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Tuesday, September 17, 2013

What is the Societal Value of Total Knee Replacement?

Post provided by American Academy of Orthopedic Surgery

With all the attention on the cost of health care, an important factor is being overlooked: the impact on society resulting from the treatment of a particular condition. Comparing that impact when both surgical and nonsurgical treatments are available is particularly important in a specialty such as orthopaedics, which focuses on restoring mobility and health.

“A number of studies have already looked at the cost-effectiveness to individual patients for certain orthopaedic procedures, including total hip and total knee arthroplasties,” said AAOS Past President John R. Tongue, MD. In outlining the goal behind “The Direct and Indirect Costs to Society of Treatment for End-Stage Knee Osteoarthritis,” a study published in the Aug. 21 issue of the Journal of Bone & Joint Surgery, Dr. Tongue noted, “We wanted to examine the cost-effectiveness of orthopaedic procedures from a societal point of view.

“For example, if you’re a 55-year-old teacher and you need a total knee arthroplasty (TKA) to keep teaching, and you undergo the procedure, you’re going to continue to work; you’re going to continue to pay taxes. If you don’t, you’re more likely to sit around, developing other comorbidities, gaining weight, having poor quality of life, and collecting disability.”

Applying a new model
Inspired by published research that attempted to quantify the societal impact of deaths and injuries from roadway trauma, Dr. Tongue contacted an economist friend to see if it might be possible to similarly quantify the impact of orthopaedic procedures.

The economist, John Duffield, PhD, proposed conducting a literature search to identify previous work that may have covered similar ground, then building on that research to develop a new methodology that could be applied to specific medical conditions. To carry out this objective, AAOS engaged KNG Health Consulting, LLC, and its research partners at IHS Global, Inc., and Duke University.

$12 billion in savings
To estimate the societal value of TKA, the research team generated results based on adults age 40 years or older who underwent TKA during 2009. According to the authors, the study population accounted for 99 percent of all TKAs performed in the United States that year.

The researchers calculated direct costs, quality-of-life, and most importantly the lifetime indirect cost of TKA. These indirect costs components capture the effects of surgery on a patient’s ability to work, patient earnings, disability payments, and missed work days. For modeling purposes, the researchers conservatively assumed that all patients retire at age 75.

The research team found that, compared with nonsurgical treatment, undergoing TKA increased direct costs per patient by an average of $20,635 (based on 2009 dollars). Those costs were offset by societal savings of an average $39,565 per patient based on reduced indirect costs, producing an estimated $18,930 in lifetime savings to society per patient.

Overall, the researchers found that 85 percent of the societal savings were associated with increased employment and earnings. The remaining 15 percent were linked to fewer missed work days and lower disability payments.

Based on the more than 600,000 TKAs performed in the United States during 2009, the study authors estimated a lifetime societal savings of approximately $12 billion for the single year studied.

“When we submitted the study, there was some concern among reviewers that the findings could be interpreted as, ‘everyone should get surgery,’” said Dr. Koenig. “It’s important to understand that is not the conclusion of the study. The conclusion is that, for the cohort of people who have surgery, there are—on average—societal savings. For many reasons, some patients don’t undergo surgery. Our analysis was based on the cohort of patients who actually underwent surgery.”

Further research
The TKA study is the first of five similar research papers planned for publication, each examining the value of a different orthopaedic procedure.

“We chose a variety of conditions based on high economic impact and to demonstrate the breadth of our specialty,” said Dr. Tongue. “We have already submitted for publication papers on rotator cuff repair and anterior cruciate ligament repair, and two more studies—one looking at hip fracture and one on lumbar diskectomy—are in the works.”

“What I find most exciting about this research,” said Dr. Tongue, “is that it changes the conversation from how expensive orthopaedic procedures are, to how valuable they are. You don’t have to try to stretch any estimates, because the value for each procedure is tremendous.”

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