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.

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.

Cost Analysis of Dual-Mobility Constructs in Revision Total Hip Arthroplasty: A European Payer Perspective.

Dual-mobility constructs have been shown to significantly and substantially decrease dislocations after revision total hip arthroplasty (THA). The authors have previously shown that dual-mobility (DM) constructs are cost-effective given their ability to decrease dislocations and re-revision for dislocation. The goal was to report the costs of DM and large femoral head (LFH) constructs in revision THAs from a European health care payer perspective. A Markov model was constructed to analyze the costs incurred by payers in the United Kingdom, Germany, Italy, and Spain over 3 years in revision THAs with DM or LFH constructs. Model states and probabilities were derived from prospectively collected registry data in 302 patients who underwent revision THA with a DM or 40-mm LFH construct and were then mapped to corresponding procedural reimbursement codes and tariffs for each country. Costs were weighted average national payments for reintervention procedures performed in the 3 years following revision THA. Probabilistic sensitivity analysis examined the effect of combined uncertainty across all model parameters. During a 3-year period following revision THA, reintervention rates were 9% for DM constructs and 19% for LFH constructs (P=.01). Comparing DM and LFH constructs, cumulative incremental costs over 3-years' follow-up were £428 vs £1447 in the United Kingdom, euro 451 vs euro 1272 in Germany, euro 540 vs euro 1425 in Italy, and euro 523 vs euro 1562 in Spain, respectively. At mid-term follow-up, DM constructs used in revision THAs were associated with a significantly lower risk of reintervention, which translated to lower health care payer costs compared with LFH constructs among European health care payers. [Orthopedics. 2020;43(4):250-255.].

Variation in the Cost of Care for Different Types of Joint Arthroplasty.

BACKGROUND: Lower-extremity arthroplasty constitutes the largest burden on health-care spending of any Medicare diagnosis group. Demand for upper extremity arthroplasty also continues to rise. It is necessary to better understand costs as health care shifts toward a bundled-payment accounting approach. We aimed (1) to identify whether variation exists in total cost for different types of joint arthroplasty, and, if so, (2) to determine which cost parameters drive this variation. METHODS: The cost of the episode of inpatient care for 22,215 total joint arthroplasties was calculated by implementing time-driven activity-based costing (TDABC) at a single orthopaedic specialty hospital from 2015 to 2018. Implant price, supply costs, personnel costs, and length of stay for total knee, total hip, anatomic total shoulder, reverse total shoulder, total elbow, and total ankle arthroplasty were analyzed. Individual cost parameters were compared with total cost and volume. RESULTS: Higher implant cost appeared to correlate with higher total costs and represented 53.8% of the total cost for an inpatient care cycle. Total knee arthroplasty was the least-expensive and highest-volume procedure, whereas total elbow arthroplasty had the lowest volume and highest cost (1.65 times more than that of total knee arthroplasty). Length of stay was correlated with increased personnel cost but did not have a significant effect on total cost. CONCLUSIONS: Total inpatient cost at our orthopaedic specialty hospital varied by up to a factor of 1.65 between different fields of arthroplasty. The highest-volume procedures-total knee and hip arthroplasty-were the least expensive, driven predominantly by lower implant purchase prices. CLINICAL RELEVANCE: We are not aware of any previous studies that have accurately compared cost structures across upper and lower-extremity arthroplasty with a uniform methodology. The present study, because of its uniform accounting process, provides reliable data that will allow clinicians to better understand cost relationships between different procedures.

Preferred Single-Vendor Program for Total Joint Arthroplasty Implants: Surgeon Adoption, Outcomes, and Cost Savings.

BACKGROUND: In total joint arthroplasty, variation in implant use can be driven by vendor relationships, surgeon preference, and technological advancements. Our institution developed a preferred single-vendor program for primary hip and knee arthroplasty. We hypothesized that this initiative would decrease implant costs without compromising performance on quality metrics. METHODS: The utilization of implants from the preferred vendor was evaluated for the first 12 months of the contract (September 1, 2017, to August 31, 2018; n = 4,246 cases) compared with the prior year (September 1, 2016, to August 31, 2017; n = 3,586 cases). Per-case implant costs were compared using means and independent-samples t tests. Performance on quality metrics, including 30-day readmission, 30-day surgical site infection (SSI), and length of stay (LOS), was compared using multivariable-adjusted regression models. RESULTS: The utilization of implants from the preferred vendor increased from 50% to 69% (p < 0.001), with greater use of knee implants than hip implants from the preferred vendor, although significant growth was seen for both (from 62% to 81% for knee, p < 0.001; and from 38% to 58% for hip, p < 0.001). Adoption of the preferred-vendor initiative was greatest among low-volume surgeons (from 22% to 87%; p < 0.001) and lowest among very high-volume surgeons (from 61% to 62%; p = 0.573). For cases in which implants from the preferred vendor were utilized, the mean cost per case decreased by 23% in the program's first year (p < 0.001), with an associated 11% decrease in the standard deviation. Among all cases, there were no significant changes with respect to 30-day readmission (p = 0.449) or SSI (p = 0.059), while mean LOS decreased in the program's first year (p < 0.001). CONCLUSIONS: The creation of a preferred single-vendor model for hip and knee arthroplasty implants led to significant cost savings and decreased cost variability within the program's first year. Higher-volume surgeons were less likely to modify their implant choice than were lower-volume surgeons. Despite the potential learning curve associated with changes in surgical implants, there was no difference in short-term quality metrics. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of Crosslinked Polyethylene in Reducing Aggregated Costs of Total Hip Arthroplasty in the United States.

BACKGROUND: Widespread adoption of crosslinked polyethylene for the acetabular articular surface for total hip arthroplasty has substantially reduced revision rates and dislocation rates. We aim to provide estimates of the resulting magnitude of the annual reduction in aggregated costs of total hip arthroplasty surgery in the United States. METHODS: After we obtained, from the literature, the contrasting mid-term rates of revisions and dislocations of total hip arthroplasty using conventional polyethylene vs those using crosslinked polyethylene, specifically from only registry studies and prospective, randomized controlled studies, we multiplied these incidence figures by the cost estimates of these failures to generate approximations of the cost savings in the United States from the use of crosslinked polyethylene. RESULTS: The estimates suggest that in the United States these savings might be one billion dollars per annual cohort over a 15-year duration. CONCLUSION: The use of crosslinked polyethylene has reduced substantially the overall costs of total hip arthroplasty surgery in the United States.

Choice of Prosthetic Implant Combinations in Total Hip Replacement: Cost-Effectiveness Analysis Using UK and Swedish Hip Joint Registries Data.

BACKGROUND: Prosthetic implants used in total hip replacements (THR) have a range of bearing surface combinations (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, and metal-on-metal), head sizes (small [<36 mm in diameter] and large [≥36 mm in diameter]), and fixation techniques (cemented, uncemented, hybrid, and reverse hybrid). These can influence prosthesis survival, patients' quality of life, and healthcare costs. OBJECTIVES: To compare the lifetime cost-effectiveness of implants for patients of different age and sex profiles. METHODS: We developed a Markov model to compare the cost-effectiveness of various implants against small-head cemented metal-on-polyethylene implants. The probability that patients required 1 or more revision surgeries was estimated from analyses of more than 1 million patients in the UK and Swedish hip joint registries, for men and women younger than 55, 55 to 64, 65 to 74, 75 to 84, and 85 years and older. Implant and healthcare costs were estimated from local procurement prices, national tariffs, and the literature. Quality-adjusted life-years were calculated using published utility estimates for patients undergoing THR in the United Kingdom. RESULTS: Small-head cemented metal-on-polyethylene implants were the most cost-effective for men and women older than 65 years. These findings were robust to sensitivity analyses. Small-head cemented ceramic-on-polyethylene implants were most cost-effective in men and women younger than 65 years, but these results were more uncertain. CONCLUSIONS: The older the patient group, the more likely that the cheapest implants, small-head cemented metal-on-polyethylene implants, were cost-effective. We found no evidence that uncemented, hybrid, or reverse hybrid implants were the most cost-effective option for any patient group. Our findings can influence clinical practice and procurement decisions for healthcare payers worldwide.

Cost-Effectiveness of Dual Mobility and a Value-Based Algorithm of Utilization.

Hip dislocation remains a major concern following total hip arthroplasty due to its high frequency and economic burden. This article evaluates the cost-effectiveness regarding dual mobility as an alternative to standard implant designs. A review of literature analyzing the PubMed Central database was undertaken using the following terms in the primary query: dual mobility, cost-effectiveness, cost-analysis, or economic analysis. Dual mobility systems may be a cost-effective alternative when the price of the implant does not exceed the traditional system by $1023. Dual mobility cups may be an essential component for the future success of value-based total hip arthroplasty.

Are Ceramic Bearings Becoming Cost-Effective for All Patients Within a 90-Day Bundled Payment Period?

BACKGROUND: We analyzed whether the total hospital cost in a 90-day bundled payment period for ceramic-on-polyethylene (C-PE) and ceramic-on-ceramic (COC) total hip arthroplasty (THA) bearings was changing over time, and whether the cost differential between ceramic bearings and metal-on-polyethylene (M-PE) bearings was approaching the previously published tipping point for cost-effectiveness of US$325. METHODS: A total of 245,077 elderly Medicare patients (65+) who underwent primary THA between 2010 and 2015 were identified from the United States Medicare 100% national administrative hospital claims database. The total inpatient cost, calculated up to 90 days after index discharge, was computed using cost-to-charge ratios, and hospital payment was analyzed. The differential total inpatient cost of C-PE and COC bearings, compared to metal-on-polyethylene (M-PE), was evaluated using parametric and nonparametric models. RESULTS: After adjustment for patient and clinical factors, and the year of surgery, the mean hospital cost up to 90 days for primary THA with C-PE or COC was within ±1% of the cost for primary THA with M-PE bearings (P < .001). From the nonparametric analysis, the median total hospital cost was US$296-US$353 more for C-PE and COC than M-PE. Cost differentials were found to decrease significantly over time (P < .001). CONCLUSION: Patient and clinical factors had a far greater impact on the total cost of inpatient THA surgery than bearing selection, even when including readmission costs up to 90 days after discharge. Our findings indicate that the cost-effectiveness thresholds for ceramic bearings relative to M-PE are changing over time and increasingly achievable for the Medicare population.

Use of the Corail stem for revision total hip arthroplasty: evaluation of clinical outcomes and cost

Background: With the growing number of total hip arthroplasty (THA) procedures performed, revision surgery is also proportionately increasing, resulting in greater health care expenditures. The purpose of this study was to assess clinical outcomes and cost when using a collared, fully hydroxyapatite-coated primary femoral stem for revision THA compared to commonly used revision femoral stems. Methods: We retrospectively identified patients who underwent revision THA with a primary stem between 2011 and 2016 and matched them on demographic variables and reason for revision to a similar cohort who underwent revision THA. We extracted operative data and information on in-hospital resource use from the patients' charts to calculate average cost per procedure. Patient-reported outcomes were recorded preoperatively and 1 year postoperatively. Results: We included 20 patients in our analysis, of whom 10 received a primary stem and 10, a typical revision stem. There were no significant between-group differences in mean Western Ontario and McMaster Universities Osteoarthritis Index score, Harris Hip Score, 12-Item Short Form Health Survey (SF-12) Mental Composite Scale score or Physical Composite Scale score at 1 year. Operative time was significantly shorter and total cost was significantly lower (mean difference ­3707.64, 95% confidence interval ­5532.85 to ­1882.43) with a primary stem than with other revision femoral stems. Conclusion: We found similar clinical outcomes and significant institutional cost savings with a primary femoral stem in revision THA. This suggests a role for a primary femoral stem such as a collared, fully hydroxyapatite-coated stem for revision THA.

Contexte: Avec le nombre croissant d'interventions pour prothèse de hanche (PTH) effectuées, la chirurgie de révision est aussi proportionnellement en hausse, ce qui entraîne des coûts supérieurs pour le système de santé. Le but de cette étude était d'évaluer les résultats cliniques et le coût associés à l'emploi d'une prothèse fémorale primaire à collerette entièrement recouverte d'hydroxyapatite pour la révision de PTH, comparativement à d'autres prothèses d'usage courant utilisées pour les révisions. Méthodes: Nous avons identifié rétrospectivement les patients ayant subi une révision de PTH avec une prothèse primaire entre 2011 et 2016 et nous les avons assortis selon les caractéristiques démographiques et le motif de la révision à une cohorte similaire soumise à une révision de PTH. Nous avons extrait les données sur l'opération et sur l'utilisation des ressources hospitalières à partir des dossiers des patients pour calculer le coût par intervention. Les résultats déclarés par les patients ont été notés avant l'intervention et 1 an après. Résultats: Nous avons inclus 20 patients dans notre analyse, dont 10 ont reçu une prothèse primaire et 10, une révision de prothèse typique. On n'a noté aucune différence significative entre les groupes pour ce qui est du score WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) moyen pour l'arthrose, du score de Harris pour la hanche, ou des sous-échelles santé mentale ou santé physique à 1 an du questionnaire SF-12 (12-Item Short Form Health Survey). L'intervention a duré significativement moins longtemps et le coût a été significativement moindre (différence moyenne ­3707,64, intervalle de confiance de 95 % ­5532,85 à ­1882,43) avec une prothèse primaire qu'avec les autres prothèses de révision. Conclusion: Nous avons observé des résultats cliniques similaires et des économies significatives pour l'établissement avec la prothèse primaire utilisée pour la révision de PTH. Cela donne à penser que la prothèse fémorale primaire, par exemple, à collerette et entièrement recouverte d'hydroxyapatite, aurait un rôle à jouer pour la révision de PTH.

Hip hemiarthroplasty for fractured neck of femur; a freedom of information study to assess national variation in implant selection and procurement.

INTRODUCTION: During 2016, according to the National Hip Fracture Database (NHFD), over 65,000 patients suffered a hip fracture of which approximately half underwent hemiarthroplasty. Clear guidelines exist on the usage of proven cemented implants. The Getting It Right First Time (GIRFT) Report highlighted the financial implications of 'unwarranted variation' and stressed the importance of rationalising and standardising service provision, in particular implant usage. The primary aims of this study were to investigate the variation in hip hemiarthroplasty implant usage and associated costs. We hypothesised there to be large variation in implants used and procurement costs. METHODS: Freedom of Information Requests (FOI) were sent to all 177 hospitals listed in the 2017 NHFD Report as treating hip fracture patients. All hospitals were asked for their most commonly used hemiarthroplasty implant and the cost of this, per patient. RESULTS: One hundred sixty six (94%) responses were received. Eighty four (51%) provided implant name and cost, 78 (47%) provided implant name but refused costs and 4 (3%) refused to provide any details. Nineteen different prostheses were used nationally with 20 hospitals using a non-ODEP (Orthopaedic Data Evaluation Panel) 10A implant. Average total cost was £725.00 (range £71-£1378). Significant cost variation was demonstrated for the same implants; one implant was £978.19 at it's most costly and £285.59 at it's cheapest. DISCUSSION: The aims of this study have been met. We have demonstrated huge variation in the implants used for hip hemiarthroplasty and their costs. Notwithstanding the nuances of departmental procurement processes, the financial implications for this variation are significant. CONCLUSIONS: This article demonstrates a requirement for rationalisation of implant usage and procurement in order to potentially improve patient outcomes and provide opportunities for significant cost saving in an already overstretched health service.

Cost Analysis of Dual-Mobility Versus Large Femoral Head Constructs in Revision Total Hip Arthroplasty.

BACKGROUND: The purpose of this study is to report healthcare payer costs of dual-mobility (DM) and large femoral head (LFH) constructs in revision total hip arthroplasties (THAs). METHODS: A Markov model was constructed to analyze costs of re-interventions incurred by Medicare and private payers over a 3-year time horizon in patients who underwent unilateral revision THA with DM (n = 126) or LFH (n = 176) implants. Model states and probabilities were derived from prospectively collected registry data. Medicare costs were estimated as the weighted-average national Medicare payment for revision THA. Private payer costs were estimated by using a multiplier of Medicare costs. RESULTS: Over a 3-year period following revision THA, re-interventions were performed in 11 (9%) DM patients and 34 (19%) LFH patients, costing $263-$1898 in DM THAs and $1285-$3946 in LFH THAs for Medicare. When compared to LFH implants, DM constructs were less costly to Medicare and private payers, resulting in cost differentials of $1536 and $2611, respectively. CONCLUSIONS: At mid-term follow-up, DM constructs utilized in revision THAs were associated with 11% lower absolute risk of re-intervention and payer savings of $1500-$2500 per case when compared to LFH constructs. LEVEL OF EVIDENCE: Economic and decision analysis, Level III.

The cost-effectiveness of dual mobility in a spinal deformity population with high risk of dislocation: a computer-based model.

AIMS: The routine use of dual-mobility (DM) acetabular components in total hip arthroplasty (THA) may not be cost-effective, but an increasing number of patients undergoing THA have a coexisting spinal disorder, which increases the risk of postoperative instability, and these patients may benefit from DM articulations. This study seeks to examine the cost-effectiveness of DM components as an alternative to standard articulations in these patients. PATIENTS AND METHODS: A decision analysis model was used to evaluate the cost-effectiveness of using DM components in patients who would be at high risk for dislocation within one year of THA. Direct and indirect costs of dislocation, incremental costs of using DM components, quality-adjusted life-year (QALY) values, and the probabilities of dislocation were derived from published data. The incremental cost-effectiveness ratio (ICER) was established with a willingness-to-pay threshold of $100 000/QALY. Sensitivity analysis was used to examine the impact of variation. RESULTS: In the base case, patients with a spinal deformity were modelled to have an 8% probability of dislocation following primary THA based on published clinical ranges. Sensitivity analysis revealed that, at its current average price ($1000), DM is cost-effective if it reduces the probability of dislocation to 0.9%. The threshold cost at which DM ceased being cost-effective was $1180, while the ICER associated with a DM THA was $71 000 per QALY. CONCLUSION: These results indicate that under specific clinical and economic thresholds, DM components are a cost-effective form of treatment for patients with spinal deformity who are at high risk of dislocation after THA. Cite this article: Bone Joint J 2018;100-B:1297-1302.

Value of External Data in the Extrapolation of Survival Data: A Study Using the NJR Data Set.

BACKGROUND: Extrapolation of time-to-event data can be a critical component of cost-effectiveness analysis. OBJECTIVES: To contrast the value of external data on treatment effects as a selection aid in model fitting to the clinical data or for the direct extrapolation of survival. METHODS: We assume the existence of external summary data on both treatment and control and consider two scenarios: availability of external individual patient data (IPD) on the control only and an absence of external IPD. We describe how the summary data can be used to extrapolate survival or to assess the plausibility of extrapolations of the clinical data. We assess the merit of either approach using a comparison of cemented and cementless total hip replacement as a case study. Merit is judged by comparing incremental net benefit (INB) obtained in scenarios with incomplete IPD with that derived from modeling external IPD on both treatment and control. RESULTS: Measures of fit with the external summary data did not identify survival model specifications that best estimated INB. Addition of external IPD for the control only did not improve estimates of INB. Extrapolation of survival using the external summary data comparing treatment and control improved estimates of INB. CONCLUSIONS: Our case study indicates that summary data comparing treatment and control are more valuable than IPD limited to the control when extrapolating event rates for cost-effectiveness analysis. These data are best exploited in direct extrapolation of event rates rather than as an aid to select extrapolations on the basis of the clinical data.

Are Ceramic Bearings Becoming Cost-Effective for All Patients?

BACKGROUND: The purpose of this study is to analyze whether the cost for ceramic-on-polyethylene (C-PE) and ceramic-on-ceramic (COC) bearings used in primary total hip arthroplasty (THA) was changing over time, and if the cost differential between ceramic bearings and metal-on-polyethylene (M-PE) bearings was approaching the previously published tipping point for cost-effectiveness of $325. METHODS: A total of 245,077 elderly Medicare patients (65+) who underwent primary THA between 2010 and 2015 were identified from the United States Medicare 100% national administrative hospital claims database. The inpatient hospital cost, calculated using cost-to-charge ratios, and hospital payment were analyzed. The differential cost of C-PE and COC bearings, compared to M-PE, were evaluated using parametric and nonparametric models. RESULTS: After adjustment for patient and clinical factors, and the year of surgery, the mean hospital cost and payments for primary THA with a C-PE or COC was within ±1% of the cost for primary THA with M-PE bearings (P < .001). From the nonparametric analysis, the median hospital cost was $318-$360 more for C-PE and COC than M-PE. The differential in median Medicare payment for THA with ceramic bearings compared to M-PE was <$100. Cost differentials were found to decrease significantly over time (P < .001). CONCLUSION: Patient and clinical factors had a far greater impact on the cost of inpatient THA surgery than bearing selection. Because we found that costs and cost differentials for ceramic bearings were decreasing over time, and approaching the tipping point, it is likely that the cost-effectiveness thresholds relative to M-PE are likewise changing over time and should be revisited in light of this study.

The Cost-Effectiveness of Dual Mobility Implants for Primary Total Hip Arthroplasty: A Computer-Based Cost-Utility Model.

BACKGROUND: Dislocation remains a clinically important problem following primary total hip arthroplasty, and it is a common reason for revision total hip arthroplasty. Dual mobility (DM) implants decrease the risk of dislocation but can be more expensive than conventional implants and have idiosyncratic failure mechanisms. The purpose of this study was to investigate the cost-effectiveness of DM implants compared with conventional bearings for primary total hip arthroplasty. METHODS: Markov model analysis was conducted from the societal perspective with use of direct and indirect costs. Costs, expressed in 2013 U.S. dollars, were derived from the literature, the National Inpatient Sample, and the Centers for Medicare & Medicaid Services. Effectiveness was expressed in quality-adjusted life years (QALYs). The model was populated with health state utilities and state transition probabilities derived from previously published literature. The analysis was performed for a patient's lifetime, and costs and effectiveness were discounted at 3% annually. The principal outcome was the incremental cost-effectiveness ratio (ICER), with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to explore relevant uncertainty. RESULTS: In the base case, DM total hip arthroplasty showed absolute dominance over conventional total hip arthroplasty, with lower accrued costs ($39,008 versus $40,031 U.S. dollars) and higher accrued utility (13.18 versus 13.13 QALYs) indicating cost-savings. DM total hip arthroplasty ceased being cost-saving when its implant costs exceeded those of conventional total hip arthroplasty by $1,023, and the cost-effectiveness threshold for DM implants was $5,287 greater than that for conventional implants. DM was not cost-effective when the annualized incremental probability of revision from any unforeseen failure mechanism or mechanisms exceeded 0.29%. The probability of intraprosthetic dislocation exerted the most influence on model results. CONCLUSIONS: This model determined that, compared with conventional bearings, DM implants can be cost-saving for routine primary total hip arthroplasty, from the societal perspective, if newer-generation DM implants meet specific economic and clinical benchmarks. The differences between these thresholds and the performance of other contemporary bearings were frequently quite narrow. The results have potential application to the postmarket surveillance of newer-generation DM components. LEVEL OF EVIDENCE: Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Revision Total Hip Arthroplasty-Reducing Hospital Cost Through Fixed Implant Pricing.

BACKGROUND: A large component of the cost of revision total hip arthroplasty (THA) is the cost of the implants. We examined the pricing of revision THA implants to determine the possible savings of different pricing models. METHODS: From our institutional database, all revision THAs done from 9/1/2013 to 8/31/2014 were identified. The cost of the implants was analyzed as a percentage of the total cost of the hospitalization and compared to direct to hospital and fixed implant pricing models. RESULTS: Of 153 revision THAs analyzed, the cost of implants amounted to 36% of the total hospital cost. The direct to hospital cost and fixed implant pricing models would reduce the cost of an all-component revision to $4395 (saving $8962 per case) and $5000 (saving $8357 per case). CONCLUSION: Both fixed implant pricing and the direct to hospital pricing models would result in a decrease in revision implant costs.

Técnica de recuperación acelerada (fast-track) aplicada a cirugía protésica primaria de rodilla y cadera. Análisis de costos y complicaciones / Fast-track recovery technique applied to primary total hip and knee replacement surgery. Analysis of costs and complications

Objetivo. Determinar el ahorro económico que supone la implantación de un sistema de recuperación rápida (fast-track) al compararlo con el método de recuperación convencional en artroplastia primaria de cadera (ATC) y rodilla (ATR). Asimismo, determinar si existen diferencias entre ambos en el índice de complicaciones. Material y métodos. Estudio retrospectivo descriptivo, incluyendo 100 artroplastias primarias utilizando el método fast-track y 100 utilizando recuperación convencional. Las variables comparadas entre ambos grupos fueron edad, sexo, índice de comorbilidad de Charlson, ASA, estancia media, complicaciones intrahospitalarias y durante los primeros seis meses e índice de reingresos y transfusiones. Se determinó el coste global para cada procedimiento y por día de ingreso, y el ahorro se calculó según la reducción de la estancia media. Resultados. Ambos grupos fueron comparables en cuanto a edad, sexo, ASA e índice de Charlson. La reducción de la estancia media hospitalaria fue de 4,5 días para el grupo de ATR y 2,1 días para el de ATC. El ahorro calculado fue de 1.266 euros para el grupo de ATR y de 583 euros en el de ATC. No se observaron diferencias significativas en cuanto a complicaciones intrahospitalarias, necesidad de transfusiones, reingresos y complicaciones durante los primeros 6 meses. Discusión. Existen pocos trabajos de análisis de costos en relación con la implantación de sistemas de recuperación rápida en cirugía protésica. Diversas series publicadas tampoco observaron un mayor índice de complicaciones utilizando este método. La utilización del método fast-track representó un ahorro de 1.266 euros para el grupo de ATR y de 583 euros para el grupo de ATC sin aparente repercusión sobre el índice de complicaciones (AU)

Purpose. To determine the cost reduction and complication rates of using an enhanced recovery pathway (Fast-track) when compared to traditional recovery in primary total hip replacement (THR) and total knee replacement (TKR), as well as to determine if there were significant differences in complication rates. Material and methods. Retrospective review of 100 primary total arthroplasties using the Fast-track recovery system and another 100 using conventional recovery. Gender, Charlston comorbidity index, ASA score, length of stay and early complications were measured, as well in-hospital complications and those in the first six months, re-admissions and transfusion rates. The total and daily cost of stay was determined and the cost reduction was calculated based on the reduction in the length of stay found between the groups. Results. Both groups where comparable as regards age, gender, ASA score, and Charlston index. The mean reduction in length of stay was 4.5 days for TKR and 2.1 days for THR. The calculated cost reduction was 1266 euros for TKR and 583 euros for THR. There were no statistically significant differences between groups regarding in-hospital complications, transfusion requirements, re-admissions and complication rates in the first six months. Discussion. There are few publications in the literature reviewed that analyse the cost implications of using fast-track recovery protocols in arthroplasty. Several published series comparing recovery protocols found no significant differences in complication rates either. The use of a fast-track recovery protocol resulted in a significant cost reduction of 1266 euros for the TKR group and 583 for the THR group, without affecting complication rates (AU)