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Patient Risk and Hospital Volume

Elena Losina, PhD; Rochelle P. Walensky, MD, MPH; Courtenay L. Kessler, MS; Parastu S. Emrani, BS; William M. Reichmann, MA; Elizabeth A. Wright, PhD; Holly L. Holt, BS; Daniel H. Solomon, MD, MPH; Edward Yelin, PhD; A. David Paltiel, PhD; Jeffrey N. Katz, MD, MS

Arch Intern Med. 2009;169(12):1113-1121.

Background  Total knee arthroplasty (TKA) relieves pain and improves quality of life for persons with advanced knee osteoarthritis. However, to our knowledge, the cost-effectiveness of TKA and the influences of hospital volume and patient risk on TKA cost-effectiveness have not been investigated in the United States.

Methods  We developed a Markov, state-transition, computer simulation model and populated it with Medicare claims data and cost and outcomes data from national and multinational sources. We projected lifetime costs and quality-adjusted life expectancy (QALE) for different risk populations and varied TKA intervention and hospital volume. Cost-effectiveness of TKA was estimated across all patient risk and hospital volume permutations. Finally, we conducted sensitivity analyses to determine various parameters' influences on cost-effectiveness.

Results  Overall, TKA increased QALE from 6.822 to 7.957 quality-adjusted life years (QALYs). Lifetime costs rose from $37 100 (no TKA) to $57 900 after TKA, resulting in an incremental cost-effectiveness ratio of $18 300 per QALY. For high-risk patients, TKA increased QALE from 5.713 to 6.594 QALY, yielding a cost-effectiveness ratio of $28 100 per QALY. At all risk levels, TKA was more costly and less effective in low-volume centers than in high-volume centers. Results were insensitive to variations of key input parameters within policy-relevant, clinically plausible ranges. The greatest variations were seen for the quality of life gain after TKA and the cost of TKA.

Conclusions  Total knee arthroplasty appears to be cost-effective in the US Medicare-aged population, as currently practiced across all risk groups. Policy decisions should be made on the basis of available local options for TKA. However, when a high-volume hospital is available, TKAs performed in a high-volume hospital confer even greater value per dollar spent than TKAs performed in low-volume centers.

Author Affiliations: Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery (Drs Losina, Wright, and Katz, Mss Kessler, Emrani, and Holt, and Mr Reichmann), Division of Infectious Disease (Dr Walensky), Section of Clinical Sciences, Division of Rheumatology, Immunology, and Allergy (Drs Losina, Wright, Solomon, and Katz), Brigham and Women's Hospital, Boston, Massachusetts; Department of Biostatistics, Boston University School of Public Health, Boston (Dr Losina and Mr Reichmann); Divisions of Infectious Disease and General Medicine, Massachusetts General Hospital, Boston (Dr Walensky); Rosalind Russell Medical Research Center for Arthritis, University of California, San Francisco (Dr Yelin); Yale School of Medicine, New Haven, Connecticut (Dr Paltiel); and Departments of Epidemiology and Environmental Health, Harvard School of Public Health, Boston (Dr Katz).

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