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Table 2 Summary of main results

From: Cost-effectiveness of surgical interventions for the management of osteoarthritis: a systematic review of the literature

No. Author & Year Intervention(s) evaluated Key result(s) Conclusion QHES scoresa
1. Higashi et al, [35] Total replacement of hip and knee Both hip and knee replacements were cost-effective compared to 'doing nothing' at the pre-defined threshold level of AUD 50,000 per DALY.
• THR : AUD 7100 to 15000 per DALY with different time cost & cost offset
• TKR : AUD 15000 to 26000 per DALY with different time cost & cost offset
Both hip and knee replacements are cost-effective interventions to improve the quality of life of people with OA. 70
2. Bedair et al, [18] Total knee arthroplasty (TKA) Treatment with TKA has a higher initial cost, but the cost benefit in favor of TKA approximately 3.5 years after surgery (a difference of US$69,800 over the same time period when treated with non-operative strategies The total economic cost to society for treatment of severe knee OA in a relatively young working person is markedly lower with TKA than it is with non-operative treatment. 74
3. Losina et al, [36] Total knee arthroplasty (TKA) performed in low, medium and high volume hospitals - Base-case ICER : US$18300 / QALY
- If willingness to pay (WTP) to improve QOL were set at US$50 000 per QALY, TKA had a 93% chance of being the preferred choice (ie, TKA had the highest net benefit) compared with no TKA.
- Low-risk patients : 96% chance that TKA would be preferred to no TKA if WTP US$50 000 per QALY
- High-risk patients : 83% chance that TKA would be preferred to no TKA
- TKA appears to be cost-effective in the US Medicare-aged population, as currently practiced across all risk groups.
- Policy decisions should be made on the basis of available local options for TKA.
- However, when a high-volume hospital is available, TKAs performed in a high-volume hospital confer even greater value per dollar spent than TKAs performed in low-volume centres.
4. Ruiz et al, [31] Total knee arthroplasty (TKA) - Relative to nonsurgical treatment, the mean lifetime net societal savings per patient resulting from TKA was US$18,930
- Each TKA increased lifetime direct costs by a mean of US$20,635, while the societal savings in lower indirect costs from improved functional status averaged US$39,565.
- Considering only direct costs, the average ICER was US$5656 per QALY gained for TKA in the entire cohort and US$12,410 for those of 80 years old and older.
Overall, TKA was cost-effective across all age groups, assuming a willingness-to-pay threshold of US$50,000 per QALY gained taken from societal perspective. 71
5. Waimann et al, [32] Total knee arthroplasty (TKA) - The ICERs for WOMAC improvement at 6 months were as follows:
1) US$33,345 to achieve an MCID
2) US$25,255 per each WOMAC20 improvement,
3) US$35,274 per each WOMAC50 improvement
4) US$56,908 per each WOMAC70 improvement
- TKA would be a cost-effective intervention if the WTP amount for the minimum clinically significant absolute or relative improvement were US$50,000.
Although there was no established WTP value for WOMAC change, TKA appeared to be a cost-effective intervention for end-stage knee OA at both low and high levels of improvement in the patients’ pain and function. 60
6. Xie et al, [27] Total knee arthroplasty (TKA) - ICUR was US$65,245/QALY from the societal perspective.
- The probability of TKA being a cost-effective strategy is less than 0.4 from the societal or patients’ perspective if the WTP is US$50,000/QALY.
- In contrast, the probability that TKR is a cost effective strategy is 0.7 from the government’s perspective if the WTP is only US$10,000/QALY
TKA gained more QALYs at higher costs compared to UKA. However, a long-term prospective study is necessary to determine the cost-effectiveness of TKR and UKA. 62
7. Koskinen et al,[21] Unicondylar knee arthroplasty (UKA) - The mean cost of one revision from UKA to TKA was €8,660 including implant, hospital stay, operation, and other direct costs. Thus, the costs saved by lower implant prices and shorter hospital stay for UKA as compared to TKA would not cover the costs of the extra revisions. At a nationwide level, UKA had significantly poorer long-term survival than TKA. UKA did not even have a theoretical cost benefit over TKA in the study. Based on the results, widespread use of UKA in the treatment of unicompartmental OA of the knee cannot be recommended. 33
8. SooHoo et al, [25] Unicondylar knee arthroplasty (UKA) - In reference case, UKA has only small gain of QALY (0.02) and minimal increment in costs, from US$18,995 to US$19,000 compared to TKA
- Reference case ICER : US$277 per QALY gained.
- In lower durability / survival of UKA in terms of function, UKA becomes less effective and more costly.
- If durability / survival of TKA is longer (range 15 to 20 years), TKR becomes more cost effective.
- If TKR durability is 20 years, the ICER for UKA would be $45,958 per QALY gained when UKA is assumed to be functional up to 17 years (abelow threshold)
This analysis demonstrates the potential for UKA to be a cost-effective alternative to TKA, depending on the cost as well as the durability and function of a UKA. 59
9. Li et al, 2013 [22] KineSpring Knee Implant System - intermediate treatment between conservative care and joint-altering surgery targeting the treatment gap in knee OA patients. - Assuming the durability of 10 years, the cost-utility ratio of each intervention compared to no treatment :
• KineSpring : €3,402 ± 4,168/QALY,
• Surgical interventions : €4,899 ± 1,094/QALY
• Conservative treatments : €9,996 ± 13,612/QALY
The KineSpring Knee Implant System for knee OA is a cost-effective strategy over other surgical and conservative treatments for patients in Germany. 44
10. Suter et al, [26] “innovative” TKA implants - Innovative implants offered ≥50% decrease in long-term TKA failure at ≤50% increased cost offered ICERs < US$100,000 regardless of age or baseline comorbidity.
- Innovative implant provided a 20% decrease in long-term failure at 50% increased cost provided ICERs < US$150,000 per QALY gained only among healthy 50–59-year-olds.
- Increasing short-term failure, consistent with recent device failures, reduced cost-effectiveness in all groups.
Innovative implants must decrease actual TKA failure, not just radiographic wear, by 50–55% or more over standard implants to be broadly cost-effective. 65
11. Mota, [38] Early primary THA - Early THA has cost-effectiveness ratios of €4100 or below in all cases.
- Among 80-year-olds, early THA is (extended) dominant = ICER of €20,406.
- Delayed THA is not cost-effective at any threshold for base-case scenario.
- At age 65 years, the ICER for THA over delayed THA was €987 in men and €466 in women.
In summary, results suggest that THA is a cost-effective treatment option, and in general should be offered without delay to functionally independent patients with severe OA. 82
12. Räsänen et al, [28] 1. Primary THA
2. Secondary / revision THA
3. Primary TKA
- The cost per QALY gained (ICUR) was lowest in the primary THA group , followed by primary TKA & revision THA.
• Primary THA : €6710 per QALY gained
• Primary TKA : €13,995 per QALY gained
• Revision THA : €52,274 per QALY gained
Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is twice that gained from hip replacement. 49
13. Bozic et al, [29] Metal-on-metal hip resurfacing arthroplasty (MoM-HRA) - Lowest ICER [most cost-effective] : men age 55 to 64 (US$28,614/QALY gain)
- Three groups with ICER below threshold [below US$50,000/QALY gained) :
• men age 55 to 64 (as above)
• women younger than 55 (US$47,468/QALY gained)
• men younger than 55 (US$48,882/ QALY gained)
MoM-HRA could be clinically advantageous and cost-effective in younger men and women. Further research on the comparative effectiveness of MoM-HRA versus THA should include assessments of the quality of life and resource use in addition to the clinical outcomes associated with both procedures. 82
14. Heintzbergen et al, [37] Metal-on-metal hip resurfacing arthroplasty (MoM-HRA) - Base-case : MoM HRA dominates with -CAD $583 and mean difference QALY 0.079.
- With WTP at CAD$50,000/QALY gain, probability HRA is cost-effective are:-
• base case : 58%
• male 60 years : 9%
• male 40 years : 92% - most cost-effective
- The results and uncertainty in base-case analyses suggest that in terms of cost-effectiveness, there is little difference between MoM HRA and THA.
- In terms of gender, MoM HRA was preferable in men and THA in women
- Age wise, MoM HRA was preferable in younger patients and THA in older patients
On average, MoM-HRA was preferred to THA for younger and male patients, but THA is still a reasonable option if the patient or clinician prefers given the small absolute differences between the options and the confidence ellipses around the cost-effectiveness estimates. 81
15. Di Tanna et al, [39] Cementless fixation technique for THA - Base-case ICER : €2402 per "revision-free" life year
- Cementless strategy dominant for patients up to 42-y-old (i.e., less costly and more beneficial compared with the hybrid solution)
- 43-yr-old onwards, it still remains more effective but with an additional cost : the resulting ICERs showed a direct proportionality to increasing age
- From CEAC:
• the cementless intervention as a strategy with a high probability (0.88) of being cost effective at 70 y from values of WTP above €2400
• In case of a 75-y-old patient with WTP of €9000, a cementless approach results cost effective with a probability of 0.89.
Following a deterministic sensitivity analysis, hybrid and cementless fixation showed a dominance profile for patients older than 83 y and younger than 43 y, whereas for all ages in between, there is a progressive increase in the ICER of cementless prostheses. 62
16. Pennington et al, [41] Cementless and hybrid prosthesis for THA - The ICER for a hybrid prosthesis compared with a cemented prosthesis was about £2100 per QALY for men and £2500 for women.
- For men aged 60 or 80 and for women aged 60, hybrid prostheses gave the highest expected net benefit and had the highest probability of being the most cost effective prosthesis.
- For women aged 80, cemented prostheses were most cost effective.
- Hybrid prostheses remained likely to be the most cost effective option for men and women aged 70.
- Cemented prostheses are the cheapest option, but hybrid prostheses lead to greater gains in mean post-operative quality of life and are the most cost effective alternative for most patients.
- Cementless prostheses do not improve health outcomes sufficiently to justify their higher costs.
17. Konopka et al, [33] High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) - Base case QALYs : 14.62 (HTO), 14.63 (UKA) and 14.64 (TKA).
- Discounted total direct medical costs : $20,436 (HTO), $24,637 (UKA) and $24,761 (TKA)
- ICER for TKA: $231,900/ QALY
- ICER for UKA: $420,100/ QALY
- PSA: At a WTP threshold of $50,000 per QALY, HTO was cost-effective 57% of the time; TKA 24%; and UKA 19%.
- At a WTP threshold of $100,000 per QALY, high HTO 43% of time, TKA 31%; and UKA 26%.
In 50 to 60-year-old patients with medial unicompartmental knee OA, HTO is an attractive option compared with UKA and TKA
The cost-effectiveness of HTO and of UKA depends on rates of conversion to TKA and the clinical outcomes of the conversions.
18. Marsh et al, [19] Arthroscopic surgery (partial resection and debridement of degenerative meniscal tears and/or articular cartilage) in addition to non-operative treatments - The ICER was $140.94 (societal), or $120.83 (payer) per one-point improvement on the 2400 point WOMAC total score, translating to $28,188 (societal) and $24,166 (payer) for a clinically important improvement.
- The ICUR was equal to − $110,569 (societal) or − $94,792.50 (payer) per QALY gained, where the negative value indicates paying more for a worse outcome.
- Uncertainty estimates suggest that even if WTP $400 000 to achieve a clinically important improvement in WOMAC score, or ≥ $50 000 for an additional QALY, there is <20% probability that the addition of arthroscopy is cost-effective compared with nonoperative therapies only.
Arthroscopic debridement of degenerative articular cartilage and resection of degenerative meniscal tears in addition to nonoperative treatments for knee OA is not an economically attractive treatment option compared with non-operative treatment only, regardless of willingness-to-pay value. 74
19. Mather et al, [20] Primary TKA without delay - In the base case, a 2-year wait-time both with and without a non-operative treatment bridge resulted in a lower number of average QALYs gained (11.57 (no bridge) and 11.95 (bridge) vs. 12.14 (no delay).
- The ICER comparing wait-time with no bridge to TKA without delay was $2,901/QALY.
- When comparing TKA without delay to waiting with non-operative bridge, TKA without delay produced greater utility at a lower cost to society.
TKA without delay is the preferred cost-effective treatment strategy when compared to a waiting for TKA without non-operative bridge. TKA without delay is cost saving when a non-operative bridge is used during the waiting period. As it is unlikely that patients waiting for TKA would not receive non-operative treatment, TKA without delay may be an overall cost-saving health care delivery strategy. 76
20. Peersman et al, [34] UKA - UKA was associated with cost reduction compared with primary TKA of –€2,807 and a utility gain of 0.04 QALYs. UKA was therefore considered superior to TKA.
- Analysis determined that the model is sensitive to clinical effectiveness, and that a marginal reduction in the clinical performance of UKA would lead to TKA being the more cost-effective solution.
- The acceptability curve shows that the probability that the ICER falls below the threshold of: €10,000 (77.1%) , €25,000 (65.1%) and €50,000 (60.5%).
UKA yields clear advantages in terms of costs and marginal advantages in terms of health effects, in comparison with TKA. 72
21. Pennington et al, [23] Different brands within types of hips prosthesis (cemented, cementless and hybrid) For women with OA aged 70 years, the Exeter V40 Elite Plus Ogee had the lowest risk of revision (5.9% revision risk, 9.0 QALYs) and the CPT Trilogy had the highest QALYs (10.9% revision risk, 9.3 QALYs).
- Compared with the Corail Pinnacle (the most commonly used brand), the CPT Trilogy is most cost effective, with an incremental net monetary benefit of £876.
- Differences in cost effectiveness between the hybrid CPT Trilogy and Exeter V40 Trident and the cementless Corail Pinnacle and Taperloc Exceed were small.
The hybrid CPT-Trilogy was the most cost effective brand but differences with the hybrid Exeter V40-Trident and the cementless Corail-Pinnacle and Taperloc-Exceed were small. Our study shows the importance of linking PROMs with data on rates of revision after THA but given the extended period of recovery after a THA, collecting further PROMs and QoL beyond the first six months after THA is an important next step which would strengthen future economic evaluations of brands of hip prostheses. 57
22. Pulikottil-Jacob et al, [40] - Metal head (cemented stem) on cemented polyethy-lene cup, CeMoP
- Metal head (cement-less stem) on cement-less hydroxyapetite coated metal cup (polyethylene liner), CeLMoP
- Ceramic head (cementless stem) on cementless hydroxyl-apetite coated metal cup (ceramic liner), CeLCoC
- Hybrid metal head (cemented stem) on cementless hydroxyl-apetite coated metal cup (polyethylene liner), HyMoP
- Ceramic head (cemented stem) on cemented polyethy-lene cup, CeCoP
- base-case analysis : At a WTP £20,000 per QALY, a cemented prosthesis with metal-onpolyethylene or ceramic-on-polyethylene bearings had the greatest probability of being cost-effective for all groups of age and gender over a lifetime.
- The differences in QALYs between categories were extremely small and differences in mean costs were borderline, between only £2550 and £3000 over a lifetime for all comparisons, irrespective of age or gender.
- There are large uncertainties, particularly regarding the costs of prostheses and the estimates of lifetime QOL.
On the basis of such small differences and such considerable uncertainties, it is difficult to make a comparison between the cost-effectiveness of different types of prosthesis. Until better data dealing with costs and outcomes become available, it is difficult to justify the recommendation of one type of device over another on considerations of cost effectiveness alone. The choice of prosthesis should be determined by rates of revision, local costs and the preferences of both the surgeon and the patient 62
23. Stan et al, [24] - Unilateral TKA (G2)
- TKA following HTO (G3)
- No statistically significant differences was found between G2 and G3 regarding clinical or radiological outcomes.
- Median benefit estimate for patients who did not previously suffered a HTO procedure was smaller then benefit for those who did.
- A median CER of 1800 € /QALY was found based on the EuroQol scores for G1; 1268 € / QALY for G2, and 1975 € / QALY for G3.
Conservative management for knee OA is neither clinically effective for pain or disease progression nor cost effective, when applied for late stages of OA. TKA proved to be a cost effective procedure in treating knee OA. This study reported the lowest cost per QALY in the literature for TKA. TKA after HTO is technically more difficult and lead to a greater rate of perioperative complications 56
  1. aGood quality = ≥75 Moderate quality = 50 to 74 Poor quality = <50