Abstract
BackgroundTotal hip replacement for end stage arthritis of the hip is currently the most common elective surgical procedure. In 2007 about 7.5% of UK implants were metal-on-metal joint resurfacing (MoM RS) procedures. Due to poor revision performance and concerns about metal debris, the use of RS had declined by 2012 to about a 1% share of UK hip procedures. This study estimated the lifetime cost-effectiveness of metal-on-metal resurfacing (RS) procedures versus commonly employed total hip replacement (THR) methods.Methodology/Principal FindingsWe performed a cost-utility analysis using a well-established multi-state semi-Markov model from an NHS and personal and social services perspective. We used individual patient data (IPD) from the National Joint Registry (NJR) for England and Wales on RS and THR surgery for osteoarthritis recorded from April 2003 to December 2012. We used flexible parametric modelling of NJR RS data to guide identification of patient subgroups and RS devices which delivered revision rates within the NICE 5% revision rate benchmark at 10 years. RS procedures overall have an estimated revision rate of 13% at 10 years, compared to <4% for most THR devices. New NICE guidance now recommends a revision rate benchmark of <5% at 10 years. 60% of RS implants in men and 2% in women were predicted to be within the revision benchmark. RS devices satisfying the 5% benchmark were unlikely to be cost-effective compared to THR at a standard UK willingness to pay of £20,000 per quality-adjusted life-year. However, the probability of cost effectiveness was sensitive to small changes in the costs of devices or in quality of life or revision rate estimates.Conclusion/SignificanceOur results imply that in most cases RS has not been a cost-effective resource and should probably not be adopted by decision makers concerned with the cost effectiveness of hip replacement, or by patients concerned about the likelihood of revision, regardless of patient age or gender.
Highlights
Hip replacement is a common elective surgical procedure
The DePuy Articular Surface Replacement (ASR) device was recently withdrawn after unacceptably high revision rates were observed, and in 2015 Smith and Nephew voluntarily withdrew some Birmingham Hip devices on the grounds that in certain populations devices with a relatively small head size failed to reach the NICE benchmark for revision
Patients who had a primary indication for surgery other than osteoarthritis were excluded along with those graded American Society of Anaesthetologists (ASA) 3, ASA4 and ASA5, and those receving the DePuy RS device and data were stratified according to sex. . .Devices produced by six of the sixteen manufaturers which contributed 96% of relevant implants were included, comprising Birmingham Hip, Biomet, Centerpulse, Corin, Finsbury and Wright UK
Summary
Hip replacement is a common elective surgical procedure. If an estimated 80,000 replacements are conducted annually at an average cost of £8,500 per procedure, this would cost the UK NHS approximately £680 million per annum [1, 2]. 80,000 procedures are performed each year and, assuming lifetime revision rates are about 5% and the average cost of revision surgery is approximately £17,000, prosthesis failure adds a further £68 million over subsequent years [4]. Total hip replacement is currently the most commonly used surgical intervention for end stage arthritis of the hip. In 2007 about 7.5% of UK implants were metal-on-metal joint resurfacing (MoM RS) procedures [5], but due to high revision rates and concerns about metal debris, the use of RS declined to about 1% of UK hip procedures in 2012. Total hip replacement for end stage arthritis of the hip is currently the most common elective surgical procedure. This study estimated the lifetime cost-effectiveness of metal-on-metal resurfacing (RS) procedures versus commonly employed total hip replacement (THR) methods
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