The cost and outcome effectiveness of total hip replacement: technique choice and volume-output effects matter.

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Applied health economics and health policy

MeSH Headings

Aged, Arthroplasty, Replacement, Hip, Centers for Medicare and Medicaid Services (U.S.), Cost-Benefit Analysis, Female, Humans, Insurance Claim Review, Maine, Male, Minimally Invasive Surgical Procedures, Outcome and Process Assessment (Health Care), Regression Analysis, United States


BACKGROUND: Total hip replacement (THR) must be managed in a more sustainable manner. More cost-effective surgical techniques and the centralization/regionalization of services are two solutions. The former requires an assessment of newer minimally invasive and muscle-sparing surgical techniques. The latter necessitates an effective volume-outcome (VO) relationship. Prior studies have failed to evaluate and control for the VO relation.

OBJECTIVE: The objective of this study was to evaluate the relative cost and outcome effectiveness of two minimally invasive and one muscle-sparing techniques while evaluating and controlling for a potentially endogenous VO relation.

METHODS: An all payer claims database for all THR performed in Maine in 2011 was used. The cost and outcome effectiveness of newer minimally invasive (modified Hardinge) and muscle-sparing (modified Watson-Jones) techniques were compared with the standard bearer posterior minimally invasive method. Using regression analysis, the outcomes analyzed were as follows: total costs, length of hospital stay, nursing care and home discharges, and use of physical therapy. Regression analysis was also used to evaluate and control for VO effects.

RESULTS: (1) Newer muscle-sparing and minimally invasive approaches are substantially more effective; (2) irrespective of technique, higher volume surgeons are more effective; (3) technique-specific VO effects for more complex techniques exist and show substantial savings when yearly volume exceeds 30-50; and (4) the anterolateral muscle-sparing technique is accessible to the average surgeon.

CONCLUSION: Reliance on newer surgical techniques and centralization/regionalization of THR services can reduce costs.




Division of Joint Replacement, Maine Medical Center.

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