EDITORIAL
Decision making and the cost effectiveness of our interventions
F. S. Haddad From The British Editorial Society of Bone and Joint Surgery, London, United Kingdom
F. S. Haddad, BSc MD (Res), FRCS (Tr&Orth), Professor of Orthopaedic Surgery, Editor-inChief The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET, UK. Correspondence should be sent to Professor F. S. Haddad; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B4. 36079 $2.00 Bone Joint J 2015;97-B:433.
VOL. 97-B, No. 4, APRIL 2015
The success or failure of a procedure will depend partly on surgical factors, partly on patient-related factors, and only partly on the implant chosen. It is critical, when reporting outcomes, to consider each of these areas and to have the means of evaluating them effectively. Future generations of surgeons will need to evaluate outcomes in a very sophisticated way and be able to capture clear metrics, not just for their own sakes, but also for the sake of their patients, and to meet the demands of healthcare commissioners. They will want to continue to innovate but will need to balance that with having appropriate data and will need to evidence their decision-making more than ever. It will also become particularly difficult to change practice without clear forethought and data to support such a change. We are also under increasing pressure to be cost effective.1-4 We have seen a significant rise in health economic research submitted to the BJJ over the past few years. Unfortunately, many of these lacked the methodological rigour that is required, and it is therefore a pleasure to highlight the paper by Pulikottil-Jacob et al,5 on the cost effectiveness of total hip arthroplasties for osteoarthritis looking at different bearings, surfaces and modes of fixation. The conclusion reached in this elegant analysis is that there is not a single device that can be recommended, and that there are a number of variables that should be considered including local costs, revision rates, and the preference of individual surgeons. This supports some work published in the BJJ over the last couple of years highlighting the difficulties in using cost effectiveness data to guide the choice of implant and debunking some of the myths that are currently being perpetuated by some commissioners and political orthopaedic leaders in relation to the perceived advantages of one type of implant, or fixation mode, over another. There
is good long-term evidence for various types of fixation and for a variety of bearing surfaces, just as there is good evidence against specific implants and some bearing couples such as the large head metal-on-metal. The reality is that local data and personal data will often show that certain combinations of implant and bearing and fixation options work well in a particular setting, whereas they may not in another. Many of our colleagues work in regions where political pressure attempts to influence implant choice, and in effect takes away some surgical autonomy, with very little real evidence of cost effectiveness on which to base these decisions. We are sadly often guided by back-of-the-envelope calculations that only look at one variable such as the cost of the implant, the operating time or length of stay. Some are also misled in that they take a shortterm view and place great emphasis on the immediate costs of an intervention, whereas the real cost lies over the lifetime of the patient. We hope that increasing interest in the cost effectiveness of our forms of treatment will lead to detailed collaborative research in this area.
References 1. Benninger E, Zingg PO, Kamath AF, Dora C. Cost analysis of fresh-frozen femoral head allografts. Bone Joint J 2014;96B:1307–1311. 2. Egol KA, Marcano AI, Lewis L, et al. Can the use of an evidence-based algorithm for the treatment of intertrochanteric fractures of the hip maintain quality at a reduced cost? Bone Joint J 2014;96-B:1192–1197. 3. Gutowski CJ, Zmistowski BM, Clyde CT, Parvizi J. The economics of using prophylactic antibiotic-loaded bone cement in total knee replacement. Bone Joint J 2014;96-B:65–69. 4. Kallala RF, Vanhegan IS, Ibrahim MS, Sarmah S, Haddad FS. Financial analysis of revision knee surgery based on NHS tariffs and hospital costs. Bone Joint J 2015;97-B:197–201. 5. Pulikottil-Jacob R, Connock M, Kandala N- B, et al. Costeffectiveness of total hip arthroplasty in osteoarthritis - comparison of devices with differing bearing surfaces and modes of fixation. Bone Joint J 2015;97-B:449–457. 433
Decision making and the cost effectiveness of our interventions
F. S. Haddad From The British Editorial Society of Bone and Joint Surgery, London, United Kingdom
F. S. Haddad, BSc MD (Res), FRCS (Tr&Orth), Professor of Orthopaedic Surgery, Editor-inChief The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET, UK. Correspondence should be sent to Professor F. S. Haddad; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B4. 36079 $2.00 Bone Joint J 2015;97-B:433.
VOL. 97-B, No. 4, APRIL 2015
The success or failure of a procedure will depend partly on surgical factors, partly on patient-related factors, and only partly on the implant chosen. It is critical, when reporting outcomes, to consider each of these areas and to have the means of evaluating them effectively. Future generations of surgeons will need to evaluate outcomes in a very sophisticated way and be able to capture clear metrics, not just for their own sakes, but also for the sake of their patients, and to meet the demands of healthcare commissioners. They will want to continue to innovate but will need to balance that with having appropriate data and will need to evidence their decision-making more than ever. It will also become particularly difficult to change practice without clear forethought and data to support such a change. We are also under increasing pressure to be cost effective.1-4 We have seen a significant rise in health economic research submitted to the BJJ over the past few years. Unfortunately, many of these lacked the methodological rigour that is required, and it is therefore a pleasure to highlight the paper by Pulikottil-Jacob et al,5 on the cost effectiveness of total hip arthroplasties for osteoarthritis looking at different bearings, surfaces and modes of fixation. The conclusion reached in this elegant analysis is that there is not a single device that can be recommended, and that there are a number of variables that should be considered including local costs, revision rates, and the preference of individual surgeons. This supports some work published in the BJJ over the last couple of years highlighting the difficulties in using cost effectiveness data to guide the choice of implant and debunking some of the myths that are currently being perpetuated by some commissioners and political orthopaedic leaders in relation to the perceived advantages of one type of implant, or fixation mode, over another. There
is good long-term evidence for various types of fixation and for a variety of bearing surfaces, just as there is good evidence against specific implants and some bearing couples such as the large head metal-on-metal. The reality is that local data and personal data will often show that certain combinations of implant and bearing and fixation options work well in a particular setting, whereas they may not in another. Many of our colleagues work in regions where political pressure attempts to influence implant choice, and in effect takes away some surgical autonomy, with very little real evidence of cost effectiveness on which to base these decisions. We are sadly often guided by back-of-the-envelope calculations that only look at one variable such as the cost of the implant, the operating time or length of stay. Some are also misled in that they take a shortterm view and place great emphasis on the immediate costs of an intervention, whereas the real cost lies over the lifetime of the patient. We hope that increasing interest in the cost effectiveness of our forms of treatment will lead to detailed collaborative research in this area.
References 1. Benninger E, Zingg PO, Kamath AF, Dora C. Cost analysis of fresh-frozen femoral head allografts. Bone Joint J 2014;96B:1307–1311. 2. Egol KA, Marcano AI, Lewis L, et al. Can the use of an evidence-based algorithm for the treatment of intertrochanteric fractures of the hip maintain quality at a reduced cost? Bone Joint J 2014;96-B:1192–1197. 3. Gutowski CJ, Zmistowski BM, Clyde CT, Parvizi J. The economics of using prophylactic antibiotic-loaded bone cement in total knee replacement. Bone Joint J 2014;96-B:65–69. 4. Kallala RF, Vanhegan IS, Ibrahim MS, Sarmah S, Haddad FS. Financial analysis of revision knee surgery based on NHS tariffs and hospital costs. Bone Joint J 2015;97-B:197–201. 5. Pulikottil-Jacob R, Connock M, Kandala N- B, et al. Costeffectiveness of total hip arthroplasty in osteoarthritis - comparison of devices with differing bearing surfaces and modes of fixation. Bone Joint J 2015;97-B:449–457. 433
