Cost effectiveness of total knee arthroplasty from a health care providers' perspective before and after introduction of an interdisciplinary clinical pathway--is investment always improvement?

BACKGROUND: Total knee arthroplasty (TKA) is an effective, but also cost-intensive health care intervention for end stage osteoarthritis. This investigation was designed to evaluate the cost-effectiveness of TKA before versus after introduction of an interdisciplinary clinical pathway from a University Orthopedic Surgery Department's cost perspective as an interdisciplinary full service health care provider. METHODS: A prospective trial recruited two sequential cohorts of 132 and 128 consecutive patients, who were interviewed by means of the WOMAC questionnaire. Direct process costs from the health care providers' perspective were estimated according to the German DRG calculation framework. The health economic evaluation was based on margiual cost-effectveness ratios (MCERs); an individual marginal cost effectiveness relation≤100 € per % WOMAC index increase was considered as primary endpoint of the confirmatory cohort comparison. The interdisciplinary clinical pathway under consideration primarily consisted of a voluntary preoperative personal briefing of patients concerning postoperatively expectable progess in health status and optimum use of walking aids after surgery. All patients were supplied with written information on these topics, attendance of the personal briefing also included preoperative training for postoperative mobilisation by the Department's physiotherapeutic staff. RESULTS: An individual marginal cost effectiveness relation≤100 €/% WOMAC index increase was found in 38% of the patients in the pre pathway implementation cohort versus in 30% of the post pathway implementation cohort (Fisher p=0.278). Both cohorts showed substantial improvement in WOMAC scores (39 versus 35% in median), whereas the cohort did not differ significantly in the median WOMAC score before surgery (41% for the pre pathway cohort versus 44% for the post pathway cohort). Despite a locally significant decrease in costs (4303 versus 4194 € in median), the individual cost/benefit relation became worse after introduction of the pathway: for the first cohort the MCER was estimated 108 € per gained % WOMAC index increase (86-150 €/%) versus 118 €/% WOMAC gain (93-173 €/%) in the second cohort after pathway implementation. In summary, the proposed critical pathway for TKA could be shown to be significantly cost efficient, but not cost effective concerning functional outcome, when the above individual marginal cost effectiveness criterion was concentrated on. CONCLUSIONS: The introduction of an interdisciplinary clinical pathway does not necessarily improve patient related outcomes. On the contrary, cost effectiveness from the health care providers' perspective may even turn out remarkably reduced in the setting considered here (functional outcome assessment after treatment by a full service health care provider).

Health economic evaluation in complementary medicine: development within the last decades concerning local origin and quality.

OBJECTIVES: This evaluation investigates characteristics of health economics evaluations in CAM. Particular emphasis is paid to differences regarding continental origin and time of publication of investigations. METHODS: Database searches to identify potential studies were carried out in Medline (via Pubmed), the Cochrane Central Register of Controlled Trials 1st Quarter 2010, the Cochrane Database of Systematic Reviews 2005 to January 2010, the Cochrane Methodology Register 1st Quarter 2010, the Database of Abstracts of Reviews of Effects 1st Quarter 2010, Health Technology Assessment (via OVID) and CAMbase. Data were screened, extracted and the methodological quality of the underlying publications was assessed. Univariate statistical analyses were carried out and Classification and Regression Tree (CART) analysis was performed. RESULTS: One hundred and forty-three studies were included in this review, 43 of which were randomised trials. Of all included studies 56% were carried out in primary care settings and 54% chose the perspective of health care provider/health insurance. When the study characteristics were stratified for the "year of publication" (before versus in/after 2002), locally significant differences were found for study setting (Chi-square p=0.014) and methodological quality (Mann/Whitney p=0.014). Furthermore, studies from America differed from those conducted in Europe with respect to the field of CAM (p<0.001, Chi-square). There were also differences in trial settings as the majority of European studies was carried out in primary care settings (n=54; 70%), whereas American studies had a broader scope with only 24 studies (42%) in the field of primary care. The CART analyses confirmed the findings of the univariate analysis. CONCLUSION: Differences in healthcare systems were mirrored by the observed differences in CAM related health economic evaluations. Basic requirements for reporting and conducting clinical trials ought to be met in more studies evaluating health economics. Such evaluations need to include validated quality of life estimates and preferably report the use of incremental cost effectiveness or net health benefit estimates.

[Health Economical Evaluation of antibiotic prophylaxis against postoperative endophthalmitis]. / Gesundheitsökonomische Bewertung einer antibiotischen Prophylaxe gegenüber postoperativen Endophthalmitiden.

BACKGROUND: Two independent epidemiological studies recently suggested the prophylactic relevance of an intraocular antibiosis against endophthalmitis after cataract surgery. The resulting intervention programme, however, has not only ethical drawbacks, but also has a health economical dimension, which will be focussed in this paper. MATERIAL AND METHODS: A cost analysis is performed to compare the direct costs saved by prevention of endophthalmitis cases and the costs generated by the prophylaxis itself. Furthermore, the clinics' indirect costs due to treatment of unprevented endophthalmitis cases are estimated. RESULTS: The overall gain in direct costs turns out to be about 368 000 Euro p. a., the indirect costs from the clinics' view can be reduced by about 260 000 Euro p. a. due to prevention of endophthalmitis cases by the antibiotic intervention. CONCLUSIONS: From an economical point of view, antibiotic prophylaxis can be suggested; the risk of longitudinally reduced antibiotic effectiveness of the antibiotic agents, however, strongly calls for an overall health political decision rather than for an immediate implementation of the corresponding intervention programme.