The Cost-Effectiveness of Computer-Assisted Compared with Conventional Total Knee Arthroplasty: A Payer's Perspective.

BACKGROUND: Recent evidence showing that computer-assisted total knee arthroplasty (TKA) is associated with better outcomes compared with conventional TKA for patients with end-stage knee osteoarthritis has not been included in economic evaluations of computer-assisted TKA, which are needed to support coverage decisions. This study evaluated the cost-effectiveness of computer-assisted TKA from a payer's perspective, incorporating recent evidence. METHODS: We compared computer-assisted TKA with conventional TKA with regard to costs (in 2022 U.S. dollars) and quality-adjusted life-years (QALYs) using Markov models for elderly patients (≥65 years of age) and patients who were not elderly (55 to 64 years of age). Costs and QALYs were estimated in the lifetime for elderly patients and in the short term for patients who were not elderly, under a bundled payment program and a Fee-for-Service program. Transition probabilities, costs, and QALYs were retrieved from the literature, a national knee arthroplasty registry, and the National Center for Health Statistics. Threshold and probabilistic sensitivity analyses were conducted to examine the robustness of key estimates used in the base-case analysis. Using projected estimates of TKA utilization, the total cost savings of performing computer-assisted TKA rather than conventional TKA were estimated. RESULTS: Compared with conventional TKA, computer-assisted TKA was associated with higher QALYs and lower costs for both elderly patients and patients who were not elderly, regardless of payment programs, making computer-assisted TKA a favorable treatment option. Widespread adoption of computer-assisted TKA in all U.S. patients would result in an estimated total cost saving of $1 billion for payers. CONCLUSIONS: Compared with conventional TKA, computer-assisted TKA reduces costs to payers while providing favorable outcomes. Payers may consider providing additional payment incentives to providers for performing computer-assisted TKA, to achieve outcome improvement and cost control by facilitating widespread adoption of computer-assisted TKA. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence.

Disparities in Telemedicine Use Among Children Seen in Surgical Clinics During the COVID-19 Pandemic: Experience of One Tertiary Care Freestanding Children's Hospital.

Background: Telemedicine use dramatically increased during the COVID-19 pandemic. However, the effects of telemedicine on pre-existing disparities in pediatric surgical access have not been well described. We describe our center's early experience with telemedicine and disparities in patients' access to outpatient surgical care. Methods: A retrospective study of outpatient visits within all surgical divisions from May to December 2020 was conducted. We assessed the rates of scheduled telemedicine visits during that period, as well as the rate of completing a visit after it has been scheduled. Descriptive and logistic regression analyses were used to test for associations between these rates and patient characteristics. Results: Over the study period, 109,601 visits were scheduled. Telemedicine accounted for 6.1% of all visits with lower cancellation rates than in-person visits (26.9% vs. 34.7%). More scheduled telemedicine encounters were observed for older patients, White, English speakers, those with private insurance, and those living in rural areas. Lower odds of telemedicine visit completion were observed among patients with public insurance (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.64-0.77), Spanish language preference (OR 0.84, 95% CI 0.72-0.97), and those living in rural areas (OR 0.73, 95% CI 0.64-0.84). In contrast, higher odds of telemedicine visit completion were associated with a higher Social Deprivation Index score (OR 1.41, 95% CI 1.27-1.58). Telemedicine visit completion was also associated with increasing community-level income and distance from the hospital. Conclusions: Telemedicine use for outpatient surgical care was generally low during the peak of the pandemic, and certain populations were less likely to utilize it. These findings call for further action to bridge gaps in telemedicine use.

Cost-effectiveness of Early Screening Home Semen Analysis in Couples Attempting to Conceive.

OBJECTIVE: To study the cost-effectiveness of incorporating home semen analysis in screening for oligospermia and expediting time to evaluation. METHODS: A decision analytic model was built using inputs from the medical literature. The index patient is the male partner in a couple seeking fertility, and entry into the model was assumed to be at the inception of the couple's attempts to conceive via natural means. Three main strategies are described and analyzed: (1) baseline strategy of no testing, (2) utilization of a home semen testing kit, (3) universal testing via a clinic visit and gold standard lab semen analysis. The primary outcome was detection of oligospermia (defined as sperm concentration <15 million/mL). Strategies were ranked by months to evaluation by a male infertility specialist saved. Costs were considered from the patient perspective and were incorporated to determine the incremental cost per month saved to evaluation (ICMS) per 100,000 patients. RESULTS: Compared to a baseline strategy of no screening, utilizing a home test would save 89,000 months at the incremental cost of $7,418,000 for an ICMS of $45.51. Shifting to a strategy of universal gold standard clinic and lab testing saves an additional 3000 months but at an ICMS of $17,691 compared to the home testing strategy. CONCLUSION: Widespread adoption and the early usage of home semen analysis may be a cost-effective method of screening for oligospermia and facilitating further evaluation with an andrology specialist.

Revisiting Short-term Outcomes of Conventional and Computer-Assisted Total Knee Arthroplasty: A Population-based Study.

BACKGROUND: Population-based studies showing the advantage of computer-assisted total knee arthroplasty (CATKA) over conventional total knee arthroplasty (TKA) are outdated. More recent institution-based studies with relatively small sample sizes may hinder wider adoption. This cohort-based study aimed to compare postoperative CATKA and TKA in-hospital complications and 90-day all-cause readmissions using 2017-2018 data. METHODS: Patients who underwent a primary unilateral CATKA or TKA were identified in the New York Statewide Planning and Research Cooperative System database. In-hospital complications were defined based on the 2020 Centers for Medicare & Medicaid Services total hip arthroplasty and TKA complications measure. Ninety-day readmissions were identified using unique patient identifiers. Logistic regression with a generalized estimating equation was used to assess associations of computer assistance with in-hospital complications and 90-day all-cause readmissions. RESULTS: A total of 80,468 TKAs were identified during the study period, of which 7,395 (9.2%) were CATKAs. Significantly fewer complications occurred among patients who had CATKAs compared with conventional TKAs (0.4% of total CATKAs vs 2.6% of total conventional TKAs, P < 0.001); patients who had CATKAs had fewer 90-day all-cause readmissions compared with those who underwent TKAs (363 vs 4,169 revisits, P < 0.01). Computer assistance was associated with significantly lower odds of in-hospital complications (odds ratio, 0.15, 95% confidence interval, 0.09 to 0.24; P < 0.05) but not 90-day all-cause readmissions. CONCLUSION: Patients undergoing CATKAs had markedly lower odds of in-hospital complications, compared with patients having TKAs, which has implications for both patient outcomes and hospital reimbursement. These more recent cohort-based findings encourage wider CATKA adoption.

Utilization Trends and Disparities in Adolescent Bariatric Surgery in the United States 2009-2017.

Background: Current reports of adolescent bariatric surgery underutilization for treating severe obesity do not comprehensively assess the extent of existing disparities. We sought to describe national trends in adolescent bariatric surgery over a 9-year period and investigate previously described ethnoracial-, insurance-, income-, and geographic-based disparities. Methods: A cross-sectional analysis of adolescents aged 10-19 years who underwent bariatric surgery from 2009 to 2017 was conducted using Healthcare Cost and Utilization Kids' Inpatient Database and National Inpatient Sample Databases. Annual rates and types of bariatric surgery were assessed using trend analysis and stratified by patient, hospital, and regional characteristics. Results: The rate of bariatric surgeries per 1,000,000 adolescents with severe obesity increased over time (227 cases in 2009 to 331cases in 2017). Roux-en-Y gastric bypass and gastric band significantly decreased (p < 0.001), while sleeve gastrectomy became the most commonly performed bariatric surgery (p < 0.001). Surgeries were increasingly performed in urban teaching hospitals (77.9%) and most commonly in the Northeast (34.4%) and South (40.9%). The proportion of black patients (12.1%-15.8%) undergoing bariatric surgery increased, although was not significant and remained below that of white patients (p = 0.06). The proportion of publicly insured patients undergoing bariatric surgery significantly increased (17.0% to 30.7%, p < 0.001), although no changes were observed based on median household income. Conclusions: Over the study period, utilization of adolescent bariatric surgery has increased. Yet, vulnerable populations, who have the highest rates of severe obesity, continue to undergo bariatric surgery at disproportionately lower rates. Further efforts to address disparities and barriers to care are urgently needed to care for these children.

Impact of the Affordable Care Act's Medicaid expansion on tertiary pediatric surgical care.

BACKGROUND: Many children gained insurance with the 2014 Affordable Care Act's (ACA) Medicaid Expansion (ME), yet its impact on access to pediatric tertiary surgical care remains unknown. We examined the effect of ME on rates of elective, ambulatory surgery (EAS), especially among publicly-insured and ethnoracial-minority patients. METHODS: Surgical patients ≤18 years between 2012 and 2018 were identified using the Pediatric Health Information System. Interrupted time series analyses were conducted to predict the monthly proportion of publicly-insured patients and EAS rates in ME and nonexpansion states. RESULTS: 3,270,842 patients were included. Nonexpansion states demonstrated a 1.10% (p<0.05) increase in the proportion of publicly-insured patients at ACA implementation, which then plateaued. No immediate change was observed in ME states, but there was an annual 1.08% (p<0.01) decrease in subsequent years. Publicly-insured EAS rates decreased by 1.09% (p<0.01) in nonexpansion states; no change was observed in ME states. A 3.36% (p<0.01) increase in EAS rates was observed in nonexpansion and ME states. The gap in EAS rates increased between private and publicly-insured patients in nonexpansion, but not ME states. CONCLUSIONS: Increased coverage for children in ME states was not associated with more access to tertiary pediatric surgical care; however, while nonexpansion states saw an increase in insurance-based disparities, ME states did not. Though insurance coverage is critical to access, other factors may be contributing to persistent disparities in access to pediatric surgical care.

Trends in Practice Patterns of Conventional and Computer-assisted Knee Arthroplasty: An Analysis of 570,671 Knee Arthroplasties Between 2010 and 2017.

BACKGROUND: Despite advances in computer-assisted knee arthroplasty (CAKA), little is known about the uptake of this technology in recent years. We aimed to explore the utilization trends and practice variation of CAKA from 2010 to 2017 and investigate the predictors of CAKA adoption. METHODS: Patients undergoing conventional knee arthroplasty and CAKA were identified from the states of New York and Florida's administrative databases using the International Classification of Diseases version 9 and 10 procedure codes. Quarterly proportions of CAKA were calculated over the study period, and logistic regression was used to estimate predictors of CAKA utilization. RESULTS: Between 2010 and 2017, quarterly proportion of CAKAs increased from 4.89% in 2010Q1 to 9.45% in 2017Q3 in New York and from 4.03% in 2010Q1 to 5.73% in 2017Q3 in Florida. The general CA code was used to code most of the procedures (81%). Being Black (odds ratio [OR]: 0.63, 95% confidence interval [CI], 0.60 to 0.67), Hispanic (OR: 0.45, CI, 0.41 to 0.50), and having Medicaid coverage (OR: 0.46, CI, 0.40 to 0.53) were associated with lower likelihood of receiving CAKA in New York; similar findings were found in Florida. CONCLUSION: Utilization of CAKA has increased substantially in both New York and Florida from 2010 to 2017; however, with most CAKAs reported using the general code, understanding adoption rates of various modalities was not possible. Black and Hispanic patients and those with Medicaid insurance are least likely to receive this high-precision technology, illustrating the presence of disparities in the adoption of CAKA.

Real World Performance of Sacral Neuromodulation and OnabotulinumtoxinA for Overactive Bladder: Focus on Safety and Cost.

PURPOSE: We aimed to determine the real world safety and cost of third line overactive bladder therapies, including onabotulinumtoxinA and sacral neuromodulation. MATERIALS AND METHODS: We performed an all-inclusive, population based cohort study of third line therapies of overactive bladder (sacral neuromodulation or onabotulinumtoxinA) using the statewide surgical data captured in the New York Statewide Planning and Research Cooperative System. The main outcome measures were 30-day safety events, and 1 and 3-year health care utilization costs. Propensity score matching was done to control for confounding factors and comparative analyses of safety events were also performed. RESULTS: Our cohort included 2,680 patients, of whom 1,328 underwent sacral neuromodulation and 1,352 received onabotulinumtoxinA from January 1, 2013 through December 31, 2016. Average ± SD age was 61.7 ± 16.3 years and 82.7% of the patients were female. Sacral neuromodulation implantation led to re-intervention in 15.8% of cases within 1 year and in 26.1% at 3 years. In this comparative analysis patients who received onabotulinumtoxinA therapy were at higher risk for urinary tract infection, hematuria, urinary retention and an emergency room visit compared to those treated with sacral neuromodulation. The overall cost of onabotulinumtoxinA was lower than the cost of the sacral neuromodulation device (cost at 1 year $2,896 vs $15,343 and at 3 years $3,454 vs $16,189, each p <0.01). CONCLUSIONS: Sacral neuromodulation implantation was more expensive than onabotulinumtoxinA injection. However, patients who underwent sacral neuromodulation had a lower complication rate than patients treated with onabotulinumtoxinA. A quality improvement collective database must be created to track information on onabotulinumtoxinA and sacral neuromodulation treatment. This would help generate better performance and comparative data for patient and physician decision making.

An umbrella review comparing computer-assisted and conventional total joint arthroplasty: quality assessment and summary of evidence.

BACKGROUND: Systematic reviews (SRs) of computer-assisted (CA) total knee arthroplasty (TKA) and total hip arthroplasty (THA) report conflicting evidence on its superiority over conventional surgery. Little is known about the quality of these SRs; variability in their methodological quality may be a contributing factor. We evaluated the methodological quality of all published SRs to date, summarized and examined the consistency of the evidence generated by these SRs. METHODS: We searched four databases through December 31, 2018. A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2) was applied to assess the methodological quality. Evidence from included meta-analyses on functional, radiological and patient-safety outcomes was summarized. The corrected covered area was calculated to assess the overlap between SRs in including the primary studies. RESULTS: Based on AMSTAR 2, confidence was critically low in 39 of the 42 included SRs and low in 3 SRs. Low rating was mainly due to failure in developing a review protocol (90.5%); providing a list of excluded studies (81%); accounting for risk of bias when discussing the results (67%); using a comprehensive search strategy (50%); and investigating publication bias (50%). Despite inconsistency between SR findings comparing functional, radiological and patient safety outcomes for CA and conventional procedures, most TKA meta-analyses favored CA TKA, whereas most THA meta-analyses showed no difference. Moderate overlap was observed among TKA SRs and high overlap among THA SRs. CONCLUSIONS: Despite conclusions of meta-analyses favoring CA arthroplasty, decision makers adopting this technology should be aware of the low confidence in the results of the included SRs. To improve confidence in future SRs, journals should consider using a methodological assessment tool to evaluate the SRs prior to making a publication decision.

Cost-Effectiveness of Surgical and Nonsurgical Treatments for Unicompartmental Knee Arthritis: A Markov Model.

BACKGROUND: There has been increased utilization of surgical options for the treatment of end-stage unicompartmental arthritis in patients at both extremes of the age spectrum. The purpose of this study was to determine how these changing paradigms affected the lifetime cost-effectiveness of total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and nonsurgical treatment (NST). METHODS: Using a Markov decision analytic model, we assessed how lifetime costs and quality-adjusted life years (QALYs) vary as a function of age at the time of initial treatment (ATIT) of patients with end-stage unicompartmental knee osteoarthritis undergoing TKA, UKA, and NST. Separate models were estimated for ATITs at 5-year intervals from 40 through 90 years. Direct medical costs, QALYs, and transition probabilities were determined from the published literature. Indirect costs (lost wages, Social Security disability collections, and value of missed workdays) were calculated. Cost-effectiveness and incremental cost-effectiveness ratios (ICERs) were calculated for each treatment at each ATIT. The model assumed no crossover from NST to UKA or TKA. ICERs were compared with a willingness-to-pay threshold of 50,000 U.S. dollars, and a 1-way sensitivity analysis was used to assess the robustness of ICER-based treatment decisions. Societal savings were estimated. RESULTS: In the base-case model, surgical treatments were less expensive and provided a greater number of QALYs than NST from 40 to 69 years of age. From 70 years of age and onward, surgical treatments remained cost-effective compared with NST, with ICERs remaining below the societal willingness-to-pay threshold. When surgical treatments were compared, UKA dominated TKA for all ATITs. The preferential use of UKA in all U.S. patients with unicompartmental osteoarthritis would result in an estimated lifetime societal savings of 987 million to 1.5 billion U.S. dollars per annual wave of patients undergoing treatment. CONCLUSIONS: In this preliminary assessment, recent expansion of surgical treatments into younger and older age demographics appears to be cost-effective in the setting of unicompartmental knee osteoarthritis. Our findings suggest that NST should be used sparingly in patients below the age of 70 years and UKA should be chosen over TKA in order to maximize cost-effectiveness. LEVEL OF EVIDENCE: Economic and decision analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Physician referral patterns and racial disparities in total hip replacement: A network analysis approach.

BACKGROUND: Efforts to reduce racial disparities in total hip replacement (THR) have focused mainly on patient behaviors. While these efforts are no doubt important, they ignore the potentially important role of provider- and system-level factors, which may be easier to modify. We aimed to determine whether the patterns of interaction among physicians around THR episodes differ in communities with low versus high concentrations of black residents. MATERIALS AND METHODS: We analyzed national Medicare claims from 2008 to 2011, identifying all fee-for-service beneficiaries who underwent THR. Based on physician encounter data, we then mapped the physician referral networks at the hospitals where beneficiaries' procedures were performed. Next, we measured two structural properties of these networks that could affect care coordination and information sharing: clustering, and the number of external ties. Finally, we estimated multivariate regression models to determine the relationship between the concentration of black residents in the community [as measured by the hospital service area (HSA)] served by a given network and each of these 2 network properties. RESULTS: Our sample included 336,506 beneficiaries (mean age 76.3 ± SD), 63.1% of whom were women. HSAs with higher concentrations of black residents tended to be more impoverished than those with lower concentrations. While HSAs with higher concentrations of black residents had, on average, more acute care beds and medical specialists, they had fewer surgeons per capita than those with lower concentrations. After adjusting for these differences, we found that HSAs with higher concentrations of black residents were served by physician referral networks that had significantly higher within-network clustering but fewer external ties. CONCLUSIONS: We observed differences in the patterns of interaction among physicians around THR episodes in communities with low versus high concentrations of black residents. Studies investigating the impact of these differences on access to quality providers and on THR outcomes are needed.

Cost-effectiveness of Common Diagnostic Approaches for Evaluation of Asymptomatic Microscopic Hematuria.

Importance: Asymptomatic microscopic hematuria (AMH) is highly prevalent and may signal occult genitourinary (GU) malignant abnormality. Common diagnostic approaches differ in their costs and effectiveness in detecting cancer. Given the low prevalence of GU malignant abnormality among patients with AMH, it is important to quantify the cost implications of detecting cancer for each approach. Objective: To estimate the effectiveness, costs, and incremental cost per cancer detected (ICCD) for 4 common diagnostic approaches evaluating AMH. Design, Setting, and Participants: A decision-analytic model-based cost-effectiveness analysis using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included adult patients with AMH on routine urinalysis with subgroups of high-risk patients (males, smokers, age ≥50 years) seen in the primary care or urologic referral setting. Interventions: Four diagnostic approaches were evaluated relative to the reference case of no evaluation: (1) computed tomography (CT) alone; (2) cystoscopy alone; (3) CT and cystoscopy combined; and (4) renal ultrasound and cystoscopy combined. Main Outcomes and Measures: At termination of the diagnostic period, cancers detected, costs (payer perspective), and ICCD per 10 000 patients evaluated for AMH. Results: Of the 4 diagnostic approaches analyzed, CT alone was dominated by all other strategies, detecting 221 cancers at a cost of $9 300 000. Ultrasound and cystoscopy detected 245 cancers and was most cost-effective with an ICCD of $53 810. Replacing ultrasound with CT detected just 1 additional cancer at an ICCD of $6 480 484. Ultrasound and cystoscopy remained the most cost-effective approach in subgroup analysis. The model was not sensitive to any inputs within the proposed ranges. Using probabilistic sensitivity analysis, ultrasound and cystoscopy was the dominant strategy in 100% of simulations. Conclusions and Relevance: The combination of renal ultrasound and cystoscopy is the most cost-effective among 4 diagnostic approaches for the initial evaluation of AMH. The use of ultrasound in lieu of CT as the first-line diagnostic strategy will optimize cancer detection and reduce costs associated with evaluation of AMH. Given our findings, we need to critically evaluate the appropriateness of our current clinical practices, and potentially alter our guidelines to reflect the most effective screening strategies for patients with AMH.

Cost-Effectiveness of Staphylococcus aureus Decolonization Strategies in High-Risk Total Joint Arthroplasty Patients.

BACKGROUND: The risk of prosthetic joint infection increases with Staphylococcus aureus colonization. The cost-effectiveness of decolonization is controversial. We evaluated cost-effectiveness decolonization protocols in high-risk arthroplasty patients. METHODS: An analytical model evaluated risk under 3 protocols: 4 swabs, 2 swabs, and nasal swab alone. These were compared to no-screening and universal decolonization strategies. Cost-effectiveness was evaluated from the hospital, patient, and societal perspective. RESULTS: Under base case conditions, universal decolonization and 4-swab strategies were most effective. The 2-swab and universal decolonization strategy were most cost-effective from patient and societal perspectives. From the hospital perspective, universal decolonization was the dominant strategy (much less costly and more effective). CONCLUSION: S aureus decolonization may be cost-effective for reducing prosthetic joint infections in high-risk patients. These results may have important implications for treatment of patients and for cost containment in a bundled payment system.

Establishing Age-Specific Cost-Effective Annual Revision Rates for Unicompartmental Knee Arthroplasty: A Meta-Analysis.

BACKGROUND: Improved survivorship has contributed to the increased use of unicompartmental knee arthroplasty (UKA) as an alternative to total knee arthroplasty (TKA) for unicompartmental knee osteoarthritis. However, heterogeneity among cost-effectiveness analysis studies comparing UKA to TKA has prevented the derivation of discrete implant survivorship targets. The aim of this meta-analysis was to determine the age-stratified annual revision rate (ARR) threshold for UKA to become consistently cost-effective for unicompartmental knee osteoarthritis. METHODS: A systematic search was performed for cost-effectiveness analysis studies of UKA vs TKA. Selected publications were rated by evidence level and assessed for methodological quality. Target UKA survivorship values determined by sensitivity analysis were retrieved, converted to ARR, and combined by age category (<65, 65-74, and ≥75 years) to estimate age-specific cost-effectiveness thresholds. RESULTS: Four studies met all inclusion criteria. All publications were evidence level I-B, with high methodological quality. Combined data indicated median threshold cost-effective ARR of 1.471% (interquartile range [IQR], 1.415-1.833; age <65), 1.135% (IQR, 1.011-1.260; age 65-74), and 1.760% (IQR, 1.660-2.880; age ≥75). Current revision rates are already below the cost-effective threshold for patients aged ≥75, but exceed recommended values in younger patients. CONCLUSION: The findings indicate that implant survivorship is a limiting factor toward achieving cost-effective UKA in patients aged <65. Strategies to improve UKA survivorship, such as shifting procedures to high-volume centers, may render UKA cost-effective in younger patients. This presents an opportunity for resource reallocation within health systems to achieve cost-effective utilization of UKA across a broader population segment.

A Crosswalk Between UCLA and Lower Extremity Activity Scales.

BACKGROUND: The University of California, Los Angeles (UCLA) activity scale and the Lower Extremity Activity Scale (LEAS) are the two most-widely used and rigorously developed scales for assessing activity level in patients having joint replacement. However, the two scales are not convertible, and the level of correlation between the two is not clear. Creating a crosswalk between these scales; that is, a concordance table to convert scores from one scale to the other and vice versa, will help compare results from existing studies using either scale, and pool those results for meta-analyses. It also will facilitate pooling data from multiple registries and data sources. QUESTIONS/PURPOSE: To create a crosswalk between the UCLA and the LEAS activity scales for patients having THA or TKA. METHODS: Preoperative and 2-year postoperative UCLA and LEAS scores for a cohort of patients undergoing primary TKA or THA at the Hospital for Special Surgery between May 2007 and December 2011 were matched from two registries. The scales were self-administered by patients. Three hundred sixty-four patients having TKAs (67% women; mean age, 67 years) and 403 having THA (66% women; mean age, 66 years) had both scores available. The equipercentile equating method was used to create the crosswalk. The standard response mean was used to assess responsiveness of the converted versus actual UCLA and LEAS scores from baseline to 2 years. Crosswalk validation also included comparing the area under the receiver operating characteristic curve of the actual and converted scores to evaluate their ability to discriminate different levels of function measured using the Hip dysfunction and Osteoarthritis Outcome Score activities of daily living subscale for patients having THA and the Knee injury and Osteoarthritis Outcome Score activities of daily living subscale for patients having TKA. Difference between scores was assessed using the inequality test. RESULTS: For patients having TKA, converted mean scores (UCLA to LEAS, 9.5 ± 3.0; LEAS to UCLA, 4.7 ± 2.1) were not different from the actual scores (UCLA, 4.8 ± 2.1; LEAS, 9.4 ± 2.9). Standard response means for the converted scores (UCLA to LEAS, 0.47; LEAS to UCLA, 0.52) were not different from those of the actual scores (UCLA, 0.48; LEAS, 0.56). The areas under the receiver operating characteristic curve also were not different for actual and converted scores for THA and TKA. CONCLUSION: We have developed and validated a crosswalk to easily convert UCLA to LEAS scores (and vice versa) for THA and TKA. Reproducing the crosswalk for other lower extremity conditions or surgical procedures may extend its utility to studies assessing activity in patients having these conditions or procedures.

Effect of age on cost-effectiveness of unicompartmental knee arthroplasty compared with total knee arthroplasty in the U.S.

BACKGROUND: Trade-offs between upfront benefits and later risk of revision of unicompartmental knee arthroplasty compared with those of total knee arthroplasty are poorly understood. The purpose of our study was to compare the cost-effectiveness of unicompartmental knee arthroplasty with that of total knee arthroplasty across the age spectrum of patients undergoing knee replacement. METHODS: Using a Markov decision analytic model, we compared unicompartmental knee arthroplasty with total knee arthroplasty with regard to lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) from a societal perspective for patients undergoing surgery at forty-five, fifty-five, sixty-five, seventy-five, or eighty-five years of age. Transition probabilities were estimated from the literature; survival, from the Swedish Knee Arthroplasty Register; and costs, from the literature and the Healthcare Cost and Utilization Project (HCUP) database. Costs and QALYs were discounted at 3.0% annually. We conducted sensitivity analyses to test the robustness of model estimates and threshold analyses. RESULTS: For patients sixty-five years of age and older, unicompartmental knee arthroplasty dominated total knee arthroplasty, with lower lifetime costs and higher QALYs. Unicompartmental knee arthroplasty was no longer cost-effective at a $100,000/QALY threshold when total knee arthroplasty rehabilitation costs were reduced by two-thirds or more for these older patients. Lifetime societal savings from utilizing unicompartmental knee arthroplasty in all older patients (sixty-five or older) in 2015 and 2020 were $56 to $336 million and $84 to $544 million, respectively. In the forty-five and fifty-five-year-old age cohorts, total knee arthroplasty had an ICER of $30,300/QALY and $63,000/QALY, respectively. Unicompartmental knee arthroplasty became cost-effective when its twenty-year revision rate dropped from 27.8% to 25.7% for the forty-five-year age group and from 27.9% to 26.7% for the fifty-five-year age group. CONCLUSIONS: Unicompartmental knee arthroplasty is an economically attractive alternative in patients sixty-five years of age or older, and modest improvements in implant survivorship could make it a cost-effective alternative in younger patients.

The potential influence of regionalization strategies on delivery of care for elective total joint arthroplasty.

Regionalization of total joint arthroplasty (TJA) to high volume hospitals (HVHs) may affect access to care and complication risk. Using administrative data, 2,560,314 patients who underwent primary total hip or knee arthroplasty from 1991 to 2006 were categorized by whether an HVH (>200 annual TJAs) was available locally. Associations among patient characteristics, hospital utilization, and in-hospital complications were estimated using regression modeling. The complication risk was higher (Odds Ratio 1.18 [95% CI: 1.16, 1.20]) if patients went to a local low volume hospital. Black and Medicaid patients were more likely to utilize the local low volume hospital than a local HVH. Utilizing a local HVH is associated with lower complication risks. However, patients from vulnerable groups were less likely to utilize these patterns.

Evaluation of two appropriateness criteria for total knee replacement.

OBJECTIVE: Insurance expansion under the Affordable Care Act will amplify a projected 6-fold increase in total knee replacement (TKR) utilization by 2030 but will not fully address TKR disparities. Promoting appropriate use of TKR would help reduce disparities and improve outcomes. There are currently no validated appropriateness criteria (AC) for TKR in the US. We evaluated the performance of 2 non-US AC in a cohort of US TKR patients. METHODS: AC1 was developed in Spain using the modified Delphi method with 624 patient scenarios. AC2 was developed in Canada using the overall Western Ontario and McMaster Universities Osteoarthritis Index score of >39 as the cutoff point for surgery. These criteria were applied to a random sample of TKR patients enrolled in our institutional registry. Preoperative clinical, radiographic, and patient-reported survey data were used in classifying patients. The rate of appropriateness was compared for the 2 AC. Inappropriate cases were further investigated to determine other mitigating factors beyond the criteria influencing the decision to operate. RESULTS: In total, 508 TKR procedures were evaluated. All patients had osteoarthritic radiographic changes. On the basis of AC1, 7.7% of cases were classified as inappropriate and 11.6% uncertain. On the basis of AC2, 31.5% were classified as inappropriate. Only 4.7% of the cases were classified as inappropriate by both ACs; however, there was poor agreement between the 2 AC (κ = -0.08). Beyond the criteria, failure of nonsurgical treatment and clinically significant valgus/varus deformities influenced the decision for surgery. CONCLUSION: There was poor agreement between 2 validated AC for TKR when tested in a US population. Culturally specific AC are needed to promote rational use of TKR.