Is More Expensive Medical Technology Better?

Abstract

A method for employing sound statistical analysis in the field of medicine - the Cochrane Collaboration, which performs systematic, evidence-based reviews of the medical literature - has not been used much in the field of orthopaedics, especially in the US. This article is a commentary on our prior peer-reviewed publication appearing in a 2011 issue of the Journal of Bone and Joint Surgery (JBJS)[1] using Cochrane analytics for identifying value in primary total knee implants. The publication suggests how payers in the US such as Medicare (public payer for those ≥65 years of age) can ensure healthcare resources are allocated more efficiently. Further, the use of comparative effectiveness, as proposed in the recently passed Patient Protection and Affordable Care Act (PPACA), is a 'new' way the US government is proposing to evaluate one technology versus another - with the goal of identifying technologies that provide better value. We believe the JBJS publication is one of the first orthopaedic articles published that identifies value by using Cochrane analytics in the orthopaedic field and with primary total knee implants.In the US, an important issue concerning inefficient allocation of resources relates to providers choosing more expensive technologies over less expensive versions without the more expensive version demonstrating a clear clinical benefit versus the less expensive one. This is part of the reason why the US spends twice as much per capita on healthcare than other developed countries. A perfect example of inefficient allocation of resources in the US is with the use total knee implants.The US market size for total knee implants exceeded 575 000 procedures in 2010. The average selling price for a total knee implant is estimated at $US5450.[2] This amount represents approximately 46% of the total Medicare reimbursement a hospital would receive for the entire total knee arthroplasty (TKA) procedure. This price also reflects the use of a cemented and uncoated metal femoral component, a cemented and metal tibial component (with a polyethylene-bearing surface), and a plastic patella component - components which are used the vast majority of the time in a total knee replacement procedure. Further, most total knee implants are performed on Medicare-eligible patients. If one were to assume that 55%[3] of all total knee implants were performed on Medicare patients, then Medicare spends $US1.7 billion (575 000 × 0.55 × $US5450) per year for total knee implants as part of the overall reimbursement for this procedure.Recently we performed a systematic review and statistical meta-analysis of randomized controlled trials (RCTs) using the Cochrane methodology[1] (we are also contributors to the Cochrane Collaboration) examining the use of a less expensive, cemented, all-polyethylene tibial component (less expensive by ∼$US1600 per implant) versus other types of tibia implants used as part of the total knee implant. RCTs are the 'gold standard of evidence' evaluated and referenced by payers and the medical community when making coverage and clinical guideline determinations. Our meta-analysis included close to 1800 patients randomized to one implant or the other. The studies we identified examined patients for up to 15 years' post procedure on the clinical outcomes of durability (how long the implant lasts until the need for replacement), function (how well a patient is able to perform everyday activities), quality-of-life assessment (via a patient-assessed health survey), and acute adverse events (e.g. infection, implant dislocation). These are the important clinical outcomes the medical community evaluates in assessing the performance of TKA. What we found in examining each of these particular outcomes was that the less expensive, all-polyethylene tibial component performed just as well as the more expensive versions on the outcomes of durability, function (which includes quality-of-life assessments), and adverse events over this 15-year period. …