Nwachukwu Benedict U, Bozic Kevin J, Schairer William W, Bernstein Jaime L, Jevsevar David S, Marx Robert G, Padgett Douglas E
Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA,
Clin Orthop Relat Res. 2015 May;473(5):1815-27. doi: 10.1007/s11999-014-3964-4. Epub 2014 Sep 30.
Total joint arthroplasty (TJA), although considered to be highly beneficial, is associated with substantial costs to the US healthcare system. Cost utility analysis has become an increasingly important means to objectively evaluate the value of a healthcare intervention from the perspective of both extending the quantity and improving the quality of life. Relatively little is known about the overall cost utility analysis evidence base in TJA.
QUESTIONS/PURPOSES: The goals of this review were to (1) determine the cost utility of TJA interventions; (2) critically assess the quality of published US-based cost utility analyses using the Quality of Health Economic Studies instrument; and (3) determine what characteristics were common among studies receiving a high quality score.
A systematic review of the literature using the MEDLINE database was performed to compile findings and critically appraise US-based cost utility analysis studies for total hip and knee arthroplasty. Based on review of 676 identified articles, 23 studies were included. We used the Quality of Health Economic Studies instrument to assess study quality and one-sided Fisher's exact tests were applied to analyze the predictors of high-quality cost utility analysis.
Very few studies compare the cost utility of TJA versus nonoperative intervention; however, the available evidence suggests that TJA can be cost-saving and is highly cost-effective compared with conservative management of end-stage arthritis. The majority of identified studies are focused on the cost utility of new implant technologies or comparisons among surgical alternatives. These studies suggest that the upfront costs associated with new technologies are cost-effective when there is a major reduction in a future cost. The quality of identified studies is quite high (Quality of Health Economic Studies Instrument score: mean 86.5; range, 63-100). National funding source (p = 0.095) and lifetime horizon for analysis (p = 0.07) correlate with high-quality evidence but do not reach significance.
Over the past 15 years, there has been a major increase in the volume of cost utility analyses published in total hip and knee arthroplasty. The quality of cost utility analyses published during that period is good. As increasing attention is paid to value in US health care, more attention should be paid to understanding the cost utility of TJA compared with nonoperative treatment modalities. Future studies may also look to incorporate patient willingness to pay.
全关节置换术（TJA）虽被认为益处显著，但给美国医疗保健系统带来了高昂成本。成本效用分析已日益成为从延长寿命和提高生活质量角度客观评估医疗干预价值的重要手段。对于全关节置换术整体成本效用分析的证据基础，人们了解相对较少。
问题/目的：本综述的目标是：（1）确定全关节置换术干预措施的成本效用；（2）使用卫生经济研究质量工具严格评估已发表的美国成本效用分析的质量；（3）确定获得高分的研究有哪些共同特征。
使用MEDLINE数据库对文献进行系统综述，以汇总研究结果并严格评估美国关于全髋关节和膝关节置换术的成本效用分析研究。在对676篇已识别文章进行综述后，纳入了23项研究。我们使用卫生经济研究质量工具评估研究质量，并应用单侧Fisher精确检验分析高质量成本效用分析的预测因素。
很少有研究比较全关节置换术与非手术干预的成本效用；然而，现有证据表明，与终末期关节炎的保守治疗相比，全关节置换术可节省成本且具有很高的成本效益。大多数已识别研究聚焦于新型植入技术的成本效用或手术替代方案之间的比较。这些研究表明，当未来成本大幅降低时，与新技术相关的前期成本具有成本效益。已识别研究的质量相当高（卫生经济研究质量工具评分：平均86.5；范围63 - 100）。国家资金来源（p = 0.095）和分析的终生期限（p = 0.07）与高质量证据相关，但未达到显著水平。
在过去15年中，全髋关节和膝关节置换术发表的成本效用分析数量大幅增加。在此期间发表的成本效用分析质量良好。随着美国医疗保健领域对价值的关注度不断提高，应更加关注理解全关节置换术与非手术治疗方式相比的成本效用。未来研究也可考虑纳入患者的支付意愿。
