The arthroplasty candidacy help engine tool to select candidates for hip and knee replacement surgery: development and economic modelling

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Title: The arthroplasty candidacy help engine tool to select candidates for hip and knee replacement surgery: development and economic modelling
Authors: Price, A
Smith, J
Dakin, H
Kang, S
Eibich, P
Cook, J
Gray, A
Harris, K
Middleton, R
Gibbons, E
Benedetto, E
Smith, S
Dawson, J
Fitzpatrick, R
Sayers, A
Miller, L
Marques, E
Gooberman-Hill, R
Blom, A
Judge, A
Arden, N
Murray, D
Glyn-Jones, S
Barker, K
Carr, A
Beard, D
Item Type: Report
Abstract: Background There is no good evidence to support the use of patient-reported outcome measures (PROMs) in setting preoperative thresholds for referral for hip and knee replacement surgery. Despite this, the practice is widespread in the NHS. Objectives/research questions Can clinical outcome tools be used to set thresholds for hip or knee replacement? What is the relationship between the choice of threshold and the cost-effectiveness of surgery? Methods A systematic review identified PROMs used to assess patients undergoing hip/knee replacement. Their measurement properties were compared and supplemented by analysis of existing data sets. For each candidate score, we calculated the absolute threshold (a preoperative level above which there is no potential for improvement) and relative thresholds (preoperative levels above which individuals are less likely to improve than others). Owing to their measurement properties and the availability of data from their current widespread use in the NHS, the Oxford Knee Score (OKS) and Oxford Hip Score (OHS) were selected as the most appropriate scores to use in developing the Arthroplasty Candidacy Help Engine (ACHE) tool. The change in score and the probability of an improvement were then calculated and modelled using preoperative and postoperative OKS/OHSs and PROM scores, thereby creating the ACHE tool. Markov models were used to assess the cost-effectiveness of total hip/knee arthroplasty in the NHS for different preoperative values of OKS/OHSs over a 10-year period. The threshold values were used to model how the ACHE tool may change the number of referrals in a single UK musculoskeletal hub. A user group was established that included patients, members of the public and health-care representatives, to provide stakeholder feedback throughout the research process. Results From a shortlist of four scores, the OHS and OKS were selected for the ACHE tool based on their measurement properties, calculated preoperative thresholds and cost-effectiveness data. The absolute threshold was 40 for the OHS and 41 for the OKS using the preferred improvement criterion. A range of relative thresholds were calculated based on the relationship between a patient’s preoperative score and their probability of improving after surgery. For example, a preoperative OHS of 35 or an OKS of 30 translates to a 75% probability of achieving a good outcome from surgical intervention. The economic evaluation demonstrated that hip and knee arthroplasty cost of < £20,000 per quality-adjusted life-year for patients with any preoperative score below the absolute thresholds (40 for the OHS and 41 for the OKS). Arthroplasty was most cost-effective for patients with lower preoperative scores. Limitations The ACHE tool supports but does not replace the shared decision-making process required before an individual decides whether or not to undergo surgery. Conclusion The OHS and OKS can be used in the ACHE tool to assess an individual patient’s suitability for hip/knee replacement surgery. The system enables evidence-based and informed threshold setting in accordance with local resources and policies. At a population level, both hip and knee arthroplasty are highly cost-effective right up to the absolute threshold for intervention. Our stakeholder user group felt that the ACHE tool was a useful evidence-based clinical tool to aid referrals and that it should be trialled in NHS clinical practice to establish its feasibility.
Issue Date: 1-Jun-2019
ISSN: 1366-5278
Publisher: National Institute for Health Research
Start Page: 1
End Page: 252
Journal / Book Title: Health Technology Assessment
The arthroplasty candidacy help engine tool to select candidates for hip and knee replacement surgery: development and economic modelling
Copyright Statement: © 2019 Queen’s Printer and Controller of HMSO. This work was produced by Price et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 3.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:
Keywords: 1117 Public Health and Health Services
0807 Library and Information Studies
0806 Information Systems
Health Policy & Services
Publication Status: Published online
Appears in Collections:Division of Surgery

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