The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 90, Issue 7

Scientific Articles | July 01, 2008

Cost-Effectiveness Analysis of Periacetabular Osteotomy

Emile Sharifi, MD¹; Husham Sharifi, SM, SM²; Saam Morshed, MD, MPH³; Kevin Bozic, MD, MBA³; Mohammad Diab, MD³

¹ School of Medicine, University of California at San Francisco, 513 Parnassus Avenue, San Francisco, CA 94143
² School of Medicine, Yale University, Harkness Hall, 367 Cedar Street, New Haven, CT 06510
³ Department of Orthopaedic Surgery, University of California at San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143. E-mail address for M. Diab: diab@orthosurg.ucsf.edu

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. 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. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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).

Investigation performed at the University of California at San Francisco, San Francisco, California

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2008 Jul 01;90(7):1447-1456. doi: 10.2106/JBJS.G.00730

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Abstract

Background: A lack of long-term outcomes data following periacetabular osteotomy makes it difficult for surgeons to recommend the most appropriate procedure to young patients who might be candidates for a joint-preserving procedure. In this study, we compared the cost-effectiveness of periacetabular osteotomy with total hip arthroplasty in terms of cost per quality-adjusted life year for the young adult.

Methods: A decision model was constructed for a cost-utility analysis of periacetabular osteotomy compared with total hip arthroplasty. Outcome probabilities and effectiveness were derived from the literature. Effectiveness was expressed in quality-adjusted life years gained. Cost data were compiled and verified from our institution. Costs and utilities were discounted in accord with the United States Panel on Cost-Effectiveness in Health and Medicine. Principal outcome measures were average incremental costs, incremental effectiveness, incremental quality-adjusted life years, and net health benefits. Multivariate sensitivity analysis was used to assess the contribution of included variables in the model's outcomes.

Results: For Tönnis grade-1 coxarthrosis, periacetabular osteotomy dominates with an average incremental cost-effectiveness of $7856 per quality-adjusted life year and an average incremental effectiveness of 0.15. For Tönnis grade-2 coxarthrosis, periacetabular osteotomy is, on the average, more cost-effective than total hip arthroplasty with an incremental cost-effectiveness of $824 per quality-adjusted life year, but it is less effective than total hip arthroplasty, on the average, with an incremental effectiveness of —1.4 quality-adjusted life years. Periacetabular osteotomy becomes more cost-effective at a longevity of 5.5 years for Tönnis grade-1 coxarthrosis and 18.25 years for Tönnis grade-2 coxarthrosis. In Tönnis grade-3 coxarthrosis, total hip replacement becomes the dominant treatment strategy.

Conclusions: Periacetabular osteotomy is, on the average, more cost-effective in Tönnis grade-1 and grade-2 coxarthrosis, while it is both more costly and less effective in Tönnis grade-3 coxarthrosis. These findings can inform clinical decision-making in the absence of long-term data. On the basis of this model, periacetabular osteotomy is preferable to total hip arthroplasty in Tönnis grade-1 and grade-2 coxarthrosis when the patient is sufficiently young and when functionality in sports is important.

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

Figures in this Article

Introduction

Developmental dysplasia of the hip may be a contributing factor to the development of osteoarthritis in as many as 20% to 40% of patients^1-3. Surgical treatment for symptomatic developmental dysplasia of the hip in a young adult includes both joint-preserving and ablative procedures. The former includes redirectional pelvic osteotomy^4-7 for a hip with early coxarthrosis or salvage pelvic osteotomy^8,9 for a hip with advanced coxarthrosis. The latter includes total hip arthroplasty and hip arthrodesis. Total hip arthroplasty is well established as a successful primary operative treatment^10-13, and it is also well established as a cost-effective procedure compared with other health-care interventions^14-16. In a young adult with moderate coxarthrosis, the preferred choice between total hip arthroplasty and a joint-preserving pelvic osteotomy remains controversial. An advantage of the former procedure is the likelihood of good early and midterm outcomes; however, the literature bears many examples of disappointing long-term results in patients under forty years old who have undergone total hip arthroplasty^17-21. Following total hip arthroplasty, younger patients have been reported to have high rates of loosening^17,22-25 and high rates of revision^17,26-29. The advantages offered by the Bernese periacetabular osteotomy are the preservation of the natural joint and fewer limitations in physical activity³⁰, and the use of the procedure is expanding as an operative alternative in young adults^31-35. However, periacetabular osteotomy is a relatively new procedure lacking long-term follow-up reports^7,36. We performed a cost-utility analysis comparing the Bernese periacetabular osteotomy with total hip arthroplasty to provide some guidelines that may inform clinical decision-making in the treatment of younger adults with symptomatic developmental dysplasia of the hip.

Materials and Methods

General Model Overview

The model and analysis in this study were constructed according to the guidelines set forth by the Panel on Cost-Effectiveness in Health and Medicine by the United States Public Health Service in 1993^37-39.

We compared the cost-effectiveness of periacetabular osteotomy and total hip arthroplasty in young adults with developmental dysplasia of the hip. The upper age limit of our population was forty-five years, and the time horizon of the model was thirty years. The cost-effectiveness for the two procedures is reported from a societal perspective, which accounts for costs and outcomes that are important for society rather than for the payer, the physician, or any other single entity⁴⁰. Effectiveness and outcome probabilities were obtained from the literature or estimated when data were lacking.

The analysis was performed through a decision tree by using a common decision-analysis package (TreeAge Pro 2005; TreeAge Software, Williamstown, Massachusetts). An essential component of this model was the assumption of a linear annual failure rate for periacetabular osteotomy and total hip arthroplasty. A systematic review of the literature and expert opinion were used to validate the decision tree^41-52. We searched PubMed through September 2006 for articles using the terms "periacetabular osteotomy" and "total hip arthroplasty." Inclusion criteria were a sample size of greater than twenty-five hips, follow-up of longer than three years, mean patient age of forty-five years or less, quantitative outcomes reported as Harris hip scores, and outcomes reported by Tönnis grade for periacetabular osteotomy. All data points for total hip arthroplasty, except for cost, were taken from the literature. Where data were not available for periacetabular osteotomy, we took the most conservative estimate based on the expert opinion of two senior orthopaedic surgeons. The model included only objective outcomes. Pain, although not directly assessed, was taken into account by use of the Harris hip score. Because several periacetabular osteotomy studies have shown a correlation between postoperative success and the preoperative radiographic grade of coxarthrosis^31,34,45,50, we ran the model once for each Tönnis grade, measuring costs and outcomes for each run. Total hip arthroplasty outcome was the same regardless of preoperative radiographic coxarthrosis grade⁵².

Decision Model

Our decision tree (Fig. 1) consists of two primary treatment arms: periacetabular osteotomy and total hip arthroplasty. Branching points thereafter represent complications and terminate in outcomes. Outcomes were assigned a quantitative health-related quality-of-life value derived from the literature. Clinical outcome probabilities, including complications and failure rates, were derived from the literature. The total hip arthroplasty arm of the model is similar to past models of arthroplasty^43,53,54. The weight of each variable was explored by means of multivariate sensitivity analysis.

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Fig. 1: Model decision tree. PAO = periacetabular osteotomy, THA = total hip arthroplasty, DDH = developmental dysplasia of the hip, OA = osteoarthritis, HO = heterotopic ossification, and s/p = status post.

Table I summarizes the sensitive variables used in the model. Sensitive variables yield quantitatively large effects on model outcome and are hence addressed in detail herein. In contrast, robust variables are those that, as determined by sensitivity analysis, do not significantly affect model outcome. Robust variables are included in the electronic Appendix. Probability inputs for the model were annual probabilities derived by dividing the overall failure rate by the average follow-up time reported in the literature, thereby yielding a linear failure rate. For total hip arthroplasty, the complications modeled were aseptic and septic failure. Our model represents quality of life after a successful revision total hip arthroplasty as being slightly lower than quality of life after a successful primary total hip arthroplasty^10,55. Similar to a previously validated total hip arthroplasty model, aseptic failure included prosthetic wear, loosening, and breakage⁴³. The literature reports an annual aseptic failure rate in the range of 1.9% to 3.7%^53,56-62. We selected a weighted average of the above studies at an annual aseptic failure rate of 2.6%.

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TABLE I Sensitive Variables Used in Model

Variable	Value
Annual probability of primary aseptic failure	0.026
Average lifespan of total hip arthroplasty (yr)	14
Average lifespan of periacetabular osteotomy (yr)	10
Utility of an excellent outcome	1.0

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TABLE I Sensitive Variables Used in Model

Variable	Value
Annual probability of primary aseptic failure	0.026
Average lifespan of total hip arthroplasty (yr)	14
Average lifespan of periacetabular osteotomy (yr)	10
Utility of an excellent outcome	1.0

For periacetabular osteotomy, the complications modeled were periacetabular osteotomy failure resulting in conversion to total hip arthroplasty, periacetabular osteotomy revision secondary to overcorrection or undercorrection, and heterotopic ossification. Failure rates of periacetabular osteotomy were modeled to be different according to Tönnis grade, with rates of 1%, 3%, and 9% for Tönnis grades 1, 2, and 3, respectively⁴⁵. The probability of revision was modeled to be 4%⁴⁷, and the probability of heterotopic ossification was 2.4%⁴⁵. Other possible complications, such as neural or vascular injury, were so rare⁴⁸ and transient that they exerted no effect on cost and effectiveness and were thus excluded from the model.

The longevity of total hip arthroplasty varies with respect to the population in which the procedure is performed. When it was possible, we used total hip arthroplasty studies that described results in an age group similar to that in which periacetabular osteotomy is a treatment option. By extracting data from articles that directly report a mean or median survival of total hip arthroplasty^57,59,63, and by confirming those values by extrapolating median survival through an assumption of a linear failure rate, we found that survival of total hip arthroplasty ranges from 6.6 to 25.9 years^53,56-61. The value we chose to use, fourteen years, is the weighted average of the above trials.

Because of the lack of longer-term follow-up with periacetabular osteotomy, the longevity of the procedure is still unknown. In order to determine a survival range for sensitivity analysis, we extrapolated the median survival of periacetabular osteotomy by assuming a linear failure rate in articles describing follow-up for periacetabular osteotomy beyond four years. The resulting range of values for median survival was 8.6 to 19.6 years, while the weighted mean survival was ten years^{31,34,45,47,64,65}. For the best and worst-case scenarios, we used empirical data derived from studies describing the survivability of periacetabular osteotomy in hips with more than four years of follow-up^31,41,65, ranging from 7.1 years in one study⁶⁵ to twelve years (twenty-two of twenty-six hips) in another³⁴. The value chosen for our reference case was ten years, and it was based on the weighted mean survival reported above.

Medical Costs

Cost data (not charge data) were compiled and verified with use of our institution's activity-based costing software (IDX, Burlington, Vermont) that tracked our hospital decision support system (see Appendix). Cost data are reported in 2004 U.S. real dollars. The range of values was determined by identifying the lowest and highest costs in our patient cohort. Costs for heterotopic ossification were estimated, and the impact of estimating that cost was assessed in the sensitivity analysis. When we varied the cost of heterotopic ossification from $5000 to $15,000, it changed the breakeven points by less than one month, which is negligible over the multiple year time horizon of our model. Thus, estimating the cost of heterotopic ossification was not deemed important. Costs were discounted at a rate of 5% in order to yield the present monetary value. The time of failure of a hip impacted cost— hips that failed earlier incurred potentially more cost in the time course of the model.

Utilities

We determined effectiveness in terms of health-related quality of life, which was ascertained by applying the continuous utility assessment method devised by Hazen et al.⁶⁶ and applied to total hip arthroplasty by Chang et al.⁴³. We mapped health-related quality-of-life values to Harris hip scores according to the system of Chang et al., and patient utility analyses done before and after total hip arthroplasty^44,67,68 (see Appendix). Consistent with the outcomes reported in the literature, a successful primary periacetabular osteotomy in hips with Tönnis grade-1, 2, and 3 coxarthrosis had health-related quality-of-life values of 1.0, 0.8, and 0.6, respectively⁴⁵. The same health-related quality-of-life value was given to either total hip arthroplasty or periacetabular osteotomy, according to the outcome assessed by Harris hip scores, and a corresponding adjectival rating was given (see Appendix). In our final analysis, utility values were multiplied by the discounted number of years spent in a health state to yield quality-adjusted life years (QALYs) gained. QALYs were discounted at a rate of 5% to yield present value^37,69,70. As with cost, the time of failure of a hip impacted the outcome—patients with a hip that failed earlier potentially may live longer with a lower health-related quality of life. A successful total hip arthroplasty subsequent to failure of a periacetabular osteotomy was assigned a good health-related quality-of-life outcome of 0.8 rather than the excellent outcome of 1.0, associated with a primary total hip arthroplasty.

Incremental cost-effectiveness ratios were used to aid comparison of treatments. The incremental cost-effectiveness ratio presented in the results is averaged over the thirty-year time horizon of the model. The incremental cost-effectiveness ratio is calculated as follows: (Cost_PAO — Cost_THA) / (QALYs_PAO — QALYs_THA), with PAO indicating periacetabular osteotomy and THA indicating total hip arthroplasty. The net health benefit was used as a measure of outcome from a societal perspective because it takes into account the willingness of the health-care system to pay (WTP). The net health benefit may be calculated as QALYs — Cost / WTP⁷¹. The net health benefit, while not usually reported in the orthopaedic literature, is used in other specialties as it offers the advantage of easy comparison between different treatment strategies. When two cost-saving treatments are compared, the better modality has the higher net health benefit, whereas it would have the lower incremental cost-effectiveness ratios since incremental cost-effectiveness ratios can be expressed in negative terms^71-74.

Sensitivity Analysis

Sensitivity analysis addressed the uncertainty inherent to drawing data from multiple sources³⁷. In the case of our model, variables that made a substantial contribution to results were deemed to be sensitive, whereas those that contributed <1% to the total outcome were deemed robust. We varied sensitive variables according to coxarthrosis, measured radiographically as grade 1, 2, or 3 according to the method of Tönnis⁷⁵.

An expanded sensitivity analysis was conducted on the average duration of Tönnis-grade 1 and grade-2 hips after periacetabular osteotomy on the basis of a best-case and a worst-case scenario for survival. For these two end-point scenarios, we chose the lowest and highest average survival rates reported in the literature for periacetabular osteotomy^34,65. We did not do this for Tönnis grade-3 hips because changing the value of hip survival does not change the results substantially.

Results

Cost

Costs were averaged over the thirty-year time horizon of the model. The average cost of total hip arthroplasty in all three Tönnis grades of coxarthrosis was $32,790. In Tönnis grade-1 and grade-2 hips, periacetabular osteotomy yielded a cost of $26,592 and $30,673, respectively. The cost of periacetabular osteotomy in Tönnis grades 1 and 2 was cost-saving compared with total hip arthroplasty, i.e., it was below the abscissa in Figure 2. Periacetabular osteotomy in Tönnis grade 3 was associated with a cost of $33,465, which resulted in an incremental cost (above the abscissa in Figure 2) of $675.

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Fig. 2: Average incremental costs and incremental quality-adjusted life years for periacetabular osteotomy compared with total hip arthroplasty. QALYs = quality-adjusted life year.

Effectiveness

QALYs gained were averaged over the thirty-year time horizon of the model. In each of the three Tönnis grades of coxarthrosis, total hip arthroplasty resulted in an average of 4.7 QALYs gained. Periacetabular osteotomy in Tönnis grade-1, 2, and 3 hips yielded an average of 4.85, 3.3, and 3.2 QALYs gained, respectively. Compared with the QALYs gained with total hip arthroplasty, the increment in QALYs gained with periacetabular osteotomy in Tönnis grade-1 coxarthrosis was 0.15 (represented in Figure 2 by the data point for Tönnis grade-1 hips lying to the right of the ordinate). In addition, for Tönnis grade-2 and grade-3 hips, total hip arthroplasty yielded, on the average, more QALYs (both data points lie to the left of the ordinate) than did periacetabular osteotomy (Fig. 2). While over thirty years, total hip arthroplasty is more effective (i.e., it yields more QALYs) on the average than periacetabular osteotomy in Tönnis grade-2 coxarthrosis, periacetabular osteotomy becomes the more effective treatment by year 19.4 of the model. For Tönnis grade-3 coxarthrosis, total hip arthroplasty is and remains more effective throughout the time period of the model.

Cost-Effectiveness and Incremental Cost-Effectiveness

Cost-effectiveness ratios were averaged over the thirty-year time horizon of our model. The cost-effectiveness ratio of total hip arthroplasty was $11,631/QALY for all three Tönnis grades. In Tönnis grade-1, 2, and 3 coxarthrosis, periacetabular osteotomy had a cost-effectiveness ratio of $7856/QALY, $10,807/QALY, and $15,005/QALY, respectively. Since periacetabular osteotomy in Tönnis grade-1 coxarthrosis is, on the average, both more effective than total hip arthroplasty and more cost-saving (lower right quadrant in Figure 2), it is the dominant procedure in this setting. For Tönnis grade-1 coxarthrosis, periacetabular osteotomy is more cost-effective over thirty years and surpasses total hip arthroplasty in cost-effectiveness at 5.5 years. In Tönnis grade-2 coxarthrosis, periacetabular osteotomy is less costly than total hip arthroplasty on the average but also less effective (lower left quadrant in Figure 2). While both incremental cost and effectiveness are negative for periacetabular osteotomy in Tönnis grade-2 coxarthrosis, the former effect is greater than the latter effect, making periacetabular osteotomy ultimately more cost-effective than total hip arthroplasty in this grade, with an associated incremental cost-effectiveness ratio of —$824/QALY. For Tönnis grade-2 coxarthrosis, periacetabular osteotomy is more cost-effective over thirty years and surpasses total hip arthroplasty in cost-effectiveness at 18.25 years. Periacetabular osteotomy was both more costly and less effective on the average than total hip arthroplasty in Tönnis grade-3 coxarthrosis (upper left quadrant in Figure 2); as a result, total hip arthroplasty is the dominant procedure in this setting.

Net Health Benefits

Figures 3 and 4 depict the results for the two treatments in terms of net health benefits. In Tönnis grade-1 coxarthrosis (Fig. 3), periacetabular osteotomy yields a greater net health benefit after 10.1 years in comparison with total hip arthroplasty. In Tönnis grade-2 coxarthrosis (Fig. 4), periacetabular osteotomy reaches equivalence by 19.1 years, after which it becomes dominant. If periacetabular osteotomy can be expected to have a greater longevity than the crossover points of 10.1 years and 19.1 years for Tönnis grade 1 and 2, respectively, then periacetabular osteotomy as a treatment would be preferable to total hip arthroplasty in terms of net health benefits. Finally, at no point does periacetabular osteotomy yield a negative net health benefit in both Tönnis grades 1 and 2, whereas total hip arthroplasty does so at 23.5 years and 25.1 years, respectively.

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Fig. 3: Incremental net health benefits (NHB in $/QALYs) of total hip arthroplasty (THA) and periacetabular osteotomy (PAO) in Tönnis grade-1 coxarthrosis. (Willingness of health-care system to pay [WTP] = $50,000.) EV = equivalence value.

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Fig. 4: Incremental net health benefits (NHB in $/QALYs) of total hip arthroplasty (THA) and periacetabular osteotomy (PAO) in Tönnis grade-2 coxarthrosis. (Willingness of health-care system to pay [WTP] = $50,000.) EV = equivalence value.

These results are summarized in Table II, which shows how long (in years) a periacetabular osteotomy must survive to become the preferred treatment modality.

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TABLE II Years of Survival Needed for Periacetabular Osteotomy to Become Preferred Treatment Over Total Hip Arthroplasty

Tönnis Grade of Coxarthrosis	Assessment (yr)
	Effectiveness	Cost	Cost-Effectiveness	Net Health Benefit
1	10.8	Periacetabular osteotomy always preferred	5.5	10.1
2	19.4	Periacetabular osteotomy always preferred	18.25	19.1
3	Total hip arthroplasty always preferred	Total hip arthroplasty always preferred	Total hip arthroplasty always preferred	Total hip arthroplasty always preferred

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TABLE II Years of Survival Needed for Periacetabular Osteotomy to Become Preferred Treatment Over Total Hip Arthroplasty

Tönnis Grade of Coxarthrosis	Assessment (yr)
	Effectiveness	Cost	Cost-Effectiveness	Net Health Benefit
1	10.8	Periacetabular osteotomy always preferred	5.5	10.1
2	19.4	Periacetabular osteotomy always preferred	18.25	19.1
3	Total hip arthroplasty always preferred	Total hip arthroplasty always preferred	Total hip arthroplasty always preferred	Total hip arthroplasty always preferred

Sensitivity Analysis

We performed a multivariate sensitivity analysis for each Tönnis grade. Multivariate analysis identified five consistently sensitive variables for Tönnis grades 1 and 2 that contributed >99% of the total variability in outcome: (1) average lifespan of the periacetabular osteotomy, (2) probability of a failed periacetabular osteotomy, (3) average lifespan of a total hip arthroplasty, (4) probability of an aseptic revision, and (5) utility of excellent outcome (see Appendix).

We summarize the results of our worst and best-case analyses in Table III. The cost-effectiveness and effectiveness of periacetabular osteotomy improved considerably as the functional life of the Tönnis grade-1 hip after periacetabular osteotomy increased. In the worst-case scenario, periacetabular osteotomy is, on the average, more cost-effective than total hip arthroplasty and reaches equivalence at 11.45 years for Tönnis grade-1 coxarthrosis. In the worst-case scenario for Tönnis grade-2 coxarthrosis, periacetabular osteotomy, while it is not more cost-effective, on the average, than total hip arthroplasty, reaches equivalence at 18.6 years. The range of reaching equivalence is broader from best-case to worst-case scenarios for Tönnis grade-1 compared with Tönnis grade-2 coxarthrosis because periacetabular osteotomy survival is not as sensitive a variable for the latter. For both Tönnis grade-1 and grade-2 hips, periacetabular osteotomy always remained below $50,000 per QALY gained for all of the values we tested in our sensitivity analysis.

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TABLE III Sensitivity Analysis Based on Worst-Case and Best-Case Scenarios of the Durability of Periacetabular Osteotomy in Terms of Cost-Effectiveness, Effectiveness, and Peak Effectiveness*

	Tönnis Grade 1			Tönnis Grade 2
	Avg. Cost-Effectiveness: Time to Equivalence ($/QALY:yr)	Avg. Incremental Effectiveness: Time to Equivalence (QALYs:yr)	Avg. Cost-Effectiveness: Time to Equivalence ($/QALY:yr)	Avg. Incremental Effectiveness: Time to Equivalence (QALYs:yr)
Worst-case scenario	—5689:11.45	—1.1:16.35	200:18.6	—1.9:19.8
Reference case	—7856:5.5	0.15:10.8	—824:18.25	—1.4:19.4
Best-case scenario	—8800:2.45	1.0:5.9	—1152:17.8	—1.1:19.2

Time to equivalence is the point when equivalence between periacetabular osteotomy and total hip arthroplasty is attained in terms of cost-effectiveness and effectiveness, and the peak effectiveness of periacetabular osteotomy is the maximum potential gain in quality-adjusted life years (QALYs) over the time span of our model.

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TABLE III Sensitivity Analysis Based on Worst-Case and Best-Case Scenarios of the Durability of Periacetabular Osteotomy in Terms of Cost-Effectiveness, Effectiveness, and Peak Effectiveness*

	Tönnis Grade 1			Tönnis Grade 2
	Avg. Cost-Effectiveness: Time to Equivalence ($/QALY:yr)	Avg. Incremental Effectiveness: Time to Equivalence (QALYs:yr)	Avg. Cost-Effectiveness: Time to Equivalence ($/QALY:yr)	Avg. Incremental Effectiveness: Time to Equivalence (QALYs:yr)
Worst-case scenario	—5689:11.45	—1.1:16.35	200:18.6	—1.9:19.8
Reference case	—7856:5.5	0.15:10.8	—824:18.25	—1.4:19.4
Best-case scenario	—8800:2.45	1.0:5.9	—1152:17.8	—1.1:19.2

Discussion

To our knowledge, this is the first study to use cost-effectiveness analysis to provide cost-effective parameters to compare periacetabular osteotomy and total hip arthroplasty for the treatment of symptomatic developmental dysplasia of the hip in the mature teenager or young adult. In our reference case for Tönnis grade-1 coxarthrosis, we found periacetabular osteotomy to be cost-effective if the hip survives 5.5 years and to be cost-saving if it survives 10.8 years. Sensitivity analysis validated the dominance of periacetabular osteotomy in Tönnis grade-1 hips by showing that periacetabular osteotomy is the more effective and cost-effective procedure in all scenarios tested. Our findings for Tönnis grade-1 coxarthrosis are borne out by the studies with the longest follow-up to date, which have described survival of up to 13.8 and fifteen years^34,47. For Tönnis grade-2 coxarthrosis, periacetabular osteotomy becomes more cost-effective starting at 18.25 years in our reference case. While several studies have described the use of periacetabular osteotomy for more severe coxarthrosis^31,33,50, our data for Tönnis grade 2 may be validated only when studies have follow-up of longer than eighteen years.

A key issue underlying the potential advantages of periacetabular osteotomy is sports performance³⁰. Periacetabular osteotomy yields Harris hip scores that are comparable with or even better than those after total hip arthroplasty^{41,45,47,63,76}; however, the Harris hip score does not assess sports performance. In cost-effectiveness analysis, a holistic quality of life is central to assessing the desirability of different health states^37,70,77. One study that addressed health-related quality of life after periacetabular osteotomy described sports outcomes in terms of the Tegner score³⁰, a measure that is absent from the total hip arthroplasty literature. For consistency between the two bodies of literature, we restricted ourselves to the Harris hip score, from which we calculated health-related quality of life following an established conversion⁴³.

We took conservative positions regarding the hypothesis that periacetabular osteotomy is more cost-effective than total hip arthroplasty for symptomatic developmental dysplasia of the hip in the mature pelvis. First, we did not include sports performance as a measure of functional outcome. Second, our model has only two revisions for total hip arthroplasty, although over a lifetime a young adult may receive more. Third, we assumed a linear rate of failure for periacetabular osteotomy. Given that periacetabular osteotomy preserves the biologic integrity of the joint, periacetabular osteotomy may alter the disease process in early coxarthrosis such that disease progression may be slower³¹. Fourth, periacetabular osteotomy outcomes for our model were derived from studies early on the "learning curve," which may bias against periacetabular osteotomy since outcomes may be better and costs may be lower in the hands of an experienced surgeon^{36,41,47,64,65}. Fifth, we assigned a less favorable health-related quality-of-life value to total hip arthroplasty secondary to a failed periacetabular osteotomy, although doing so has been questioned⁷⁸.

Cost-effectiveness analysis is established as a useful tool in decision-making for policy makers, insurers, and clinicians^37,79-83. This study demonstrates that the average incremental gain in effectiveness for periacetabular osteotomy in Tönnis grade-1 coxarthrosis yields a 4.3% to 22% (base-case to best-case scenario) increase over total hip arthroplasty. Such a magnitude of increase is comparable with gains in effectiveness that are considered clinically relevant in the literature^53,54,84. Interventions below $50,000/QALY gained are regarded as moderately cost-effective, while interventions below $25,000/QALY are regarded as highly cost-effective³⁷. Ankle arthroplasty yields a cost-effectiveness ratio of $18,419/QALY⁵³, while mammographic screening, colon-cancer screening, and osteoporosis screening all have been shown to yield cost-effectiveness ratios in the $10,000 to $25,000 range^84,85. By these criteria, periacetabular osteotomy is a highly cost-effective treatment for Tönnis grade-1, 2, and 3 coxarthrosis, which may lend support for inclusion of even Tönnis grade-3 hips in certain studies.

While our results provide a framework for evaluating new technologies, we caution against absolute statements favoring any clinical treatment only on the basis of cost to the exclusion of effectiveness. Cost-effectiveness analysis may be misused to support a given treatment when other modalities of care may be preferable after all of the clinically relevant factors are considered. Even for the clinician for whom cost is the least important consideration, cost-effectiveness analysis still may shed light on the usefulness of a procedure in terms of effectiveness, i.e., QALYs gained or lost. The purpose of decision analyses such as ours is not to influence individual clinical decisions for individual patients; rather, it provides 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 periacetabular osteotomy.

There are several limitations to this study. First, cost-effectiveness analysis allows rigorous assessment of both health-related quality-of-life outcome and cost, thereby enhancing the ability of a physician to make a comprehensive recommendation for the treatment in question^37,77,86-89. In interpreting results from a cost-effectiveness analysis, the clinician must weigh the three components of such an analysis—cost, effectiveness, and cost-effectiveness—against other patient-specific and disease-specific factors in making a decision regarding optimal treatment strategies.

Second, the use of a simple branching decision tree to represent different treatment strategies does not contain the level of detail of a more sophisticated model, such as a Markov model that represents progression through different health states as discrete stages driven by an abundant amount of probability inputs. There are insufficient data in the periacetabular osteotomy literature to provide input for a Markov model. Moreover, the greater detail of Markov modeling has not been shown to increase the fidelity of results in cost-effectiveness analysis^37,90.

Third, our model is predicated on the use of Tönnis grading, which we recognize is neither the most sensitive nor the exclusive indicator of the extent of coxarthrosis. For example, the newer methodology of delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) has revealed that cartilage damage may precede radiographic change^91,92. We used the Tönnis grade because the studies on which our model was based consistently used this system.

Fourth, there is no consensus on the upper age limit for periacetabular osteotomy. We arrived at forty-five years for our model on the basis of a synthesis of the existing literature (which includes patients in the sixth decade) as a reasonable intermediate value for consideration of this procedure. We recognize that this is not an absolute number and defer to the clinician's judgment on the most appropriate treatment for each individual patient.

Fifth, the costs of periacetabular osteotomy and total hip arthroplasty may differ from institution to institution. Sensitivity analysis was used to address the issue of representing uncertain values and costs. We found that cost was a robust variable to which our model was not sensitive, accounting for <0.5% of model outcome in all Tönnis grades.

In conclusion, our study supports periacetabular osteotomy for young adults with Tönnis grade-1 coxarthrosis in the setting of developmental dysplasia of the hip. For Tönnis grade-2 coxarthrosis, our study suggests that periacetabular osteotomy is more cost-effective than total hip arthroplasty, but it awaits validation from more studies with longer-term follow-up than are presently available from the literature. In Tönnis grade-3 coxarthrosis, total hip arthroplasty is the more cost-effective treatment.

Appendix

Tables showing independent robust variables, cost data, utilities, and weight of sensitive variables according to the Tönnis grade 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). Image Not Available

Acknowledgements

Note: The authors thank the University of California at San Francisco School of Medicine Research Fellowship for their support and guidance.

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Topics

cost effectiveness ; osteoarthritis, hip ; hip replacement arthroplasty ; cost-effectiveness analysis ; sensitivity analysis ; periacetabular osteotomy

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Emile Sharifi, Husham Sharifi, Saam Morshed, Kevin Bozic, Mohammad Diab; Cost-Effectiveness Analysis of Periacetabular Osteotomy. The Journal of Bone & Joint Surgery. 2008 Jul;90(7):1447-1456.

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