Economic evaluation of access to musculoskeletal care: the case of waiting for total knee arthroplasty.
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BACKGROUND: The projected demand for total knee arthroplasty is staggering. At its root, the solution involves increasing supply or decreasing demand. Other developed nations have used rationing and wait times to distribute this service. However, economic impact and cost-effectiveness of waiting for TKA is unknown. METHODS: A Markov decision model was constructed for a cost-utility analysis of three treatment strategies for end-stage knee osteoarthritis: 1) TKA without delay, 2) a waiting period with no non-operative treatment and 3) a non-operative treatment bridge during that waiting period in a cohort of 60 year-old patients. Outcome probabilities and effectiveness were derived from the literature. Costs were estimated from the societal perspective with national average Medicare reimbursement. Effectiveness was expressed in quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, effectiveness, and quality-adjusted life years; and net health benefits. RESULTS: In the base case, a 2-year wait-time both with and without a non-operative treatment bridge resulted in a lower number of average QALYs gained (11.57 (no bridge) and 11.95 (bridge) vs. 12.14 (no delay). The average cost was $1,660 higher for TKA without delay than wait-time with no bridge, but $1,810 less than wait-time with non-operative bridge. The incremental cost-effectiveness ratio comparing wait-time with no bridge to TKA without delay was $2,901/QALY. When comparing TKA without delay to waiting with non-operative bridge, TKA without delay produced greater utility at a lower cost to society. CONCLUSIONS: TKA without delay is the preferred cost-effective treatment strategy when compared to a waiting for TKA without non-operative bridge. TKA without delay is cost saving when a non-operative bridge is used during the waiting period. As it is unlikely that patients waiting for TKA would not receive non-operative treatment, TKA without delay may be an overall cost-saving health care delivery strategy. Policies aimed at increasing the supply of TKA should be considered as savings exist that could indirectly fund those strategies.
SubjectArthroplasty, Replacement, Knee
Decision Support Techniques
Health Care Costs
Health Care Rationing
Health Services Accessibility
Health Services Needs and Demand
Health Services Research
Insurance, Health, Reimbursement
Quality-Adjusted Life Years
Published Version (Please cite this version)10.1186/1471-2474-15-22
Publication InfoBolognesi, Michael Paul; Hug, KT; Koenig, L; Mather, Richard Charles III; Nunley, RM; Orlando, Lori Ann; & Watters, TS (2014). Economic evaluation of access to musculoskeletal care: the case of waiting for total knee arthroplasty. BMC Musculoskelet Disord, 15. pp. 22. 10.1186/1471-2474-15-22. Retrieved from http://hdl.handle.net/10161/15648.
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Professor of Orthopaedic Surgery
As chief of the adult reconstruction service, the majority of my research effort has been directed toward clinical outcomes, implant survivorship, functional recovery, the biology of hip and knee arthritis and cost effectiveness.
Assistant Professor of Orthopaedic Surgery
Richard C. “Chad” Mather III MD, MBA is an assistant professor and vice chairman of practice innovation in the Department of Orthopaedic Surgery at Duke University School of Medicine. He is also a faculty member at the Duke Clinical Research Institute. Dr. Mather is a health services researcher and decision scientist with a focus on economic analysis, health policy, health preference measurement and personalized decision-making. His current work focuses on buildi
Associate Professor of Medicine
Dr. Lori A. Orlando, MD MHS is an Associate Professor of Medicine and Director of the Precision Medicine Program in the Center for Applied Genomics and Precision Medicine at Duke University. She attended Tulane Medical Center for both medical school (1994-1998) and Internal Medicine residency (1998-2000). There she finished AOA and received a number of awards for teaching and clinical care from the medical school and the residency programs, including the Musser-Burch-Puschett award in 2000 fo
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