Orthopedics

Feature Article Supplemental Data

Cost Analysis of Dual-Mobility Constructs in Revision Total Hip Arthroplasty: A European Payer Perspective

Matthew P. Abdel, MD; Larry E. Miller, PhD; Stephen A. Hull, MHS; Andréa B. Coppolecchia, MPH; Arlen D. Hanssen, MD; Mark W. Pagnano, MD

Abstract

Dual-mobility constructs have been shown to significantly and substantially decrease dislocations after revision total hip arthroplasty (THA). The authors have previously shown that dual-mobility (DM) constructs are cost-effective given their ability to decrease dislocations and re-revision for dislocation. The goal was to report the costs of DM and large femoral head (LFH) constructs in revision THAs from a European health care payer perspective. A Markov model was constructed to analyze the costs incurred by payers in the United Kingdom, Germany, Italy, and Spain over 3 years in revision THAs with DM or LFH constructs. Model states and probabilities were derived from prospectively collected registry data in 302 patients who underwent revision THA with a DM or 40-mm LFH construct and were then mapped to corresponding procedural reimbursement codes and tariffs for each country. Costs were weighted average national payments for reintervention procedures performed in the 3 years following revision THA. Probabilistic sensitivity analysis examined the effect of combined uncertainty across all model parameters. During a 3-year period following revision THA, reintervention rates were 9% for DM constructs and 19% for LFH constructs (P=.01). Comparing DM and LFH constructs, cumulative incremental costs over 3-years' follow-up were £428 vs £1447 in the United Kingdom, euro 451 vs euro 1272 in Germany, euro 540 vs euro 1425 in Italy, and euro 523 vs euro 1562 in Spain, respectively. At mid-term follow-up, DM constructs used in revision THAs were associated with a significantly lower risk of reintervention, which translated to lower health care payer costs compared with LFH constructs among European health care payers. [Orthopedics. 2020;43(4):250–255.]

Abstract

Dual-mobility constructs have been shown to significantly and substantially decrease dislocations after revision total hip arthroplasty (THA). The authors have previously shown that dual-mobility (DM) constructs are cost-effective given their ability to decrease dislocations and re-revision for dislocation. The goal was to report the costs of DM and large femoral head (LFH) constructs in revision THAs from a European health care payer perspective. A Markov model was constructed to analyze the costs incurred by payers in the United Kingdom, Germany, Italy, and Spain over 3 years in revision THAs with DM or LFH constructs. Model states and probabilities were derived from prospectively collected registry data in 302 patients who underwent revision THA with a DM or 40-mm LFH construct and were then mapped to corresponding procedural reimbursement codes and tariffs for each country. Costs were weighted average national payments for reintervention procedures performed in the 3 years following revision THA. Probabilistic sensitivity analysis examined the effect of combined uncertainty across all model parameters. During a 3-year period following revision THA, reintervention rates were 9% for DM constructs and 19% for LFH constructs (P=.01). Comparing DM and LFH constructs, cumulative incremental costs over 3-years' follow-up were £428 vs £1447 in the United Kingdom, euro 451 vs euro 1272 in Germany, euro 540 vs euro 1425 in Italy, and euro 523 vs euro 1562 in Spain, respectively. At mid-term follow-up, DM constructs used in revision THAs were associated with a significantly lower risk of reintervention, which translated to lower health care payer costs compared with LFH constructs among European health care payers. [Orthopedics. 2020;43(4):250–255.]

Total hip arthroplasty (THA) provides durable and clinically meaningful improvements in pain, function, and quality of life in most patients. However, due to factors such as greater THA demand in younger and more active patients, increasing life expectancy, and higher obesity prevalence,1–3 the number of revision procedures has been increasing at an exponential rate in recent years, with an alarming 4-fold increase in the frequency of revision THAs anticipated in the United Kingdom (UK) over the next few decades.4

In the revision setting, dislocation remains one of the most common causes of re-revision.5 Use of large femoral heads (LFHs) reduces the risk of dislocation in revision THAs6 due to improvements in jump distance and impingement-free range of motion. Dual-mobility (DM) constructs have 2 points of articulation that provide an increased range of motion before impingement and dislocation7,8 and have demonstrated reductions in dislocation in revision THA.9 Until recently, comparative data on LFH and DM constructs in revision THA have been lacking. Hartzler et al9 reported that patients treated with DM constructs in revision THA had fewer dislocations and re-revisions compared with LFH constructs during a mean follow-up of 3.6 years.

With the number of revision procedures increasing, so follows the potential economic burdens of these procedures. Bozic et al10 evaluated both revision THAs and revision total knee arthroplasties and found that revision THAs had greater resource utilization and higher average costs compared with revision total knee arthroplasties. They also found that revision for dislocation comprised 22% of the total revision THAs analyzed.10 Others have evaluated the cost of treating dislocation episodes and found that it increased the cost of the initial procedure by up to 352%, depending on the treatment modalities used.11,12 However, health care payer costs with DM vs LFH constructs in revision THA remain unclear. The purpose of this study was to report the incremental costs of DM vs LFH constructs in revision THA procedures from a European health care payer perspective.

Materials and Methods

The probability of reintervention during the 3-year period following revision THA, along with estimates of uncertainty, were derived from prospectively collected registry data of 302 revision THA procedures: 126 procedures using a DM construct (Modular Dual Mobility; Stryker, Mahwah, New Jersey) and 176 procedures using a 40-mm LFH construct (various manufacturers). Re-intervention procedures, which included both closed reductions and revision surgery, were performed between 2011 and 2014 and all patients had a minimum of 2 years of follow-up (mean, 3.6 years). Patient characteristics were generally comparable between the DM and LFH groups, including mean age (66 vs 65 years, respectively), body mass index (31 kg/m2 in each group), and female sex (52% vs 41%, respectively). There was a bias to use DM constructs more frequently in patients being revised specifically for a history of dislocation (33% vs 10%, respectively; P<.001).

During a 3-year period following revision THA, reintervention was performed in 9% (11 of 126) of patients with DM vs 19% (34 of 176) of patients with LFH (P=.01; Figure 1). Complete clinical outcomes from this study have been reported elsewhere.9

Reinterventions over 3 years following index revision total hip arthroplasty.9

Figure 1:

Reinterventions over 3 years following index revision total hip arthroplasty.9

Health care costs were determined using country-specific procedural reimbursement codes and tariffs. Health care payer costs were derived from Health care Resource Group codes in the UK, Diagnosis Related Groups codes in Germany and Italy, and Related Diagnostic Groups codes in Spain. A listing of diagnosis codes by reintervention type is presented by country in Table A (available in the online version of the article). All procedure codes were reviewed for accuracy by orthopedic surgeons and reimbursement specialists within each region. Mean payments for each reintervention type were calculated as weighted average national payments based on procedure volume. Mean payments by reintervention type and country, as well as applicable source data, are listed in Table 1. Reimbursements were reported as pound sterling (UK) or euro (Germany, Italy, Spain). The number of patient-years of follow-up and the number of reintervention events of each type for DM and LFH implants are reported in Table 2, and the associated probabilities entered into the Markov decision-analytic model are reported in Table 3.

Hip arthroplasty reintervention mapping to diagnostic codes by countryHip arthroplasty reintervention mapping to diagnostic codes by countryHip arthroplasty reintervention mapping to diagnostic codes by countryHip arthroplasty reintervention mapping to diagnostic codes by countryHip arthroplasty reintervention mapping to diagnostic codes by country

Table A.

Hip arthroplasty reintervention mapping to diagnostic codes by country

Health Care Costs for Hip Arthroplasty Reinterventions by Country

Table 1:

Health Care Costs for Hip Arthroplasty Reinterventions by Country

Reoperations Through 3 Years Following Index Revision Total Hip Arthroplasty

Table 2:

Reoperations Through 3 Years Following Index Revision Total Hip Arthroplasty

Markov Model Inputs of Annual Reoperation Probability in the 3 Years Following Revision Total Hip Arthroplastya

Table 3:

Markov Model Inputs of Annual Reoperation Probability in the 3 Years Following Revision Total Hip Arthroplasty

A Markov decision-analytic model (TreeAge Pro; TreeAge Software, Inc, Williamstown, Massachusetts) was developed to analyze the costs of subsequent reinterventions in patients who underwent revision THA with DM or LFH constructs. The model estimated the mean cost of reinterventions incurred by health care payers by country. Reimbursements accumulated annually during a 3-year period, during which 4 distinct states were specified: no reintervention, procedure for dislocation (successful closed reduction or unsuccessful closed reduction followed by re-revision), re-revision for aseptic loosening, or re-revision for periprosthetic joint infection. Health care costs were discounted by 3% per annum. Probabilistic sensitivity analysis examined the effect of combined uncertainty across all model parameters.

Results

Comparing DM with LFH constructs, the risk per 100 person-years was 1.2 vs 3.4 for dislocation, 0.9 vs 1.8 for periprosthetic joint infection, and 1.2 vs 1.6 for aseptic loosening, respectively. Among the reinterventions that were performed in the 3-year follow-up interval, 91% occurred during the first year after revision THA.

The cumulative health care cost curve at 3 years by country is shown in Figure 2. Comparing DM with LFH constructs, cumulative incremental costs over 3 years of follow-up were £428 (95% confidence interval [CI], £109 to £783) vs £1447 (95% CI, £787 to £2211) in the UK, euro 451 (95% CI, euro 99 to euro 852) vs euro 1272 (95% CI, euro 673 to euro 1971) in Germany, euro 540 (95% CI, euro 115 to euro 1024) vs euro 1425 (95% CI, euro 719 to euro 2234) in Italy, and euro 523 (95% CI, euro 119 to euro 984) vs euro 1562 (95% CI, euro 884 to euro 2336) in Spain (Table 4). Ultimately, DM implants were cost saving for patients undergoing revision THA, at a cost differential of £1019 in the UK, euro 820 in Germany, euro 885 in Italy, and euro 1039 in Spain. Therefore, if the incremental cost of DM implants relative to LFH implants was lower than these cost thresholds, the cost to health care payers for revision THA may be lower during the 3-year period following revision surgery.

Graphs showing the cumulative health care costs associated with dual-mobility (DM) and large femoral head (LFH) constructs over 3 years following revision total hip arthroplasty in the United Kingdom (A), Germany (B), Italy (C), and Spain (D). Values derived from 1000 simulations using probabilistic sensitivity analysis, which accounts for combined uncertainty across all model parameters. Shaded area indicates the incremental cost difference between DM and LFH constructs across all simulations.

Figure 2:

Graphs showing the cumulative health care costs associated with dual-mobility (DM) and large femoral head (LFH) constructs over 3 years following revision total hip arthroplasty in the United Kingdom (A), Germany (B), Italy (C), and Spain (D). Values derived from 1000 simulations using probabilistic sensitivity analysis, which accounts for combined uncertainty across all model parameters. Shaded area indicates the incremental cost difference between DM and LFH constructs across all simulations.

Cumulative Costs of Dual-Mobility and Large Femoral Head Constructs Over 3 Years and Cost Differentials

Table 4:

Cumulative Costs of Dual-Mobility and Large Femoral Head Constructs Over 3 Years and Cost Differentials

Discussion

Instability after primary and revision THA remains a clinical challenge. Large femoral heads and DM constructs have each been shown to lower dislocation rates in primary THA,13–15 yet few studies have compared these implants in the revision setting. The findings of the current study revealed that the use of DM constructs in revision THAs lowered health care costs relative to LFH constructs by approximately euro 800 to euro 1200 over 3 years, with the majority of clinical and cost-benefit realized in the first year after revision.

Approximately half of the reinterventions performed in this series were due to dislocation. The risk of dislocation was approximately 3-fold higher with LFH vs DM constructs and was the main determinant of higher associated health care payer costs. Only 3% of patients treated with the DM construct dislocated within 3 years of revision THA, which is comparable to the 3% dislocation rate reported in a systematic review of DM constructs in more than 5000 revision THA procedures.13 The efficacy of DM constructs to reduce dislocation rates supports their use in high-risk patients, such as those with neurological disease, those with hip abductor weakness, or those undergoing revision surgery.

A unique aspect of this study was its utilization of a large sample of 302 revision THA cases, which allowed for the calculation of annual reintervention rates with high precision. However, patients were not randomly allocated to the DM or LFH groups; therefore, selection bias may have confounded study results. Indeed, revision THA was performed for dislocation in 33% of patients treated with DM, but in only 10% of patients treated with LFH. Thus, it is plausible that the clinical and cost-benefits of DM may be underestimated in the current study given a greater baseline risk for recurrent instability in the DM group.14–19

In addition, reintervention probabilities were derived from the clinical experience of a single institution, which may limit the generalizability of study findings. However, the rate of dislocation in the study was comparable to that reported in a large systematic review,13 suggesting that it is reasonable to assume that similar outcomes may be realized by other institutions. Another limitation of this study was that functional outcomes and quality of life data were not available, which prohibited a formal cost-effectiveness calculation (eg, cost per quality-adjusted life year). Finally, the incremental costs reported here were derived from mid-term clinical follow-up. Long-term follow-up data will be required to draw more definitive conclusions regarding the comparative clinical performance and cost utility of the DM and LFH constructs in revision THA.

Upward trends and projections of both primary and revision total joint arthroplasty in the United States have been well cited.10,20 Other countries have examined trends of total joint arthroplasty and found increases in total joint procedures and revision joints as well. Patel et al4 evaluated data from the UK National Joint registry and predicted a 137% growth in revision THA by 2030.

Villanueva-Martinez et al21 observed a significant increase revision THA during a 7-year period evaluating data from the Spanish National Hospital Discharge Database. Pilz et al22 examined trends in hip arthroplasties in Germany and expected a 27% growth in THA by 2040. Torre et al23 performed an analysis of procedure trends in the Italian Arthroplasty Registry and found a 34.1% increase, at a growth rate of 2.3% per year, in revision THA from 2001 to 2014. In all evaluations of revision, dislocation was one of the most common reasons. Given the growth in these regions and the knowledge that revision THAs incur greater utilization of health services and costs, it is appropriate to evaluate the potential for cost-effective treatment options in revision THA related to dislocation.

Conclusion

At mid-term follow-up, DM constructs used in revision THA were associated with a significantly lower risk of reintervention, which translated to lower health care payer costs compared with LFH constructs among European health care payers.

References

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Health Care Costs for Hip Arthroplasty Reinterventions by Country

Reintervention TypeAverage Paymenta

United Kingdom (£)Germany (Euro)Italy (Euro)Spain (Euro)
Successful closed reduction3129193112094130
Unsuccessful closed reduction and aseptic re-revision7961913811,15210,504
Re-revision, aseptic loosening7961913811,15210,504
Re-revision, periprosthetic joint infection13,058981811,15210,504

Reoperations Through 3 Years Following Index Revision Total Hip Arthroplasty

Years After RevisionDual-Mobility Construct, No.Large Femoral Head Construct, No.


Patient-yearsPeriprosthetic Joint InfectionAseptic LooseningDislocationPatient-yearsPeriprosthetic Joint InfectionAseptic LooseningDislocation
11263331769617
2126000176010
397011155010
Total3493445079817

Markov Model Inputs of Annual Reoperation Probability in the 3 Years Following Revision Total Hip Arthroplastya

ReoperationDual-Mobility ConstructLarge Femoral Head Construct


Base-Case EstimateRange for Probabilistic Sensitivity AnalysisBase-Case EstimateRange for Probabilistic Sensitivity Analysis


LowHighLowHigh
Dislocationb
  Year 12.40.05.09.75.314.0
  Year 20.10.02.90.10.02.1
  Year 31.00.03.00.10.02.3
Aseptic loosening
  Year 12.40.05.03.40.76.1
  Year 20.10.02.90.60.01.7
  Year 31.00.03.00.60.01.9
Periprosthetic joint infection
  Year 12.40.05.05.11.98.4
  Year 20.10.02.90.10.02.1
  Year 30.10.03.80.10.02.4

Cumulative Costs of Dual-Mobility and Large Femoral Head Constructs Over 3 Years and Cost Differentials

CountryDual-MobilityLarge Femoral HeadCost Differential


3-Year Cumulative Cost95% Confidence Interval3-Year Cumulative Cost95% Confidence Interval
United Kingdom£428£109, £783£1447£787, £2211£1019
Germanyeuro 451euro 99, euro 852euro 1272euro 673, euro 1971euro 820
Italyeuro 540euro 115, euro 1024euro 1425euro 719, euro 2234euro 885
Spaineuro 523euro 119, euro 984euro 1562euro 884, euro 2336euro 1039

Hip arthroplasty reintervention mapping to diagnostic codes by country

Reintervention TypeDiagnosis Code and Description
UK*Germany*Italy*Spain
Successful closed reductionHN14A: Intermediate Hip Procedures for Non-Trauma, 19 years and over, with CC Score 6+171B: Disorders of muscles and tendons except in para-/tetraplegia or distortion, strain, luxation of hip joint, pelvis and thigh, w/o cerebral paresis, w/o contracture249: Aftercare, musculoskeletal system and connective tissue249: Malfunction, reaction or complication of orthopedic device
HN14B: […] with CC Score 4–5
HN14C: […] with CC Score 2–3
HN14D: […] with CC Score 1
HN14E: […] with CC Score 0
Unsuccessful closed reduction & aseptic re-revisionHN81A: Complex, Hip or Knee Procedures for Non-Trauma, with CC Score 9+108G: Other interventions on hip joint and femur with moderately complex intervention, without very severe CC or without moderately complex intervention, with specified osseous transplantation or pseudarthrosis or revision of an endoprosthesis, more than one day545: Revision of hip or knee replacement817: Revision or substitution of hip due to complications
HN81B: […] with CC Score 6–8146A: Exchange of prosthesis on the hip joint with very severe CC or intervention on multiple localizations
HN81C: […]with CC Score 4–5146B: Exchange of prosthesis on the hip joint without very severe CC, without intervention on multiple localizations, with periprosthetic fracture on the hip or the knee
HN81D: […]with CC Score 2–3146C: Exchange of prosthesis on the hip joint without very severe CC, without intervention on multiple localizations, without periprosthetic fracture on the hip or the knee
HN81E: […]with CC Score 0–1
Re-revision, aseptic looseningHN81A: Complex, Hip or Knee Procedures for Non-Trauma, with CC Score 9+108G: Other interventions on hip joint and femur with moderately complex intervention, without very severe CC or without moderately complex intervention, with specified osseous transplantation or pseudarthrosis or revision of an endoprosthesis, more than one day545: Revision of hip or knee replacement817: Revision or substitu tion of hip due to complications
HN81B: […] with CC Score 6–8146A: Exchange of prosthesis on the hip joint with very severe CC or intervention on multiple localizations
HN81C: […]with CC Score 4–5146B: Exchange of prosthesis on the hip joint without very severe CC, without intervention on multiple localizations, with periprosthetic fracture on the hip or the knee
HN81D: […] with CC Score 2–3146C: Exchange of prosthesis on the hip joint without very severe CC, without intervention on multiple localizations, without periprosthetic fracture on the hip or the knee
Re-revision, periprosthetic joint infectionHN80A: Very Complex, Hip or Knee Procedures for Non-Trauma, with CC Score 9+103A: Revision or exchange of the hip joint with complex diagnosis or arthrodesis or age < 16 years or bilateral or various large interventions on joints of the lower extremities with complex intervention, with very severe CC or multi-stage exchange or interventions on multiple localizations545: Revision of hip or knee replacement817: Revision or substitution of hip due to complications
HN80B: […] with CC Score 6–8103B: […] without very severe CC or multi-stage exchange or interventions on multiple localizations
HN80C: […] with CC Score 3–5108D: Other intervention son hip joint and femur with multiple interventions or with complex diagnosis or with complex procedure or with very severe CC, age > 5 years
HN80D: […] with CC Score 0–2112C: Bone and joint infection or inflammation with diverse interventions on the muscular-skeletal system and conjunctive tissue with severe CC, without revision of the knee joint, without osteomyelitis, age > 15 years
Authors

The authors are from the Department of Orthopedic Surgery (MPA, ADH, MWP), Mayo Clinic, Rochester, Minnesota; Miller Scientific Consulting, Inc (LEM), Asheville, North Carolina; Hull Associates, LLC (SAH), Rockland, Maine; and Stryker Orthopaedics (ABC), Mahwah, New Jersey.

Dr Abdel is a paid consultant for and receives royalties from Stryker. Dr Miller served as a paid consultant to Stryker for this analysis. Mr Hull served as a paid consultant to Stryker for this analysis. Ms Coppolecchia is a paid employee of Stryker. Dr Hanssen receives royalties from Stryker. Dr Pagnano is a paid consultant for Pacira and Heron Therapeutics and receives royalties from Stryker and DePuy.

Correspondence should be addressed to: Matthew P. Abdel, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ( abdel.matthew@mayo.edu).

Received: January 29, 2019
Accepted: May 20, 2019

10.3928/01477447-20200625-01

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