Background: The rising cost of health care has increased the need
for the orthopaedic community to understand and apply economic evaluations. We
critically reviewed the literature on orthopaedic cost-utility analysis to
determine which subspecialty areas are represented, the cost-utility ratios
that have been utilized, and the quality of the present literature.
Methods: We searched the English-language medical literature
published between 1976 and 2001 for orthopaedic-related cost-utility analyses
in which outcomes were reported as cost per quality-adjusted life year. Two
trained reviewers independently audited each article to abstract data on the
methods and reporting practices used in the study as well as the cost-utility
ratios derived by the analysis.
Results: Our search yielded thirty-seven studies, in which 116
cost-utility ratios were presented. Eleven of the studies were investigations
of treatment strategies in total joint arthroplasty. Study methods varied
substantially, with only five studies (14%) including four key criteria
recommended by the United States Panel on Cost-Effectiveness in Health and
Medicine. According to a reader-assigned measure of study quality,
cost-utility analyses in orthopaedics were of lower quality than those in
other areas of medicine (p = 0.04). While the number of orthopaedic studies
has increased in the last decade, the quality did not improve over time and
did not differ according to subspecialty area or journal type. For the
majority of the interventions that were studied, the cost-utility ratio was
below the commonly used threshold of $50,000 per quality-adjusted life year
for acceptable cost-effectiveness.
Conclusions: Because of limitations in methodology, the current body
of literature on orthopaedic cost-utility analyses has a limited ability to
guide policy, but it can be useful for setting priorities and guiding
research. Future research with clear and transparent reporting is needed in
all subspecialty areas of orthopaedic practice.
Level of Evidence: Economic and decision analysis, Level
III. See Instructions to Authors for a complete description of levels of