conventional rotator cuff repair results in incremental costs of $232,468 and an additional 18 healed RCTs per 100 treated patients over 1 year. The estimated incremental cost-effectiveness ratio (ICER) is $13,061/healed RCT compared to conventional RCR alone. When return to work was included in the model, RBI + conventional RCR was found to be cost saving. Cost-effectiveness improved with tear size with the largest benefit seen in massive tears compared to large tears, as well as patients at higher risk of retearing. Conclusions: This economic analysis demonstrated that RBI + conventional RCR delivered improved healing rates at a marginal increase in costs when compared to conventional RCR alone and is, therefore, cost-effective in this patient population. Considering indirect costs, RBI + conventional RCR resulted in lower costs compared to conventional RCR alone and is, therefore, deemed to be cost saving. Level of Evidence: Level IV, economic analysis.

Projections and Epidemiology of Primary Hip and Knee Arthroplasty in Medicare Patients to 2040-2060.

National projections of future joint arthroplasties are useful for understanding the changing burden of surgery and related outcomes on the health system. The aim of this study is to update the literature by producing Medicare projections for primary total joint arthroplasty (TJA) procedures until 2040 and 2060. Methods: The present study used data from the Centers for Medicare & Medicaid Services (CMS) Medicare/Medicaid Part B National Summary and combined procedure counts with use of Current Procedural Terminology (CPT) codes to identify whether the procedure was a primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedure. In 2019, the annual volume of primary TKA was 480,958 and that of primary THA was 262,369. These values formed a baseline from which we generated point forecasts for 2020-2060 and 95% forecast intervals (FIs). Results: Between 2000 and 2019, the estimated annual volume of THA increased by 177% and that of TKA increased by 156% on average. Regression analysis projected an annual growth rate of 5.2% for THA and 4.44% for TKA. Based on these yearly projected increases, an estimated increase of 28.84% and 24.28% is expected for each 5-year period after 2020 for THA and TKA, respectively. By 2040, the number of THAs is projected to be 719,364 (95% FI, 624,766 to 828,286) and the number of TKA is projected to be 1,222,988 (95% FI, 988,714 to 1,512,772). By 2060, the number of THAs is projected to be 1,982,099 (95% FI, 1,624,215 to 2,418,839) and the number of TKAs is projected to be 2,917,959 (95% FI, 2,160,951 to 3,940,156). In 2019, Medicare data showed that THA constituted approximately 35% of TJA procedures performed. Conclusions: Based on 2019 total volume counts, our model forecasts an increase in THA procedures of 176% by 2040 and 659% by 2060. The estimated increase for TKA is projected to be 139% by 2040 and 469% by 2060. An accurate projection of future primary TJA procedure demands is important in order to understand future health-care utilization and surgeon demand. This finding is only applicable to a Medicare population and demands further analysis to see if this extends to other population groups. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

In reply to the letter to the editor regarding "Comparison of a twin interlocking derotation and compression screw cephalomedullary nail (InterTAN) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric fractures".

BACKGROUND: Intertrochanteric hip fractures are common and devastating injuries, especially for the elderly. Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows early rehabilitation and functional recovery. The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain limited to relatively small studies which create uncertainty in attempts to establish evidence-based best practice. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies to assess the clinical effectiveness of two commonly used intramedullary devices: a twin-screw integrated cephalomedullary nail (InterTAN) versus a single-screw cephalomedullary nail (proximal femoral nail antirotation) in patients with intertrochanteric fractures. The following outcomes were considered: revisions, implant-related failures, non-unions, pain, Harris hip score and intra-operative outcomes. Odds ratios or mean differences with 95% confidence intervals in brackets are reported. RESULTS: Six studies met the inclusion criteria: two randomised controlled trials and four observational studies enrolling 970 patients with a mean age of 77 years and 64% of patients being female. There was a statistically significant difference (p value < 0.05) for revisions OR 0.27 (0.13-0.56), implant-related failures OR 0.16 (0.09-0.27) and proportion of patients complaining of pain OR 0.50 (0.34-0.74). There was no difference in non-unions and Harris hip score (p value > 0.05). There was a significant difference in blood loss and fluoroscopy usage in favour of PFNA, while no difference in operating times was observed between the two devices. CONCLUSIONS: Our meta-analysis suggests that a twin-screw integrated cephalomedullary nail (InterTAN) is clinically more effective when compared to a single-screw cephalomedullary nail proximal femoral nail antirotation resulting in fewer complications, fewer revisions and fewer patients complaining of pain. No difference has been established regarding non-unions and Harris hip score. Intra-operative outcomes favour PFNA with less blood loss and fluoroscopy usage. Further studies are warranted to explore the cost-effectiveness of these and other implants in managing patients with intertrochanteric fractures.

Early Economic Analysis of Robotic-Assisted Unicondylar Knee Arthroplasty May Be Cost Effective in Patients with End-Stage Osteoarthritis.

Unicondylar knee arthroplasty (UKA), as an alternative to total knee arthroplasty (TKA), has been shown to be an effective option for patients with single-compartment end-stage knee osteoarthritis. Implant survival is contingent upon proper alignment, which has been improved with the advent of robotic-assisted surgery (r-UKA), but whether this outweighs the increased cost of the robotic-assist device has not been analyzed in the literature. The purpose of this study was to investigate the mid-term cost-effectiveness of r-UKA compared with UKA with traditional instrumentation (t-UKA) in the United States. A cost-effectiveness analysis using a four-state Markov model was performed using data from the 2018 National Joint Registry of England and Wales and a retrospective multicenter, cohort study on a cohort of 65-year-old patients having undergone r-UKA. The main outcome was cost per revision avoided and sensitivity analyses were conducted to evaluate the impact of using different model assumptions on the results. The Markov model illustrated that the benefit derived from r-UKA versus t-UKA was beneficial from a payer's perspective. The estimated incremental cost-effectiveness ratio (ICER) was $14,737 per revision avoided in a facility seeing 100 patients a year. Case volume was shown to be the primary variable affecting cost-effectiveness, with the value of r-UKA directly increasing with higher case volumes. Cost-effectiveness analyses demonstrated that the use of r-UKA is an effective alternative to t-UKA in patients with single-compartment knee osteoarthritis. While this study could benefit from longer follow-up clinical studies to illustrate the benefits of r-UKAs beyond the current 2 years time horizon, r-UKAs remained cost-effective, even after investigating several different assumptions.

Cost-effectiveness of dual-mobility components in patients with displaced femoral neck fractures.

AIMS: Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA. METHODS: Costs and benefits were established for patients aged 75 to 79 years over a five-year time period in the base case from the Canadian Health Payer's perspective. One-way and probabilistic sensitivity analysis assessed the robustness of the base case model conclusions. RESULTS: DM-THA was found to be cost-effective, with an estimated incremental cost-effectiveness ratio (ICER) of CAD $46,556 (£27,074) per quality-adjusted life year (QALY). Sensitivity analysis revealed DM-THA was not cost-effective across all age groups in the first two years. DM-THA becomes cost-effective for those aged under 80 years at time periods from five to 15 years, but was not cost-effective for those aged 80 years and over at any timepoint. To be cost-effective at ten years in the base case, DM-THA must reduce the risk of dislocation compared to SB-THA by at least 62%. Probabilistic sensitivity analysis showed DM-THA was 58% likely to be cost-effective in the base case. CONCLUSION: Treating patients with a displaced femoral neck fracture using DM-THA components may be cost-effective compared to SB-THA in patients aged under 80 years. However, future research will help determine if the modelled rates of adverse events hold true. Surgeons should continue to use clinical judgement and consider individual patients' physiological age and risk factors for dislocation. Cite this article: Bone Joint J 2021;103-B(12):1783-1790.

Single-use negative pressure wound therapy reduces costs in closed surgical incisions: UK and US economic evaluation.

OBJECTIVE: Single-use negative pressure wound therapy (sNPWT) following closed surgical incisions has a demonstrable effect in reducing surgical site complications (SSC). However, there is little health economic evidence to support its widespread use. We sought to evaluate the cost-effectiveness of sNPWT compared with standard care in reducing SSCs following closed surgical incisions. METHOD: A decision analytic model was developed to explore the total costs and health outcomes associated with the use of the interventions in patients following vascular, colorectal, cardiothoracic, orthopaedic, C-section and breast surgery from the UK National Health Service (NHS) and US payer perspective over a 12-week time horizon. We modelled complications avoided (surgical site infection (SSI) and dehiscence) using data from a recently published meta-analysis. Cost data were sourced from published literature, NHS reference costs and Centers for Medicare and Medicaid Services. We conducted subgroup analysis of patients with diabetes, an American Society of Anesthesiologists (ASA) score ≥3 and body mass index (BMI) ≥30kg/m2. A sensitivity analysis was also conducted. RESULTS: sNPWT resulted in better clinical outcomes and overall savings of £105 per patient from the UK perspective and $637 per patient from the US perspective. There were more savings when higher-risk patients with diabetes, or a BMI ≥30kg/m2 or an ASA≥3 were considered. We conducted both one-way and probabilistic sensitivity analysis, and the results suggested that this conclusion is robust. CONCLUSION: Our findings suggest that the use of sNPWT following closed surgical incisions saves cost when compared with standard care because of reduced incidence of SSC. Patients at higher risk should be targeted first as they benefit more from sNPWT. This analysis is underpinned by strong and robust clinical evidence from both randomised and observational studies.

An economic analysis of a wearable patient sensor for preventing hospital-acquired pressure injuries among the acutely ill patients.

More than 2.5 million people in the United States develop pressure injuries annually, which are one of the most common complications occurring in hospitals. Despite being common, hospital-acquired pressure injuries (HAPIs) are largely considered preventable by regular patient turning. Although current methodologies to prompt on-time repositioning have limited efficacy, a wearable patient sensor has been shown to optimize turning practices and improve clinical outcomes. The purpose of this study was to assess the cost-effectiveness of patient-wearable sensor in the prevention of HAPIs in acutely ill patients when compared to standard practice alone. A decision analytic model was developed to simulate the expected costs and outcomes from the payer's perspective using data from published literature, including a recently published randomized controlled trial. Both univariate and probabilistic sensitivity analysis were conducted. The patient-wearable sensor was found to be cost saving (dominant). It resulted in better clinical outcomes (77% reduction in HAPIs) compared to standard care and an expected cost savings of $6,621 per patient over a one-year period. Applying the model to a cohort of 1,000 patients, an estimated 203 HAPIs would be avoided with annualized cost reduction of $6,222,884 through all patient treatment settings. The probabilistic analysis returned similar results. In conclusion, the patient-wearable sensor was found to be cost-effective in the prevention of HAPIs and cost-saving to payers and hospitals. These results suggest that patient-wearable sensors should be considered as a cost-effective alternative to standard care in the prevention of HAPIs.

Cost-effectiveness analysis of Coblation versus mechanical shaver debridement in patients following knee chondroplasty.

BACKGROUND: To compare costs and outcomes following knee chondroplasty with Coblation versus mechanical shaver debridement (MSD) in patients with grade III articular cartilage lesions of the knee. METHODS: A decision-analytic model was developed to compare costs and outcomes of the two methods from a US payer perspective. We used published clinical data from a single-center randomized clinical trial (RCT) designed to compare outcomes between Coblation and MSD in patients with grade III articular cartilage lesions of the medial femoral condyle. Following primary knee chondroplasty, patients experienced either treatment success (no additional surgery required) or required a revision over the 4 year follow-up period. Costs associated with the initial chondroplasty, physical therapy sessions through the 6 week postoperative period, and revision rates at 4 years post-surgery were estimated using 2018 US Medicare Physician Fee Schedule. Sensitivity analyses including a 10 year time horizon and threshold analyses were performed to test the robustness of the model. RESULTS: The estimated total cost per patient was $4614 and $7886 for Coblation and MSD, respectively, resulting in cost-savings of $3272 in favor of Coblation, making it a dominant strategy because of lower costs and improved clinical outcomes. Threshold analysis showed that Coblation remained dominant even when revision rates were assumed to increase from the base case rate of 14-66%. Sensitivity analyses showed that cost-saving results were insensitive to variations in revision rates, number of physical therapy sessions and the time horizon used. CONCLUSION: Coblation chondroplasty is a cost-saving procedure compared with MSD in the treatment of patients with grade III articular cartilage lesions of the knee.

A cost-effectiveness assessment of dual-mobility bearings in revision hip arthroplasty.

AIMS: The rate of dislocation when traditional single bearing implants are used in revision total hip arthroplasty (THA) has been reported to be between 8% and 10%. The use of dual mobility bearings can reduce this risk to between 0.5% and 2%. Dual mobility bearings are more expensive, and it is not clear if the additional clinical benefits constitute value for money for the payers. We aimed to estimate the cost-effectiveness of dual mobility compared with single bearings for patients undergoing revision THA. METHODS: We developed a Markov model to estimate the expected cost and benefits of dual mobility compared with single bearing implants in patients undergoing revision THA. The rates of revision and further revision were calculated from the National Joint Registry of England and Wales, while rates of transition from one health state to another were estimated from the literature, and the data were stratified by sex and age. Implant and healthcare costs were estimated from local procurement prices and national tariffs. Quality-adjusted life-years (QALYs) were calculated using published utility estimates for patients undergoing THA. RESULTS: At a minimum five-year follow-up, the use of dual mobility was cost-effective with an estimated incremental cost-effectiveness ratio (ICER) of between £3,006 and £18,745/QALY for patients aged < 55 years and between 64 and 75 years, respectively. For those aged > 75 years dual mobility was only cost-effective if the timeline was beyond seven years. The use of dual mobility bearings was cost-saving for patients aged < 75 years and cost-effective for those aged > 75 years if the time horizon was beyond ten years. CONCLUSION: The use of dual mobility bearings is cost-effective compared with single bearings in patients undergoing revision THA. The younger the patient is, the more likely it is that a dual mobility bearing can be more cost-effective and even cost-saving. The results are affected by the time horizon and cost of bearings for those aged > 75 years. For patients aged > 75 years, the surgeon must decide whether the use of a dual mobility bearing is a viable economic and clinical option. Cite this article: Bone Joint J 2020;102-B(9):1128-1135.

Early Economic Evaluation Demonstrates That Noncomputerized Tomography Robotic-Assisted Surgery Is Cost-Effective in Patients Undergoing Unicompartmental Knee Arthroplasty at High-Volume Orthopaedic Centres.

BACKGROUND: For over fifty years, unicompartmental knee arthroplasty (UKA) has been used to treat single-compartment osteoarthritis of the knee and is considered a safe alternative to total knee arthroplasty (TKA). The development and use of robotic-assisted surgery (r-UKA) have made the execution of the procedure more precise, and various studies have reported improved radiographic outcomes and implant survival rates; however, its cost-effectiveness is unknown. This study aimed at assessing the cost-effectiveness of noncomputerized tomography (non-CT) r-UKA compared to the traditional unicompartmental knee arthroplasty (t-UKA) method in patients with unicompartmental knee osteoarthritis from the UK payer's perspective. METHODS: We developed a 5-year four-state Markov model to evaluate the expected costs and outcomes of the two strategies in patients aged 65 years. Failure rates for t-UKA were taken from the British National Joint Registry while data for non-CT r-UKA were obtained from a 2-year observational study. Cost was obtained from the NHS reference cost valued at 2018/19 GBP£, and a discount rate of 3.5% was applied to both costs and benefits. RESULTS: For a high-volume orthopaedic centre that performs 100 UKA operations per year, non-CT r-UKA was more costly than t-UKA but offered better clinical outcomes, and the estimated cost per QALY was £2,831. The results were more favourable in younger patients aged less than 55 and sensitive to case volumes and follow-up period. CONCLUSION: Non-CT r-UKA is cost-effective compared with t-UKA over a 5-year period. Results are dependent on case volumes and follow-up period and favour younger age groups.

Cost-effectiveness analysis of single use negative pressure wound therapy dressings (sNPWT) compared to standard of care in reducing surgical site complications (SSC) in patients undergoing coronary artery bypass grafting surgery.

BACKGROUND: There is a growing interest in using negative pressure wound therapy in closed surgical incision to prevent wound complications which continue to persist following surgery despite advances in infection measures. OBJECTIVES: To estimate the cost-effectiveness of single use negative pressure wound therapy (sNPWT) compared to standard of care in patients following coronary artery bypass grafting surgery (CABG) procedure to reduce surgical site complications (SSC) defined as dehiscence and sternotomy infections. METHOD: A decision analytic model was developed from the Germany Statutory Health Insurance payer's perspective over a 12-week time horizon. Baseline data on SSC, revision operations, length of stay, and readmissions were obtained from a prospective observational study of 2621 CABG patients in Germany. Effectiveness data for sNPWT was taken from a randomised open label trial conducted in Poland which randomised 80 patients to treatment with either sNPWT or standard care. Cost data (in Euros) were taken from the relevant diagnostic related groups and published literature. RESULTS: The clinical study reported an increase in wounds that healed without complications 37/40 (92.5%) in the sNPWT compared to 30/40 (75%) patients in the SC group p = 0.03. The model estimated sNPWT resulted in 0.989 complications avoided compared to 0.952 and the estimated quality adjusted life years were 0.8904 and 0.8593 per patient compared to standard care. The estimated mean cost per patient was €19,986 for sNPWT compared to €20,572 for SC resulting in cost-saving of €586. The findings were robust to a range of sensitivity analyses. CONCLUSION: The sNPWT can be considered a cost saving intervention that reduces surgical site complications following CABG surgery compared to standard care. We however recommend that additional economic studies should be conducted as new evidence on the use of sNPWT in CABG patients becomes available to validate the results of this economic analysis.

Comparing the costs and outcomes of an integrated twin compression screw (ITCS) nail with standard of care using a single lag screw or a single helical blade cephalomedullary nail in patients with intertrochanteric hip fractures.

BACKGROUND: Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows for early rehabilitation and functional recovery. The purpose of the study was to assess the cost-effectiveness of commonly used cephalomedullary nails for the treatment of unstable intertrochanteric hip fractures. METHODS: A decision analytic model was developed from a US payer's perspective using clinical data from a pairwise meta-analysis of randomised controlled trials (RCTs) and comparative observational studies comparing the integrated twin compression screw (ITCS) nail versus two single-screw or blade cephalomedullary nails [single lag screw (SLS) nail and single helical blade (SHB) nail]. The model considered a cohort of 1000 patients with a mean age of 76, as reported in the clinical studies over a 1-year time period. Cost data was obtained from the Center for Medicare and Medicaid Services website and published literature and adjusted for inflation. One-way and probabilistic sensitivity analyses were conducted to assess the effect of uncertainty in model parameters on model conclusions. RESULTS: The model estimated 0.546 quality-adjusted life years (QALYs) and 0.78 complications avoided by using the ITCS nail and 0.455 QALYs and 0.67 complications avoided for the standard of care, using SLS or SHB nails. The cost per patient was $34,336 for patients treated with an ITCS nail and $37,036 for patients treated with the standard of care respectively, resulting in a cost saving of $2700 in favour of the ITCS nail. More savings were observed when the ITCS nail was compared to the SHB ($3280 per patient) and SLS ($1652 per patient). The findings were robust to a range of both one-way and the probabilistic sensitivity analyses. CONCLUSION: In conclusion, the ITCS nail can be considered a cost saving intervention in patients undergoing intertrochanteric fracture fixation with an intramedullary device. Clinicians and policy makers should be encouraged to adopt healthcare technologies such as ITCS that will help them to provide quality healthcare despite falling budgets.

Comparison of a twin interlocking derotation and compression screw cephalomedullary nail (InterTAN) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric fractures.

BACKGROUND: Intertrochanteric hip fractures are common and devastating injuries especially for the elderly. Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows early rehabilitation and functional recovery. The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain limited to relatively small studies which create uncertainty in attempts to establish evidence-based best practice. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies to assess the clinical effectiveness of two commonly used intramedullary devices: a twin screw integrated cephalomedullary nail (InterTAN) versus a single screw cephalomedullary nail (proximal femoral nail antirotation) in patients with intertrochanteric fractures. The following outcomes were considered: revisions, implant-related failures, non-unions, pain, Harris Hip Score and intraoperative outcomes. Odds ratios or mean differences with 95% confidence intervals in brackets are reported. RESULTS: Six studies met the inclusion criteria, two randomised controlled trials and four observational studies enrolling 970 patients with mean age of 77 years, and 64% of patients were female. There was a statistically significant difference (p value < 0.05) for revisions OR 0.27 (0.13 to 0.56), implant-related failures OR 0.16 (0.09 to 0.27) and proportion of patients complaining of pain OR 0.50 (0.34 to 0.74). There was no difference in non-unions and Harris Hip Score (p value > 0.05). There was a significant difference in blood loss and fluoroscopy usage in favour of PFNA, whilst no difference in operating times were observed between the two devices. CONCLUSIONS: Our meta-analysis suggests that a twin screw integrated cephalomedullary nail InterTAN is clinically more effective when compared to a single screw cephalomedullary nail proximal femoral nail antirotation resulting in fewer complications, fewer revisions and fewer patients complaining of pain. No difference has been established regarding non-unions and Harris Hip Score. Intraoperative outcomes favour PFNA with less blood loss and fluoroscopy usage. Further studies are warranted to explore the cost-effectiveness of these and other implants in managing patients with intertrochanteric fractures.

Cost-effectiveness Analysis of Silver Delivery Approaches in the Management of Partial-thickness Burns.

INTRODUCTION: Burn injury is a common type of traumatic injury that causes considerable morbidity and mortality, resulting in about 30,000 admissions annually in specialist burn centers and costing around $1 billion per year in the United States. One percent silver sulfadiazine has been utilized widely in the management of burns and newer silver dressings are on the market, including nanocrystalline silver dressings, silver-impregnated hydrofiber dressings, and silver-impregnated foam dressings. OBJECTIVE: This study sought to determine the cost effectiveness of the newer silver dressings using clinical data from an indirect treatment comparison using silver sulfadiazine as the baseline. MATERIALS AND METHODS: A decision analytic model was developed from a US payer's perspective for burn patients with a total body surface area of < 20%. Outcomes were length of stay, infections and incidence of surgical procedures, quality adjusted life years (QALYs), and cost. RESULTS: The meta-analysis reported a statistically significant reduction in length of hospital stay and clinically important reductions in infections and incidence of surgical procedures in favor of the silver barrier dressing compared with other silver dressings. The estimated QALYs were 0.970 versus 0.969 versus 0.969 and mean cost per patient was $15,892, $23,799, and $24,269 for the nanocrystalline silver dressing, silver-impregnated hydrofiber dressing, and silver-impregnated foam dressing, respectively. The analysis showed the nanocrystalline silver dressing to be a dominant strategy (less costly with better outcomes). These findings were robust to a range of sensitivity analyses. CONCLUSIONS: According to data from an indirect treatment comparison, this analysis suggests that nanocrystalline silver dressing is the most cost-effective silver delivery system. Prospective head-to-head research on the costs and outcomes of these silver delivery systems in this patient population is necessary to validate the results of this economic evaluation.

Silver delivery approaches in the management of partial thickness burns: A systematic review and indirect treatment comparison.

Silver-containing products play an important role in the management of burn wound infections. We sought to compare the efficacy of commonly used silver delivery approaches including nanocrystalline silver, silver-impregnated hydrofiber dressing, and silver-impregnated foam dressing as the main products in the management of partial thickness burns. A systematic review was performed by searching PubMed, EMBASE, Cochrane, and other databases to identify relevant randomized controlled trials and observational studies. Due to the paucity of direct head-to-head trials, an indirect treatment comparison was performed. The use of nanocrystalline silver was associated with a statistically significant reduction in length of stay when compared to silver-impregnated hydrofiber dressing (p = 0.027) and a shorter time to healing when compared to silver-impregnated foam dressing (p = 0.0328). There were no statistically significant differences in infection rates and surgical procedures between nanocrystalline silver, silver-impregnated hydrofiber dressing, and silver-impregnated foam dressing; however, nanocrystalline silver was found to be the most beneficial for all the outcomes, including infection rates and surgical procedures, according to the Monte Carlo simulation method. In conclusion, current evidence from the published literature suggests that where the clinical and microbiological priority is to get in control of infection quickly it would seem prudent to use the most potent silver delivery system, which is nanocrystalline silver. Nanocrystalline silver may offer both clinical and economic benefits compared to alternative treatments in the management of patients with mixed burns that are at high risk of infection.

Cost-effectiveness analysis of single-use negative pressure wound therapy dressings (sNPWT) to reduce surgical site complications (SSC) in routine primary hip and knee replacements.

We sought to evaluate the cost-effectiveness of single-use negative pressure wound therapy in patients undergoing primary hip and knee replacements using effectiveness data from a recently completed non-blinded randomized controlled trial. A decision analytic model was developed from UK National Health Service perspective using data from a single-centre trial. 220 patients were randomized to treatment with either single-use negative pressure wound therapy or standard care i.e., film dressings of clinician choice and followed for 6 weeks. Outcomes included dressing changes, length of stay, surgical site complications, cost and quality adjusted life years. The randomized controlled trial reported a reduction in dressing changes (p = 0.002), SSC (p = 0.06) and LOS (p = 0.07) in favor of single-use negative pressure wound therapy compared with standard care. The model estimated 0.116 and 0.115 QALY gained, 0.98 and 0.92 complications avoided for single-use negative pressure wound therapy and standard care, respectively. The cost/patient was £5,602 ($7,954) and £6,713 ($9,559) for single-use negative pressure wound therapy and standard care respectively resulting in cost-saving of £1,132 ($1,607) in favor of single-use negative pressure wound therapy. Greater savings were observed in subgroups of higher risk patients with BMI ≥ 35 and ASA ≥ 3 i.e., £7,955 ($11,296) and £7,248 ($10,293), respectively. The findings were robust to a range of sensitivity analyses. In conclusion, single-use negative pressure wound therapy can be considered a cost saving intervention to reduce surgical site complications following primary hip and knee replacements compared with standard care. Providers should consider targeting therapy to those patients at elevated risk of surgical site complications to maximize efficiency.