Abstract
The emergence of skeletal prosthetic attachments leaves governmental organizations facing the challenge of implementing equitable policies that support the provision of bone-anchored prostheses (BAPs). In 2013, the Queensland Artificial Limb Service (QALS) started a five-year research project focusing on health service delivery and economic evaluation of BAPs. This paper reflects on the QALS experience, particularly the lessons learned. QALS' jurisdiction and drivers are presented first, followed by the impact of outcomes, barriers, and facilitators, as well as future developments of this work. The 21 publications produced during this project (e.g., reimbursement policy, role of prosthetists, continuous improvement procedure, quality of life, preliminary cost-utilities) were summarized. Literature on past, current, and upcoming developments of BAP was reviewed to discuss the practical implications of this work. A primary outcome of this project was a policy developed by QALS supporting up to 22 h of labor for the provision of BAP care. The indicative incremental cost-utility ratio for transfemoral and transtibial BAPs was approximately AUD$17,000 and AUD$12,000, respectively, per quality-adjusted life-year compared to socket prostheses. This project was challenged by 17 barriers (e.g., limited resources, inconsistency of care pathways, design of preliminary cost-utility analyses) but eased by 18 facilitators (e.g., action research plan, customized database, use of free repositories). In conclusion, we concluded that lower limb BAP might be an acceptable alternative to socket prostheses from an Australian government prosthetic care perspective. Hopefully, this work will inform promoters of prosthetic innovations committed to making bionic solutions widely accessible to a growing population of individuals suffering from limb loss worldwide.
Highlights
This work will inform promoters of prosthetic innovations committed to making bionic solutions widely accessible to a growing population of individuals suffering from limb loss worldwide
Over the last 20 years, I witnessed genuine interest in osseointegration morphing into international momentum, leading to the emergence of a global ecosystem slowly paving the way toward recognition of direct skeletal prosthetic attachments
We estimated that 24% of the barriers to the project were specific to Queensland Artificial Limb Service (QALS), while 39% of the facilitators were transferable to other organizations
Summary
A handful of patients were first fitted with a screw-type implant in 2000 by a team in Melbourne, Victoria, in collaboration with the pioneering group in Sweden.[6] Curious to know more, I invited Dr Kerstin Hagberg, an acclaimed Rehabilitation Specialist from Sahlgrenska University Hospital, to give a talk on her Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) study for consumers, clinicians, and healthcare administrators in Brisbane, Queensland, in 2005.2,7,8 This presentation gave us a better understanding of the rehabilitation program as well as the benefits (e.g., improvement in health-related quality of life, prosthetic use, embodiment, prosthetic knee and hip range of motion, sitting comfort, donning and doffing, osseoperception, walking ability) and harms of osseointegration (e.g., skin irritation around the stoma, loosening, periprosthetic fractures, mechanical failure of implant parts, deep and superficial infections, removal).[1,7,9] It highlighted that bone-anchored prostheses (BAPs) could lessen expenditure from socket fittings and residuumrelated skin treatments.[4] This was the first time I wondered how the emergence of new treatments relying on direct skeletal attachment and the subsequent provision of BAP could impact the day-to-day work of a governmental organization such as QALS.
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