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Total Knee Replacement Appears
Cost-Effective in Older Adults
Newswise — Total knee
replacement (arthroplasty) appears to be a
cost-effective procedure for older adults
with advanced osteoarthritis, according to a
report in the June 22 issue of Archives of
Internal Medicine, one of the JAMA/Archives
journals.
The procedure appears to be
cost-effective across all patient risk
groups, and appeared more costly and less
effective in low-volume centers than in
high-volume centers.
Approximately 12 percent of
adults older than 60 have symptoms of knee
osteoarthritis, and their direct medical
costs are estimated to range from $1,000 to
$4,100 per person per year, according to
background information in the article.
“Total knee arthroplasty is a
frequently performed and effective procedure
that relieves pain and improves functional
status in patients with end-stage knee
osteoarthritis,” the authors write.
“Almost 500,000 total knee
arthroplasties were performed in the United
States in 2005 at a cost exceeding $11
billion. Projections indicate dramatic
growth in the use of total knee arthroplasty
over the next two decades.”
Elena Losina, Ph.D., of
Brigham and Women’s Hospital and the Boston
University School of Public Health, and
colleagues developed a computer simulation
model and populated it with Medicare claims
data and cost and outcomes data from
national and multinational sources.
They then projected lifetime
costs and quality-adjusted life
expectancy—or the number of years remaining
of good health—for patients at different
levels of risk and receiving total knee
arthroplasty at high-volume or low-volume
facilities.
Overall, having a total knee
arthroplasty increased quality-adjusted life
expectancy of the Medicare population
(average age 74) from 6.822 to 7.957
quality-adjusted life years (years of life
in perfect health).
Total costs increased from
$37,100 among individuals not receiving
total knee arthroplasty to $57,900 per
person undergoing total knee arthroplasty,
resulting in a cost-effectiveness ratio of
$18,300 per quality-adjusted life year.
Therefore, total knee
arthroplasty is a highly cost-effective
procedure for the management of end-stage
knee osteoarthritis compared with
non-surgical treatments and is within the
range of accepted cost-effectiveness for
other musculoskeletal procedures, the
authors note.
“This result is robust across
a broad range of assumptions regarding both
patient risk and hospital volume,” they
write.
“For patients who choose to
undergo total knee arthroplasty, hospital
volume plays an important role: regardless
of patient risk level, higher-volume centers
consistently deliver better outcomes.
But the additional survival
benefits associated with high-volume centers
provide limited cost-effectiveness benefits
for high-risk patients deliberating between
medium- and high-volume centers.”
Even procedures performed in
low-volume centers were more cost-effective
than not having total knee arthroplasty,
regardless of the patient’s risk of
complications.
“Clinicians, patients and
policy makers should consider the relative
cost-effectiveness of total knee
arthroplasty in making decisions about who
should undergo total knee arthroplasty,
where and when,” the authors conclude.
Editorial: Results Highlight Dilemmas in
Health Care System
“Although total knee arthroplasty is a safe
and effective treatment for advanced knee
osteoarthritis, lingering questions remain
regarding variations in patient outcomes due
to differences among patients undergoing the
procedure and among the hospitals where it
is performed,” write Stephen Lyman, Ph.D.,
of Weill Medical College of Cornell
University, and colleagues in an
accompanying editorial.
“In this issue of the
Archives, Losina et al examine these
questions from the perspective of
cost-effectiveness, with a focus on Medicare
enrollees who were 65 years or older,” they
write.
“The overall findings were
favorable to total knee arthroplasty, which
had an incremental cost-effectiveness ratio
of $18,300 per quality-adjusted life year
gained compared with medical treatment
alone.
This figure falls below the
cost-effectiveness thresholds often
mentioned as appropriate, such as the
£20,000 to £30,000 (approximately $29,000 to
$44,000) per quality-adjusted life year
threshold used by the British National
Health Service’s National Institute for
Health and Clinical Excellence.”
“Analyses such as the one
conducted by Losina et al, carefully
conducted and wholly transparent, highlight
several of the dilemmas policy makers face
in evaluating widely used medical
technologies,” they conclude.
“At least in the United
States, even well-performed
cost-effectiveness analyses do not influence
either payers or physicians directly.
"
Payers do not use the results to make
coverage determinations nor do physicians
use them to make treatment decisions. How we
move from this current state to a system in
which cost-effectiveness of procedures
affects medical practice is unclear.”
Approximately 12 percent of
adults older than 60 have symptoms of knee
osteoarthritis, and their direct medical
costs are estimated to range from $1,000 to
$4,100 per person per year, according to
background information in the article.
“Total knee arthroplasty is a
frequently performed and effective procedure
that relieves pain and improves functional
status in patients with end-stage knee
osteoarthritis,” the authors write.
“Almost 500,000 total knee
arthroplasties were performed in the United
States in 2005 at a cost exceeding $11
billion.
"Projections
indicate dramatic growth in the use of total
knee arthroplasty over the next two
decades.”
Elena Losina, Ph.D., of
Brigham and Women’s Hospital and the Boston
University School of Public Health, and
colleagues developed a computer simulation
model and populated it with Medicare claims
data and cost and outcomes data from
national and multinational sources.
They then projected lifetime
costs and quality-adjusted life
expectancy—or the number of years remaining
of good health—for patients at different
levels of risk and receiving total knee
arthroplasty at high-volume or low-volume
facilities.
Overall, having a total knee
arthroplasty increased quality-adjusted life
expectancy of the Medicare population
(average age 74) from 6.822 to 7.957
quality-adjusted life years (years of life
in perfect health).
Total costs increased from
$37,100 among individuals not receiving
total knee arthroplasty to $57,900 per
person undergoing total knee arthroplasty,
resulting in a cost-effectiveness ratio of
$18,300 per quality-adjusted life year.
Therefore, total knee
arthroplasty is a highly cost-effective
procedure for the management of end-stage
knee osteoarthritis compared with
non-surgical treatments and is within the
range of accepted cost-effectiveness for
other musculoskeletal procedures, the
authors note.
“This result is robust across
a broad range of assumptions regarding both
patient risk and hospital volume,” they
write.
“For patients who choose to
undergo total knee arthroplasty, hospital
volume plays an important role: regardless
of patient risk level, higher-volume centers
consistently deliver better outcomes.
"But
the additional survival benefits associated
with high-volume centers provide limited
cost-effectiveness benefits for high-risk
patients deliberating between medium- and
high-volume centers.”
Even procedures performed in
low-volume centers were more cost-effective
than not having total knee arthroplasty,
regardless of the patient’s risk of
complications.
“Clinicians, patients and
policy makers should consider the relative
cost-effectiveness of total knee
arthroplasty in making decisions about who
should undergo total knee arthroplasty,
where and when,” the authors conclude.
Editor’s Note: This research
was supported in part by National Institutes
of Health, National Institute of Arthritis
and Musculoskeletal and Skin Diseases
grants, and an Arthritis Foundation
Innovative Research Grant. Please see the
article for additional information,
including other authors, author
contributions and affiliations, financial
disclosures, funding and support, etc.
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