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.

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.

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.

Applying economic evaluation to public health interventions: the case of interventions to promote physical activity.

BACKGROUND: This paper explores the application of alternative approaches to economic evaluation of public health interventions, using a worked example of exercise referral schemes (ERSs). METHODS: Cost-utility (CUA) and cost-consequence analyses (CCA) were used to assess the cost-effectiveness of ERSs. For the CUA, evidence was synthesized using a decision analytic model that adopts a lifetime horizon and NHS/Personal Social Services perspective. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). CCA was conducted from a partial-societal perspective, including health and non-healthcare costs and benefits. Outcomes were reported in natural units, such as cases of strokes or CHD avoided. RESULTS: Compared with usual care, the incremental cost per QALY of ERS is £20 876. Based on a cohort of 100 000 individuals, CCA estimates cost of ERS at £22 million to the healthcare provider and £12 million to participants. The benefits of ERS include additional 3900 people becoming physically active, 51 cases of CHD avoided, 16 cases of stroke avoided, 86 cases of diabetes avoided and a gain of ∼800 QALYs. CONCLUSIONS: CCA might provide greater transparency than CUA in reporting the outcomes of public health interventions and have greater resonance with stakeholders involved in commissioning these interventions.

Physical activity and health related quality of life.

BACKGROUND: Research on the relationship between Health Related Quality of Life (HRQoL) and physical activity (PA), to date, have rarely investigated how this relationship differ across objective and subjective measures of PA. The aim of this paper is to explore the relationship between HRQoL and PA, and examine how this relationship differs across objective and subjective measures of PA, within the context of a large representative national survey from England. METHODS: Using a sample of 5,537 adults (40-60 years) from a representative national survey in England (Health Survey for England 2008), Tobit regressions with upper censoring was employed to model the association between HRQoL and objective, and subjective measures of PA controlling for potential confounders. We tested the robustness of this relationship across specific types of PA. HRQoL was assessed using the summary measure of health state utility value derived from the EuroQol-5 Dimensions (EQ-5D) whilst PA was assessed via subjective measure (questionnaire) and objective measure (accelerometer-actigraph model GT1M). The actigraph was worn (at the waist) for 7 days (during waking hours) by a randomly selected sub-sample of the HSE 2008 respondents (4,507 adults--16 plus years), with a valid day constituting 10 hours. Analysis was conducted in 2010. RESULTS: Findings suggest that higher levels of PA are associated with better HRQoL (regression coefficient: 0.026 to 0.072). This relationship is consistent across different measures and types of PA although differences in the magnitude of HRQoL benefit associated with objective and subjective (regression coefficient: 0.047) measures of PA are noticeable, with the former measure being associated with a relatively better HRQoL (regression coefficient: 0.072). CONCLUSION: Higher levels of PA are associated with better HRQoL. Using an objective measure of PA compared with subjective shows a relatively better HRQoL.

Should we invest in environmental interventions to encourage physical activity in England? An economic appraisal.

BACKGROUND: The Department of Health in England asked the National Institute for Health and Clinical Excellence (NICE) to develop guidance on environmental interventions that promote physical activity. The economic appraisals summarized in this study informed the development of that guidance. In view of the difficulties inherent in applying conventional health economic evaluation techniques to public health interventions, the economic appraisal employed a multi-faceted approach. METHODS: The analyses comprised of three components. Two cost-utility analyses; the first used a life-time disease progression model which sought to take into account the long-term benefits of physical activity on health outcomes, whereas the second used data from a regression analysis which captured some of the short-term, process benefits of physical activity which might manifest themselves in terms of improved mental health and wellbeing. The third approach was a cost-benefit analysis that took into account benefits beyond healthcare. RESULTS: The cost-utility approaches generated cost-effectiveness estimates ranging between £100 and £10 000 per QALY depending on the level of effectiveness of the intervention and the proportion of the intervention cost that was deemed to be attributable to health. The standardized cost-benefit ratio was 11:1. CONCLUSION: The findings present a consistent case to support environmental interventions that promote increased physical activity in the sedentary adult population. However, some degree of caution should be taken in interpreting the findings due to the limitations of the evidence upon which they are based. Further consideration should also be given to the relative merits of alternative approaches to assessing the value of changes to the built environment that might also benefit health as a positive externality.

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.

The cost-effectiveness of exercise referral schemes.

BACKGROUND: Exercise referral schemes (ERS) aim to identify inactive adults in the primary care setting. The primary care professional refers the patient to a third party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the patient. This paper examines the cost-effectiveness of ERS in promoting physical activity compared with usual care in primary care setting. METHODS: A decision analytic model was developed to estimate the cost-effectiveness of ERS from a UK NHS perspective. The costs and outcomes of ERS were modelled over the patient's lifetime. Data were derived from a systematic review of the literature on the clinical and cost-effectiveness of ERS, and on parameter inputs in the modelling framework. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses investigated the impact of varying ERS cost and effectiveness assumptions. Sub-group analyses explored the cost-effectiveness of ERS in sedentary people with an underlying condition. RESULTS: Compared with usual care, the mean incremental lifetime cost per patient for ERS was £169 and the mean incremental QALY was 0.008, generating a base-case incremental cost-effectiveness ratio (ICER) for ERS at £20,876 per QALY in sedentary individuals without a diagnosed medical condition. There was a 51% probability that ERS was cost-effective at £20,000 per QALY and 88% probability that ERS was cost-effective at £30,000 per QALY. In sub-group analyses, cost per QALY for ERS in sedentary obese individuals was £14,618, and in sedentary hypertensives and sedentary individuals with depression the estimated cost per QALY was £12,834 and £8,414 respectively. Incremental lifetime costs and benefits associated with ERS were small, reflecting the preventative public health context of the intervention, with this resulting in estimates of cost-effectiveness that are sensitive to variations in the relative risk of becoming physically active and cost of ERS. CONCLUSIONS: ERS is associated with modest increase in lifetime costs and benefits. The cost-effectiveness of ERS is highly sensitive to small changes in the effectiveness and cost of ERS and is subject to some significant uncertainty mainly due to limitations in the clinical effectiveness evidence base.

Economic evaluation of Vacuum Assisted Closure® Therapy for the treatment of diabetic foot ulcers in France.

The objective of the study was to assess the cost-effectiveness of Vacuum Assisted Closure® (V.A.C.®) Therapy compared with advanced wound care (AWC) for the treatment of diabetic foot ulcers (DFUs) in France. A cost-effectiveness model intended to reflect the management of DFUs was updated for the French setting. The Markov model follows the progression of 1000 hypothetical patients over a 1-year period. The model was populated with French-specific data, obtained from published sources and clinical experts. The analysis evaluated costs and health outcomes, in terms of quality-adjusted life-years (QALYs), wounds healed and amputations, from the perspective of the payer. The patients treated with V.A.C.® Therapy experienced more QALYs (0.787 versus 0.784) and improved healing rates (50.2% versus 48.5%) at a lower total cost of care (€24,881 versus €28,855 per patient per year) when compared with AWC. Sensitivity analyses conducted around key model parameters indicated that the results were affected by hospital resource use and costs. DFU treatment using V.A.C.® Therapy in France was associated with lower costs, additional QALYs, more healed ulcers and fewer amputations than treatment with AWC. V.A.C.® Therapy was therefore found to be the dominant treatment option.

Direct and indirect economic burden associated with rotator cuff tears and repairs in the US.

OBJECTIVE: This retrospective study examined treatment characteristics and the economic burden associated with rotator cuff tears (RCT) and rotator cuff repairs (RCR). Additionally, this study aimed to explore the economic implications associated with delayed surgical intervention. METHODS: Adult RCT patients meeting eligibility criteria were identified from 1/1/2013-6/30/2017 using the IBM Watson Health MarketScan Commercial database. Patients with incident RCR within 12 months post-index and 12 months continuous enrollment after the RCR date were also analyzed. Early surgery was defined as RCR within 6 months and 1 month from the partial-thickness tear and full-thickness tear diagnoses, respectively. Patient characteristics, all-cause direct costs (plan paid and patient out-of-pocket), RCT-related costs, pre-surgical costs, post-surgical costs, and healthcare resource utilization were reported by RCT type. Attributable indirect costs, absenteeism and short-term disability (STD), were also estimated. RESULTS: 102,488 RCT patients were identified (partial-thickness tears: 46,856 [45.7%]; full-thickness tears: 55,632 [54.3%]). Fifty per cent RCT patients underwent RCR within 12-months of diagnosis. Full-thickness RCT patients had an average total baseline (one year pre-diagnosis) and post-index costs of $17,096 and $32,110, respectively. Similarly, partial thickness patients had baseline costs of $16,385 and post-index costs of $27,017. Mean all-cause annual post-surgery costs were $34,086 for patients with partial-thickness tears and $34,249 for patients with full-thickness tears, of which 40% and 38% of costs were RCT-related, respectively. Productivity losses due to absenteeism and STD in the 12-month post-surgery period averaged $5843 and $4493, respectively, for partial-thickness tear patients and $5770 and $4382, respectively, for full-thickness tear patients. Average additional spending per delayed surgical patient between diagnosis and surgery was $8524 and $3213 (both p <0.001) for partial- and full-thickness tear patients, respectively. CONCLUSIONS: This exploratory analysis indicates considerable RCT and RCR economic burden to the healthcare system. High healthcare utilization and costs highlight the importance of efficiently managing patients with RCT diagnosis. Data also suggest that early surgical intervention may be economically beneficial if surgical intervention is anticipated post-RCT.

Coverage with Evidence Development: applications and issues.

OBJECTIVES: The aim of this study was to describe the current issues surrounding Coverage with Evidence Development (CED). CED is characterized by restricted coverage for a new technology in parallel with targeted research when the stated goal of the research or data collection is to provide definitive evidence for the clinical or cost-effectiveness impact of the new technology. METHODS: Presented here is information summarized and interpreted from presentations and discussions at the 2008 Health Technology Assessment International (HTAi) meeting and additional information from the medical literature. This study describes the differences between CED and other conditional coverage agreements, provides a brief history of CED, describes real-world examples of CED, describes the areas of consensus between the stakeholders, discusses the areas for future negotiation between stakeholders, and proposes criteria to assist stakeholders in determining when CED could be appropriate. RESULTS: Payers could interpret the evidence obtained from a CED program either positively or negatively, and a range of possible changes to the reimbursement status of the new technology may result. Striking an appropriate balance between the demands for prompt access to new technology and acknowledging that some degree of uncertainty will always exist is a critical challenge to the uptake of this innovative form of conditional coverage. CONCLUSIONS: When used selectively for innovative procedures, pharmaceuticals, or devices in the appropriate disease areas, CED may provide patients access to promising medicines or technologies while data to minimize uncertainty are collected.

Estimating the direct costs of bowel cancer services provided by the National Health Service in England.

OBJECTIVES: Bowel cancer is the second most common cancer in England and Wales, accounting for approximately 13,000 deaths per year. Economic evaluations and national guidance have been produced for individual treatments for bowel cancer. However, it has been suggested that Primary Care Trusts develop program budgeting or equivalent methodology demonstrating a whole system approach to investment and disinvestment. The objective of this study was to provide a baseline framework for considering a whole system approach to estimate the direct costs of bowel cancer services provided by the National Health Service (NHS) in England. METHODS: A treatment pathway, developed in 2005, was used to construct a service pathway model to estimate the direct cost of bowel cancer services in England. RESULTS: The service pathway model estimated the direct cost of bowel cancer services to the NHS to be in excess of £1 billion in 2005. Thirty-five percent of the cost is attributable to the screening and testing of patients with suspected bowel cancer, subsequently diagnosed as cancer-free. CONCLUSIONS: This study is believed to be the most comprehensive attempt to identify the direct cost of managing bowel cancer services in England. The approach adopted could be useful to assist local decision makers in identifying those aspects of the pathway that are most uncertain in terms of their cost-effectiveness and as a basis to explore the implications of re-allocated resources. Research recommendations include the need for detailed costs on surgical procedures, high-risk patients and the utilization of the methods used in this study across other cancers.

The economics of pressure relieving surfaces: an illustrative case study of the impact of high-specification surfaces on hospital finances.

Pressure ulcers are associated with a significant economic burden that, in many cases, is recognised as being avoidable. The effectiveness of pressure relieving surfaces is well documented and acknowledged in clinical guidelines on the prevention and management of pressure ulcers. Whilst pressure relieving surfaces are more expensive than traditional hospital mattresses, judicious use, targeted to patients most at risk, can help to reduce the incidence and costs of pressure ulcers in hospital settings. This review paper includes a summary of pivotal clinical evidence on pressure relieving surfaces as well as a suggested approach for modelling their financial impact on hospital budgets. Simple financial modelling suggests that pressure relieving surfaces could lead to financial savings for a hospital when used appropriately.

To what extent can pressure relieving surfaces help reduce the costs of pressure ulcers?

Pressure ulcers in acute care often involve extended hospital stays and additional health service resources. As well as the economic burden, pressure ulcers have a significant impact on patient morbidity. Pressure relieving surfaces have been recommended as a form of pressure ulcer prevention for patients at risk of developing ulcers, although such surfaces can be considerably more expensive than the standard ones used in hospitals. This summary looks at the clinical and economic evidence on pressure relieving surfaces, and discusses the likely impact on hospital budgets as a result of investing in a range of pressure relieving surfaces. The findings suggest that using pressure relieving surfaces for those at risk of developing a pressure ulcer can result in health service efficiencies and quality of life gains for patients.

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.

The feasibility of harmonizing health technology assessments across jurisdictions: a case study of drug eluting stents.

OBJECTIVES: There is considerable interest in the potential for harmonizing health technology assessments (HTA) across jurisdictions. This study aims to consider four HTAs of drug eluting stents to determine the degree to which the methods adopted, evidence considered, and resulting recommendations diverge. METHODS: Four HTAs of drug eluting stents were selected for inclusion and evaluated using a framework developed to systematically capture information on the process adopted, the evidence considered and the recommendations of each HTA. RESULTS AND CONCLUSIONS: The findings suggest that, although there is a common core data set considered by most of the agencies, differences in the approach to HTA, heterogeneity of studies, and the limited relevance of research findings to local practice meant that the core data set had only limited influence on the resulting recommendations. Of the HTA agencies considered in the analysis, many sought to generate additional primary research from local settings to help inform the development of recommendations that were relevant to local practice. This raises questions about the extent to which HTA methods can be harmonized across jurisdictions.

Economic burden of surgical site infections within the episode of care following joint replacement.

BACKGROUND: Recent policy initiatives, including Bundled Payments for Care Improvement (BPCI) Initiative by the Centers for Medicare and Medicaid Health Services (CMS), encourage healthcare providers to manage the total episode of care, rather than just the surgical episode. Surgical site infections (SSI) following total joint replacement result in preventable morbidity and suffering for patients and excess healthcare utilization for healthcare providers. This study sought to estimate the additional resources associated with SSIs within the 90-day episode of care following hip and knee joint replacement. METHODS: Using the 2013 Nationwide Readmissions Database (NRD), healthcare resource utilization was compared between propensity score matched patient groups with and without SSI-related readmissions within the 90-day episode of care following total joint replacement. RESULTS: Surgical site infections were associated with significantly longer hospital length of stay and increased costs following hip and knee joint replacement procedures. Generalized estimating equation regression results confirmed that additional costs associated with SSIs following both cohorts were significant, with additional hospital length of stay and costs following total hip and knee replacement procedures ranging from 4.9 to 5.2 days and $12,689 to $12,890, respectively. CONCLUSION: Surgical site infections following total joint replacement account for significant additional healthcare resource use within the 90-day episode of care.

Cost-effectiveness considerations for home health V.A.C. Therapy in the United States of America and its potential international application.

Vacuum-assisted closure (V.A.C.) Therapy (KCI International, San Antonio, TX) has been widely used in hospital settings. However, use of V.A.C.) Therapy in home health settings outside of the United States of America (USA) is often limited because of financial considerations. This review paper considers the published evidence on V.A.C. Therapy in home health settings from the USA and beyond and explores the potential economic implications of V.A.C. Therapy in home health settings.