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Impact of Hospital Volume on the Economic Value of Computer Navigation for Total Knee Replacement
James D. Slover, MD, MS1; Anna N.A. Tosteson, ScD2; Kevin J. Bozic, MD, MBA3; Harry E. Rubash, MD4; Henrik Malchau, MD, PhD5
1 Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1616, New York, NY 10010. E-mail address: james.slover@nyumc.org
2 Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, HB7505, Dartmouth Medical School, One Medical Center Drive, Lebanon, NH 03756
3 Department of Orthopaedic Surgery, University of California at San Francisco, 500 Parnassus Avenue, MU 320W, San Francisco, CA 94143
4 Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 3700, Boston, MA 02114
5 Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, GR1126, Boston, MA 02114
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the National Institutes of Health National Institute of Arthritis and Musculoskeletal and Skin Diseases (P60 AR48094). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Commercial entities (Zimmer, Smith and Nephew, Biomet, and UnitedHealthcare) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
Investigation performed at Massachusetts General Hospital, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jul 01;90(7):1492-1500. doi: 10.2106/JBJS.G.00888
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Background: An aim of the use of computer navigation is to reduce rates of revisions of total knee replacements by improving the alignment achieved at the surgery. However, the decision to adopt this technology may be difficult for some centers, especially low-volume centers, where the cost of purchasing this equipment may be high. The purpose of this study was to examine the impact of hospital volume on the cost-effectiveness of this new technology in order to determine its feasibility and the level of evidence that should be sought prior to its adoption.

Methods: A Markov decision model was used to evaluate the impact of hospital volume on the cost-effectiveness of computer-assisted knee arthroplasty in a theoretical cohort of sixty-five-year-old patients with end-stage arthritis of the knee to coincide with the peak incidence of knee arthroplasty in the United States.

Results: Computer-assisted surgery becomes less cost-effective as the annual hospital volume decreases, as the cost of the navigation increases, and as the impact on revision rates decreases. Centers at which 250, 150, and twenty-five computer-navigated total knee arthroplasties are performed per year will require a reduction of the annual revision rate of 2%, 2.5%, and 13%, respectively, per year over a twenty-year period for computer navigation to be cost-effective.

Conclusions: Computer navigation is less likely to be a cost-effective investment in health-care improvement in centers with a low volume of joint replacements, where its benefit is most likely to be realized. However, it may be a cost-effective technology for centers with a higher volume of joint replacements, where the decrease in the rate of knee revision needed to make the investment cost-effective is modest, if improvements in revision rates with the use of this technology can be realized.

Level of Evidence: Economic and decision analysis, Level II. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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