Cost-utility analysis and economic burden of knee osteoarthritis treatment: the analysis from the real clinical practice.

BACKGROUND: Non-steroidal anti-inflammatory drug (tNSAIDs) or selective COX-II inhibitor (COXIBs) are generally used as the first-line intervention of knee osteoarthritis (OA). Total knee arthroplasty (TKA) is suggested for those who dissatisfy from non-surgical treatment. However the long-term usage of tNSAIDs may lead to articular cartilage and resulted in higher rate of TKA. The evaluation of real clinical practice needs to be scrutinized as the inappropriate treatment will be socially burden. OBJECTIVE: To evaluate cost-utility of selective COX-II inhibitors (COXIBs) compared to traditional NSAIDs in patients with knee osteoarthritis (OA) and to estimate health and economic burden of disease of knee OA. MATERIAL AND METHOD: The present study is an economic evaluation alongside a prospective observational study. The data of cost and treatment outcomes were collected from real clinical practice. EQ-5D questionnaire was employed to calculate utility values at baseline and 6 months after treatment. RESULTS: Total 939 patients were prescribed tNSAIDs and 380 patients received celecoxib. Eleven cases (1.17%) of all tNSAIDs usages and 3 cases (0.79%); p = 0.56 of celecoxib usages were detected GI complication. Two cases of tNSAIDs group were dead from severe GI bleeding. TKA was markedly reported with 12.99% of tNSAIDs and 9.80% of celecoxib; p = 0.06. QALYs gained from 6 months was 0.34 (+/- 0.11) for tNSAIDs and 0.36 (+/- 0.11) for celecoxib; p = 0.004. Average direct medical expenses per patient were comparable with 17,468.97 THB for tNSAIDs and 17,495.07 THB for celecoxib. Cost of TKA was a key element in both groups with 90% and 67% of total expenses in tNSAIDs and celecoxib groups, respectively. Incremental cost-effectiveness ratio (ICER) per Quality-adjusted life years (QALY) gained comparing celecoxib and tNSAIDs was 1,382.70 THB. CONCLUSION: The finding from our study can be a concrete evidence to support the appropriate future decision of clinical judgment and health care provider.

Cost analysis of peri-operative antibiotic administration in total knee arthroplasty.

BACKGROUND: Rationale perioperative antibiotic for prevent infection in total knee arthroplasty is well established. The recommendation are preoperative antibiotic should be administered within 1 h before skin incision and prophylactic antibiotics should be administered within 1 h before skin incision, if prolong surgery more than 4-6 hours need addition doses and duration of prophylactic antibiotic administration should not exceed the 24-hour postoperative period then not need for additional antibiotic. If there is evidences of infection, intravenous antibiotic and follow by oral antibiotic is mandatory in acute infection in conjuction with scrub and debridement. Because the burden of infection in joint replacement is disaster, it seemed to increase the antibiotic uses and impact about the cost concerned after total knee arthroplasty. No data available about the pharmaco-economical study of perioperative antibiotic in total knee arthroplasty have been established. OBJECTIVE: Primary outcomes is cost anaylsis of perioperative antibiotic uses in real clinical practice for total knee arthroplasty. Secondary outcome is infectioned total knee that need to reoperative for scrub and debridement. MATERIAL AND METHOD: Prospective opened lable study from joint registry in Police General Hospital from June, 2010 till March, 2011. With minimum 12 months follow-up. Total Knee Arthroplasty was enrolled in the present study about 218 cases. 3 patients lossed follow-up in each groups, so the total number in the present study are 209 patients. Perioperative antibiotic consumption initial doses and followed for 48 hour is divided in 3 group: group 1 Fosmycin 4 g (2 g initially plus 2 g intraoperatively) for 70 patients group 2: Fosmycin 2 g for 68 patients. Group 3: Cefalosporin group for 71 patients. The cost of subsequence uses of intravenous and oral antibiotic were record. And also the cases that need to scrub debridement with the indication of infected total knee arthroplasty were recorded. The minimum follow-up about 12 months (range 12-18 months). RESULTS: The extend of intravenous antibiotic administration postop more than 48 hours in group 1 is 38 patients (54.28%) and oral antibiotic 42 patients (60%), in group 2 is 45 patients (66.18%) and oral antibiotic 40 patients (58.2%), in group 3 58 patients (81.7%) and oral antibiotic 60 patients (84.51%). The percentage of expenses preoperative intravenous and postoperative 48 hour: intravenous antibiotic during hospitalization: post operative antibiotic in group 1 is 19.82%: 59.69%: 20.49%; group 2 is 10.41%: 68.40%: 21.19% and group 3 is 1.39% 80.85%: 17.76%. The average total perioperative cost antibiotic (baht) in group 1: group 2: group 3 are 4,068: 4,776: 5,468. The infected case need operated for scrub and debridement in group 1 is 1 cases, group 2 is one cases and group 3 is 1 cases. CONCLUSION: Overall expense increased in both intravenous and oral antibiotic prophylaxis in total knee arthtroplasty for prevention of infection. The major cost of perioperative antibiotic is intravenous antibiotic more than 48 hours during hospitalization, the least number of patients and percentages of cost is in group 1 than group 2 and 3. The percentage of patients oral antibiotics are least in group 2 than group 1, 3 but the average cost is likely to be quite substantially lower in group 1 then group 2, 3.

Gastrointestinal and cardiovascular risk of non-selective NSAIDs and COX-2 inhibitors in elderly patients with knee osteoarthritis.

OBJECTIVE: To evaluate the incidence and risk profiles for gastrointestinal (GI) events and cardiovascular (CV) events in elderly patients (aged > or =60 years) with knee osteoarthritis using tNSAIDs (traditional non-steroidal anti-inflammatory drugs) or coxibs users in patients with knee osteoarthritis aged > or =60 years. MATERIAL AND METHOD: A hospital-based retrospective cohort study was applied. Data on prescription drug (NSAIDs, celecoxib, etoricoxib) was obtained from hospital database. Data on CV events and GI adverse events was obtained from the registry of the Cardiology Unit and Gastroesophagoscope Diagnosis Center, GI Center, Department of Internal medicine, Police General Hospital. Patients visiting the hospitals' outpatient clinics from June 2004 to June 2007 were included if they were aged > or =60 years and received at least one follow-up visit on the prescription of a tNSAIDNSAID or coxibs (etoricoxib or celecoxib). Patients with a history of gastrointestinal disease or heart disease were excluded. All patients were followed-up from their first visit to the date of their earliest event or to the end of the study period. The interested event was assumed to be attributed to the last prescription shown in the study period. RESULTS: A total 12,591 prescriptions from 1030 patients, an average of 4 prescriptions/patient/year, were screened -3,982 (31.6%) prescriptions were for NSAIDs, 4426 (35.2%) were for celecoxib, and 4183 (33.2%) were for etoricoxib. The most common traditional NSAID prescribed was meloxicam (24%), followed by nimesulide (21.4%) and naproxen (13.1%). The mean age of cohort was 69.6 years, with the majority being female (74%). We found a comparable dose of celecoxib (200 mg OD) and etoricoxib (90 mg OD) prescribed in the respective patients. A total of 78 gastrointestinal events occurred and Esophagogastroscopy indicated that 37 (47.4%) were dyspepsia, 22 (28.2%) were anemia (28.2%), 17 (21.7%) were upper GI bleeding, and 2 (2.6%) were others. Forty (40) of these events were attributed to NSAIDs, 21 to celecoxib and 17 to etoricoxib. Observed GI events included gastritis (50, 64.1%), gastric ulcer (14, 17.9%), duodenal ulcer (3, 3.8%), and normal (11, 14.1%). Patients receiving traditional NSAIDs, celecoxib and etoricoxib had 20, 18, and 11 CV events respectively. Of these 49 CV events, the most common was heart failure (20), followed by chronic heart failure (9), angina pectoris (9), unstable angina (6), and myocardial infarction (5). Comparing celecoxib with NSAID use in logistic regression analysis, patients who received celecoxib were significantly less likely to suffer GI events than those who received NSAIDs; OR = 0.36 (95% CI 0.21-0.63, p = 0.00.). Similarly, etoricoxib was less likely to cause GI events than NSAIDs; OR = 0.52 (95% CI 0.28-0.98, p = 0.04). Comparing to patients aged under 60 years, patients aged >70 years had a significantly higher chance of developing GI events, OR = 1.79 (95% CI 1.13-2.4) for patients aged 70-80 years and 3.36 (95% CI 1.78-5.81) for those aged > 80 years. Drug exposure time, which was defined as the number of days of medication supplied significantly increased the GI risks. For CV event, there were only 3 significantly associated with CV events -female (OR = 0.29, 95% CI 0.16-0.59, p = 0.00), age >80 years (OR = 2.98, 95% CI 1.57-4.23, p = 0.00), and drug exposure time (OR = 1.05, 95% CI 1.02-1.54, p = 0.00). CONCLUSION: Incidence of GI and CV events was lower for coxibs than for NSAIDs and celecoxib had a lower incidence than etoricoxib. Patients with advanced age and higher drug exposure time had a significantly increased risk ofGI; the use of gastroprotective agents significantly decreased GI risks. Being female, advanced age, and drug exposure time significantly affected CV events.