The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue 4

Scientific Articles | April 01, 2006

Use of Cost-Effectiveness Analysis to Evaluate New Technologies in Orthopaedics: The Case of Alternative Bearing Surfaces in Total Hip Arthroplasty

Kevin J. Bozic, MD, MBA¹; Saam Morshed, MD¹; Marc D. Silverstein, MD²; Harry E. Rubash, MD³; James G. Kahn, MD, MPH⁴

¹ Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus, MU 320W, San Francisco, CA 94143-0728. E-mail address for K.J. Bozic: bozick@orthosurg.ucsf.edu
² Institute for Health Care Research and Improvement, Baylor Health Care System, 8080 North Central Expressway, Suite 500, LB 81, Dallas, TX 75206
³ Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, YAW-3700, Boston, MA 02114
⁴ Institute for Health Policy Studies, University of California, Box 0936, San Francisco, CA 94143

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A commentary is available with the electronic versions of this article, on our web site () and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from an Orthopaedic Research and Education Foundation Health Services Research Fellowship grant. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at Department of Orthopaedic Surgery and Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 Apr 01;88(4):706-714. doi: 10.2106/JBJS.E.00614

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Abstract

Background: Alternative bearing surfaces offer the potential to reduce wear and improve implant longevity following total hip arthroplasty. However, these technologies are associated with higher costs, the potential for unintended consequences, and uncertain benefits in terms of long-term survival of the implants. The purpose of this study was to evaluate the cost-effectiveness of the use of alternative bearings in total hip arthroplasty.

Methods: A decision-analysis model was constructed to estimate the cost-effectiveness of the use of alternative bearings for patients undergoing total hip arthroplasty. Model inputs, including costs, clinical outcome probabilities, and health utility values, were derived from a review of the literature. Sensitivity analyses were performed to evaluate the impact of patient age at the time of surgery, implant costs, and reductions in revision rates on the cost-effectiveness of alternate bearing surfaces.

Results: In a population of fifty-year-old patients, use of an alternative bearing with an incremental cost of $2000 would be cost-saving over the individual's lifetime if it were associated with at least a 19% reduction in the twenty-year implant failure rate when compared with the failure rate for a conventional bearing. In a population of patients over the age of sixty-three years, the same implant would be associated with higher lifetime costs than would a conventional bearing, regardless of the presumed reduction in the revision rate. Conversely, an alternative bearing that adds only $500 to the cost of a conventional total hip arthroplasty could be cost-saving in a population of patients over the age of sixty-five years, even if it were associated with only a modest reduction in the revision rate. In a population of patients over the age of seventy-five years, no alternative bearing would be associated with lifetime cost-savings, regardless of the cost or the presumed reduction in the revision rate.

Conclusions: The cost-effectiveness of alternative bearings is highly dependent on the age of the patient at the time of surgery, the cost of the implant, and the associated reduction in the probability of revision relative to that associated with conventional bearings. Our findings provide a quantitative rationale for requiring greater evidence of effectiveness in reducing the probability of implant failure when more costly alternative bearings are being considered, particularly for older patients.

Level of Evidence: Decision analysis, Level I. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Excellent long-term clinical and radiographic outcomes have been reported following the use of traditional bearing couples of metal and ultra-high molecular weight polyethylene in total hip arthroplasty^1,2. However, concerns regarding implant longevity and the durability of conventional ultra-high molecular weight polyethylene as a bearing surface, particularly in younger, more active patients, have renewed interest in the use of alternative bearing surfaces for total hip arthroplasty^3-5.

Within the past decade, alternative bearings such as highly cross-linked polyethylene and second-generation ceramic-on-ceramic and metal-on-metal bearings have been introduced. Although these newer bearings offer the potential to reduce implant failures related to bearing-surface wear⁶, they are associated with higher implant costs and the possibility for unintended consequences, including instability, impingement, ceramic fracture, material failure of cross-linked polyethylene, and biological responses to metal ions (e.g., hypersensitivity or cancer), all of which could increase revision rates. As with all new health-care technologies, any potential benefits that could be derived from the use of these implants need to be considered in light of any additional clinical risks and economic costs that are associated with their use. Although in vitro laboratory tests with use of hip simulators, clinical retrieval studies, and radio-stereometric analysis⁷ have shown promising results in terms of lower wear rates with metal-on-highly cross-linked polyethylene^8-10, ceramic-on-ceramic^4,11-13, and metal-on-metal bearing couples^5,14-16 when compared with bearing couples consisting of metal and conventional ultra-high molecular weight polyethylene, evidence of improved long-term clinical outcomes in terms of superior implant survival is lacking¹⁷.

The gold standard for demonstrating clinical benefits of new technologies is the randomized, controlled trial. However, performance of such a trial to compare long-term revision rates between total hip arthroplasties with an alternative bearing and total hip arthroplasties with a metal-on-conventional ultra-high molecular weight polyethylene bearing would necessitate randomizing large numbers of patients and following them for a long period (e.g., fifteen to twenty years or more) in order to detect small differences in failure rates. Practical considerations of time and cost make these types of studies difficult to execute¹⁸. In contrast, decision-analysis techniques offer the potential to analyze the performance of a new technology prior to the availability of long-term clinical outcome data. Furthermore, by identifying the variables that have the greatest influence on the cost-effectiveness of a new technology, the findings from a well-designed decision-analysis study can be used to guide further clinical and laboratory research. This cost-effectiveness framework can also be readily updated as new information on costs and clinical effectiveness emerges from randomized trials and cohort studies.

The primary objectives of this study were to establish a framework with which to evaluate the cost-effectiveness of alternative bearings for use in total hip arthroplasty and to analyze how variables such as patient age at the time of the primary total hip arthroplasty, implant costs, and reductions in revision rates affect this determination.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Study Design

The design and parameters used in this cost-utility analysis were based on the guidelines of the Panel on Cost-Effectiveness Analysis in Health and Medicine¹⁹. The target group for the baseline analysis was a population of male patients who were fifty years of age, had advanced osteoarthritis of the hip, and were candidates for total hip arthroplasty. The time horizon was the remaining life expectancy of the patient. All direct medical costs associated with the initial surgery and the treatment of any complications and follow-up care, including revision total hip arthroplasty, were considered in the analysis.

Analytic Model

An expected-value decision-analysis model was constructed to calculate the present value of the expected lifetime costs and quality-adjusted life years gained with the use of an alternative bearing couple instead of a metal-on-conventional ultra-high molecular weight polyethylene bearing. A Markov health state model¹⁹ was used to simulate the initial management, clinical course, and outcomes associated with each treatment strategy. A one-year cycle time was used, and patients were moved through transition health states (candidate for primary total hip arthroplasty, after primary total hip arthroplasty, revision total hip arthroplasty, and after a second revision total hip arthroplasty) in the Markov model until they reached one of two absorbing states (death related to the total hip arthroplasty or death from a competing cause) (see Appendix).

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Fig. 1: Impact of age at the time of the primary total hip arthroplasty on the lifetime incremental cost-effectiveness ratio (ICER) of total hip arthroplasty with a hard-on-hard alternative bearing couple compared with that of total hip arthroplasty with a conventional bearing couple. The range of reduction in the probability of implant failure at twenty years is shown for five-year intervals of age at the time of the primary total hip arthroplasty. Thresholds for cost-effectiveness are shown where each ICER curve intersects with a horizontal line representing a willingness-to-pay of $50,000. Cost-savings thresholds occur where each ICER curve crosses the ICER = $0 value.

Model Inputs (Table I)

Costs

Costs for primary and revision total hip arthroplasty were based on actual hospital costs for these procedures, derived from an activity-based hospital cost accounting system (TSI, Eclipsys, Brighton, Massachusetts). Costs associated with routine followup care were derived from outpatient billing records. These data have been reported elsewhere²⁰. The advantages of using actual cost data rather than charges or cost-to-charge ratios in cost-effectiveness models have been well documented in the literature^21,22. The incremental costs associated with alternative bearing couples were based on published data²³.

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TABLE I Input Values (Point Estimates and Ranges), Including Costs, Clinical Outcome Probabilities, and Health State Utilities, Used to Calculate the Cost-Effectiveness of Alternative Bearings in Total Hip Arthroplasty

Description	Value	Low	High	Comment/Reference
Age at primary total hip arthroplasty (yr)	50	50	90
Cost ($)
Alternative bearing couple	2000	500	4000	²³
Primary total hip arthroplasty	24,200	15,000	30,000	¹⁹
Revision total hip arthroplasty	31,300	20,000	40,000	¹⁹
Year of onset of reduction in failure associated with alternative bearings	5	0	10	¹
Probability of death
All causes	0.004443			²⁷
Due to primary total hip arthroplasty	0.006	0.001	0.015	^{23,25,34,52-55}
Due to revision total hip arthroplasty	0.012	0.003	0.026	^23,25,34
Discount rate	0.03	0	0.05	¹⁹
Quality of life (utility value)
With osteoarthritis before primary total hip arthroplasty	0.5	0.32	0.85	^31-33
Following successful primary total hip arthroplasty	0.92	0.66	0.98	^31-33
Following successful revision total hip arthroplasty	0.80	0.6	0.95	^33,56

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Description	Value	Low	High	Comment/Reference
Age at primary total hip arthroplasty (yr)	50	50	90
Cost ($)
Alternative bearing couple	2000	500	4000	²³
Primary total hip arthroplasty	24,200	15,000	30,000	¹⁹
Revision total hip arthroplasty	31,300	20,000	40,000	¹⁹
Year of onset of reduction in failure associated with alternative bearings	5	0	10	¹
Probability of death
All causes	0.004443			²⁷
Due to primary total hip arthroplasty	0.006	0.001	0.015	^{23,25,34,52-55}
Due to revision total hip arthroplasty	0.012	0.003	0.026	^23,25,34
Discount rate	0.03	0	0.05	¹⁹
Quality of life (utility value)
With osteoarthritis before primary total hip arthroplasty	0.5	0.32	0.85	^31-33
Following successful primary total hip arthroplasty	0.92	0.66	0.98	^31-33
Following successful revision total hip arthroplasty	0.80	0.6	0.95	^33,56

Clinical Outcome Probabilities

Clinical outcome probabilities, including perioperative mortality, death from other causes, complication rates, and implant survival, were derived from the literature^24-26. Implant survival varied according to the age of the patient at the time of the primary total hip arthroplasty, with younger patients having higher rates of failure¹. Life expectancy and rates of mortality unrelated to the total hip arthroplasty were derived from age-specific actuarial life tables²⁷.

Health-Related Quality of Life (Health Utility)

Quality-adjusted life years, which combine the preference for a specified health state and the time spent in that state into a single quantitative measure, were used as a measure of health utility. Specific utility values for each health state considered in the model were derived from the literature^28-31. On the basis of previous studies in which investigators measured health-state utilities associated with total hip arthroplasty^28,32-34, a utility value of 0.92 was chosen as a baseline value for a successful total hip arthroplasty. On the basis of the finding, by Hozack et al.³⁰, that the health-related quality of life following a successful revision total hip arthroplasty was lower than that following a successful primary total hip arthroplasty, a successful revision total hip arthroplasty was assigned an initial value of 0.80. Subsequent revisions were associated with even lower health-related quality of life.

Analysis

All analyses were performed with TreeAge Pro 2005 software (TreeAge, Williamstown, Massachusetts). The projected survival of an adult with osteoarthritis who had undergone primary total hip arthroplasty at the age of fifty years or older was calculated with use of perioperative mortality data for patients undergoing total hip arthroplasty^26,35 combined with age-specific mortality rates for this patient population²⁷. For the baseline analysis, the present value for the lifetime incremental costs per quality-adjusted life year gained following total hip arthroplasty in a fifty-year-old patient treated with an alternative bearing couple with an incremental cost of $2000 was compared with the value for a patient of the same age treated with a metal-on-conventional ultra-high molecular weight polyethylene bearing couple. An incremental implant cost of $2000 was chosen for the baseline analysis since this is the average difference in cost between a hard-on-hard bearing (e.g., ceramic-on-ceramic or metal-on-metal) and a metal-on-conventional ultra-high molecular weight polyethylene bearing²³. A metal-on-conventional ultra-high molecular weight polyethylene bearing was chosen as the comparator or referent group¹⁹ because it has historically been the most widely used bearing surface as well as the bearing surface about which the largest amount of clinical and laboratory data have been published in the literature^36,37. According to the recommendations of the Panel on Cost-Effectiveness Analysis in Health and Medicine, all costs and health benefits were discounted at a constant rate of 3% per annum in order to determine the net present value of costs and quality-adjusted life years gained with each treatment strategy¹⁹.

Multiple sensitivity analyses were conducted to assess the impact of variation in age at the time of the primary total hip arthroplasty, incremental implant costs, and reduction in the probability of implant failure at twenty years on the relative cost-effectiveness and lifetime cost-savings associated with each treatment strategy. In order to assess the influence of age on the cost-effectiveness of alternative bearings, the age at the primary total hip arthroplasty was varied from fifty to seventy-five years in five-year increments. In order to evaluate the impact of implant cost on the cost-effectiveness of less costly alternative bearings such as highly cross-linked polyethylene, more costly bearings such as metal-on-metal and ceramic-on-ceramic couples, and even more costly alternatives that are currently being explored such as diamond-on-diamond bearings³⁸, incremental implant costs were varied from $500 to $4000 in $500 increments. Finally, in order to assess the influence of the difference in the probability of revision between alternative bearings and conventional bearings, the reduction in the probability of implant failure at twenty years was varied from 0% to 70%. Thresholds for both cost-savings and cost-effectiveness based on a willingness-to-pay of $50,000 per quality-adjusted life year gained were calculated for each treatment strategy.

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Fig. 2: Impact of incremental implant cost on the lifetime incremental cost-effectiveness ratio (ICER) of total hip arthroplasty with an alternative bearing couple instead of a conventional bearing in a fifty-year-old patient. The range of reduction in the probability of implant failure at twenty years is shown for a range of incremental alternate-bearing-implant costs. Thresholds for cost-effectiveness are shown where each ICER curve intersects with a horizontal line representing a willingness-to-pay of $50,000. Cost-savings thresholds occur where each ICER curve crosses the ICER = $0 value.

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Figs. 3-A, 3-B, and 3-C: Relationship between variation in age, implant cost, and reduction in the twenty-year failure rate on the relative lifetime cost-savings associated with alternative bearings. The graphs show the ranges of reduction in the probability of implant failure at twenty years and ages at the total hip arthroplasty (THA) where an alternate bearing surface (green area) or a conventional bearing surface (blue area) would have a lower lifetime cost for alternate bearing surfaces with incremental costs of $500 (Fig. 3-A), $2000 (Fig. 3-B), or $4000 (Fig. 3-C) more than a conventional bearing surface. UHMWPE = ultra-high molecular weight polyethylene. Fig. 3-A An alternate bearing couple with an incremental cost of $500 more than a conventional bearing surface (the average cost of a highly cross-linked polyethylene acetabular liner) could result in lifetime cost-savings for the range of ages and reduction in probability of implant failure at twenty years represented by the green area of the graph. An alternate bearing couple with an incremental cost of $2000 more than a conventional bearing surface (the average cost of a hard-on-hard bearing) would be cost-saving only for patients under the age of sixty-three years for the range of reduction in probability of implant failure at twenty years represented by the green area of the graph. An alternate bearing couple with an incremental cost of $4000 more than a conventional bearing surface would be cost-saving only for patients under the age of fifty-five years for the range of reduction in probability of implant failure at twenty years represented by the green area of the graph.

Results

Materials and Methods | Results | Discussion | Appendix | References

Impact of Age at Primary Total Hip Arthroplasty

The impact of age at the time of the primary total hip arthroplasty on the cost-effectiveness of alternative bearings is illustrated in Figure 1. In a population of fifty-year-old patients, an alternative bearing with an incremental cost of $2000 (the average incremental cost associated with a hard-on-hard bearing couple) would need to be associated with at least an 18.7% reduction in the probability of implant failure at twenty years, when compared with the probability of failure of a conventional metal-on-ultra-high molecular weight polyethylene bearing, in order to be cost-saving over the lifetime of this group of patients. The same implant in the same patients would have to result in a 3.8% reduction in the twenty-year probability of implant failure in order to be considered cost-effective on the basis of a willingness-to-pay of $50,000 per quality adjusted life year gained. An alternative bearing with an incremental cost of $2000 would not be cost-saving over the lifetime of a patient over the age of sixty-three years, regardless of the reduction in the probability of revision at twenty years. In patients over the age of seventy years, an alternative bearing with a cost of $2000 would need to be associated with at least a 45.5% reduction in the twenty-year probability of revision in order to be considered cost-effective on the basis of a willingness-to-pay of $50,000 per quality-adjusted life year gained.

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Impact of Incremental Implant Cost

The impact of the incremental cost of the bearing surface on the cost-effectiveness of alternative bearings is shown in Figure 2. In fifty-year-old patients, a bearing couple with an incremental cost of $500 (the average cost of a highly-cross linked polyethylene acetabular liner) would result in lifetime cost-savings, compared with the cost of conventional bearing surfaces, if the reduction in the twenty-year probability of implant failure was =4.6%, and it would be considered cost-effective on the basis of a willingness-to-pay of $50,000 if the incremental reduction in the probability of revision at twenty years was =1.1%. Conversely, a hypothetical bearing surface with an incremental cost of $4000 would be considered cost-saving only if it were associated with a >38% reduction in the probability of implant failure at twenty years, and it would be considered cost-effective if the probability of failure at twenty years was reduced by =7.5% in patients undergoing total hip arthroplasty at the age of fifty years.

Three-Way Sensitivity Analyses

The relationship between variation in age, implant cost, and reduction in the twenty-year failure rate on the lifetime cost-savings associated with each treatment strategy is illustrated in Figures 3-A, 3-B, and 3-C. As the incremental cost of an alternate bearing surface increases, the age threshold for cost-savings decreases, and a higher evidence standard (in terms of reduction in the probability of implant failure at twenty years compared with that associated with conventional bearings) is required in order to justify the additional cost of the implant.

Discussion

Materials and Methods | Results | Discussion | Appendix | References

New technologies such as alternative bearings offer the potential to reduce wear and osteolysis, prolong implant survival, and lower revision rates following total hip arthroplasty. Nevertheless, in an era of limited health-care resources, the benefits of any new, more costly technology that is intended to replace a proven technology with a high success rate, such as total hip arthroplasty with conventional bearings, must be considered in light of any additional clinical risks and economic costs that are associated with its use³⁹.

Although several in vitro^40-42 and early in vivo^4,8,14 reports have suggested that modern alternative bearings have lower wear rates, long-term data demonstrating a clinical benefit in terms of lower overall revision rates are lacking¹⁷. Furthermore, the impact of unintended consequences of the use of alternative bearings, such as instability, impingement, ceramic fracture, material failure of cross-linked polyethylene, and potential biological responses to metal ions (including hypersensitivity and cancer), on long-term revision rates and patient outcomes remains unknown. It should be noted that, although our analysis assumed no benefit associated with alternative bearings over conventional bearings in terms of improved implant survival during the first five years following primary total hip arthroplasty, failures associated with either bearing surface could occur at any time.

Expected-value decision-analysis models provide a useful tool for evaluating the impact of patient characteristics, cost, clinical outcome probabilities, and quality-adjusted life years gained on the cost-effectiveness of a new, relatively unproven technology, especially in the face of uncertainty due to a lack of long-term outcome data^43,44. Moreover, by identifying the variables that have the greatest impact on cost-effectiveness, these models are valuable for guiding further clinical and laboratory research related to new technologies⁴⁵. Our results indicate that cost-effectiveness estimates for alternative bearings are highly sensitive to age at the time of the primary total hip arthroplasty, reductions in the probability of revision relative to conventional bearings, and the incremental costs associated with the alternative bearing.

Previous investigators have attempted to assess the incremental cost-effectiveness of new technologies for use in total hip arthroplasty. Vale et al.⁴⁶ used clinical effectiveness data from randomized, controlled trials and cost data from the United Kingdom National Health System to estimate the cost-effectiveness of metal-on-metal resurfacing for the treatment of osteoarthritis of the hip in patients under the age of sixty-five years. They reported that metal-on-metal resurfacing could be considered cost-effective when compared with conventional total hip arthroplasty if revision rates with metal-on-metal resurfacing were assumed to be 20% lower than those with total hip arthroplasty. Daellenbach et al.⁴⁷ used scenario analyses to compare the lifetime costs associated with the use of cemented and cementless prostheses in total hip arthroplasty. They reported that, in most scenarios that they tested, the expected survival of the cementless prosthesis would have to be double that of the cemented prosthesis for the cementless implant to have a lower net present-value cost. They also found that the "cross-over age" at which a cementless prosthesis would have lower lifetime costs was about fifty-five to sixty years for men and sixty-five to seventy years for women. Using data from the Swedish National Total Hip Arthroplasty Register, Briggs et al.⁴⁸ constructed probabilistic decision models to compare the Charnley and Spectron hip prostheses in terms of lifetime costs and quality-adjusted life years gained. The authors reported that, on the basis of a willingness-to-pay of $20,000 per quality-adjusted life year, the probability of the Spectron being the more cost-effective prosthesis ranged between 70% and 100%, depending on the age and sex of the patient.

In our study, we used an expected-value decision-analysis model to evaluate the incremental cost-effectiveness of alternative bearings in total hip arthroplasty. Our findings provide a quantitative rationale for requiring greater evidence of effectiveness in reducing the probability of implant failure and revision when more costly alternative bearings are being considered, particularly for older patients. In the future, this analysis could be updated as new information on long-term outcomes associated with alternative bearings emerges or as additional innovations in total hip arthroplasty implants and techniques are introduced.

Although this study provided novel information regarding the cost-effectiveness of alternative bearings for use in total hip arthroplasty, it also had several limitations. As with any cost-effectiveness study, the validity and generalizability of the results are limited by the quality of the data used in the analysis. While there is a substantial amount of published data regarding the long-term rates of in vivo wear and osteolysis and the long-term clinical outcomes associated with conventional ultra-high molecular weight polyethylene¹, there is much less information on long-term in vivo failure and revision rates associated with the current generation of alternative bearings. In addition to using historical data from studies on earlier-generation ceramic-on-ceramic¹² and metal-on-metal bearings⁵, data from laboratory hip-simulator studies^42,49-51, and more recently published short-term clinical outcome data on second-generation alternative bearings^4,9,17,52, we used extensive sensitivity analyses to evaluate the impact of patient age at the time of the primary total hip arthroplasty, relative reductions in revision rates, and incremental implant costs on the cost-effectiveness of alternative bearings.

Another potential limitation of our study is that we considered only direct medical costs in our analysis. We did this because these are the most easily quantifiable costs for which accurate data could be obtained. Furthermore, it is likely that other types of costs, including indirect costs (e.g., those associated with lost productivity) and nonmedical costs, would parallel direct costs because a revision, if needed, would increase direct costs, mortality risk, productivity losses, and nonmedical direct costs. Future models should take into account the impact of all societal costs, including direct, indirect, and nonmedical costs, on the cost-utility of total hip arthroplasty.

We also recognize that chronological age is an imperfect surrogate for physiological age and activity level, which may be more appropriate criteria on which to base a decision-analysis model. However, most investigators who have evaluated predictors of wear rates and implant survival following total hip arthroplasty have used chronological age as a proxy for activity level^6,37,53.

Finally, it should be noted that the purpose of decision-analysis studies such as ours is not to influence individual clinical decisions for individual patients but rather to provide a framework to help clinicians, patients, hospitals, payers, and health policy makers to evaluate the relative cost and relative clinical effectiveness of new health-care technologies such as alternative bearing surfaces.

The cost-effectiveness of alternative bearings will ultimately be determined by their ability to reduce wear, prolong implant longevity, and therefore delay and in some cases prevent the need for revision surgery. The incremental costs associated with the use of alternative bearings could be offset by lower revision rates, thereby delaying or avoiding future costs and the reductions in quality of life that are associated with revision surgery. However, the cost-effectiveness of alternative bearings will also be influenced by rates of complications specific to the bearing surface, such as ceramic fracture, instability, impingement, material failure of highly cross-linked polyethylene, and the potential for metal-ion toxicity, all of which could influence short-term and long-term revision rates. The results of our analysis could help surgeons, patients, hospitals, and payers to understand how patient age at the time of the primary surgery, implant costs, and assumptions regarding implant-specific failure and complication rates influence the overall cost-effectiveness of alternative bearings. Our findings suggest that, under current pricing in the United States market, hard-on-hard bearing surfaces such as ceramic-ceramic and metal-metal couples could be cost-saving for patients under the age of sixty-three years and less costly bearing surfaces such as highly cross-linked polyethylene could be cost-saving for patients up to seventy years old, depending on the impact of the bearing surface on revision rates. The validity of these findings will need to be confirmed as long-term clinical experience with these new technologies accumulates.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

The details of the decision-analysis model are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ?

References

Materials and Methods | Results | Discussion | Appendix | References

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Topics

hip replacement arthroplasty ; cost-effectiveness analysis

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Kevin J. Bozic, Saam Morshed, Marc D. Silverstein, Harry E. Rubash, James G. Kahn; Use of Cost-Effectiveness Analysis to Evaluate New Technologies in OrthopaedicsThe Case of Alternative Bearing Surfaces in Total Hip Arthroplasty. The Journal of Bone & Joint Surgery. 2006 Apr;88(4):706-714.

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