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Local anaesthetic wound infiltration in addition to standard anaesthetic regimen in total hip and knee replacement: long-term cost-effectiveness analyses alongside the APEX randomised controlled trials.

Marques EM, Blom AW, Lenguerrand E, Wylde V, Noble SM - BMC Med (2015)

Bottom Line: The economic results were bootstrapped incremental net monetary benefit statistics (INMB) and cost-effectiveness acceptability curves.Administering LAI is a cost-effective treatment option in THR and TKR surgeries.In TKR, there is more uncertainty around the economic result, and smaller QALY gains.

View Article: PubMed Central - PubMed

Affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. e.marques@bristol.ac.uk.

ABSTRACT

Background: The Arthroplasty Pain Experience (APEX) studies are two randomised controlled trials in primary total hip (THR) and total knee replacement (TKR) at a large UK orthopaedics centre. APEX investigated the effect of local anaesthetic wound infiltration (LAI), administered before wound closure, in addition to standard analgesia, on pain severity at 12 months. This article reports results of the within-trial economic evaluations.

Methods: Cost-effectiveness was assessed from the health and social care payer perspective in relation to quality adjusted life years (QALYs) and the primary clinical outcome, the WOMAC Pain score at 12-months follow-up. Resource use was collected from hospital records and patient-completed postal questionnaires, and valued using unit cost estimates from local NHS Trust finance department and national tariffs. Missing data were addressed using multiple imputation chained equations. Costs and outcomes were compared per trial arm and plotted in cost-effectiveness planes. If no arm was dominant (i.e., more effective and less expensive than the other), incremental cost-effectiveness ratios were estimated. The economic results were bootstrapped incremental net monetary benefit statistics (INMB) and cost-effectiveness acceptability curves. One-way deterministic sensitivity analyses explored any methodological uncertainty.

Results: In both the THR and TKR trials, LAI was the dominant treatment: cost-saving and more effective than standard care, in relation to QALYs and WOMAC Pain. Using the £20,000 per QALY threshold, in THR, the INMB was £1,125 (95 % BCI, £183 to £2,067) and the probability of being cost-effective was over 98 %. In TKR, the INMB was £264 (95 % BCI, -£710 to £1,238), but there was only 62 % probability of being cost-effective. When considering an NHS perspective only, LAI was no longer dominant in THR, but still highly cost-effective, with an INMB of £961 (95 % BCI, £50 to £1,873).

Conclusions: Administering LAI is a cost-effective treatment option in THR and TKR surgeries. The evidence, because of larger QALY gain, is stronger for THR. In TKR, there is more uncertainty around the economic result, and smaller QALY gains. Results, however, point to LAI being cheaper than standard analgesia, which includes a femoral nerve block.

Trial registration: ISRCTN96095682 , 29/04/2010.

Show MeSH
a. Total hip replacement: primary and secondary analyses cost-effectiveness plane and cost-acceptability curve. b. Total knee replacement: base care cost-effectiveness plane and cost-acceptability curve
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Fig1: a. Total hip replacement: primary and secondary analyses cost-effectiveness plane and cost-acceptability curve. b. Total knee replacement: base care cost-effectiveness plane and cost-acceptability curve

Mentions: Figure 1 plots the 1,000 replications of the adjusted bootstrapped incremental cost-effectiveness estimates in the cost-effectiveness planes and the corresponding CEACs for the various willingness-to-pay per QALY thresholds. Most estimates fall within the southeast quadrant of the plane, indicating the dominance of the intervention over standard care, more notably so for THR than TKR. The CEAC shows the uncertainty around the economic results, with a probability of LAI being cost-effective in TKR only slightly over 60 % at the £20,000 threshold. In THR, there is over 98 % probability of LAI being cost-effective at £20,000 per QALY and over 95 % at £10,000 per QALY.Fig. 1


Local anaesthetic wound infiltration in addition to standard anaesthetic regimen in total hip and knee replacement: long-term cost-effectiveness analyses alongside the APEX randomised controlled trials.

Marques EM, Blom AW, Lenguerrand E, Wylde V, Noble SM - BMC Med (2015)

a. Total hip replacement: primary and secondary analyses cost-effectiveness plane and cost-acceptability curve. b. Total knee replacement: base care cost-effectiveness plane and cost-acceptability curve
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4496938&req=5

Fig1: a. Total hip replacement: primary and secondary analyses cost-effectiveness plane and cost-acceptability curve. b. Total knee replacement: base care cost-effectiveness plane and cost-acceptability curve
Mentions: Figure 1 plots the 1,000 replications of the adjusted bootstrapped incremental cost-effectiveness estimates in the cost-effectiveness planes and the corresponding CEACs for the various willingness-to-pay per QALY thresholds. Most estimates fall within the southeast quadrant of the plane, indicating the dominance of the intervention over standard care, more notably so for THR than TKR. The CEAC shows the uncertainty around the economic results, with a probability of LAI being cost-effective in TKR only slightly over 60 % at the £20,000 threshold. In THR, there is over 98 % probability of LAI being cost-effective at £20,000 per QALY and over 95 % at £10,000 per QALY.Fig. 1

Bottom Line: The economic results were bootstrapped incremental net monetary benefit statistics (INMB) and cost-effectiveness acceptability curves.Administering LAI is a cost-effective treatment option in THR and TKR surgeries.In TKR, there is more uncertainty around the economic result, and smaller QALY gains.

View Article: PubMed Central - PubMed

Affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. e.marques@bristol.ac.uk.

ABSTRACT

Background: The Arthroplasty Pain Experience (APEX) studies are two randomised controlled trials in primary total hip (THR) and total knee replacement (TKR) at a large UK orthopaedics centre. APEX investigated the effect of local anaesthetic wound infiltration (LAI), administered before wound closure, in addition to standard analgesia, on pain severity at 12 months. This article reports results of the within-trial economic evaluations.

Methods: Cost-effectiveness was assessed from the health and social care payer perspective in relation to quality adjusted life years (QALYs) and the primary clinical outcome, the WOMAC Pain score at 12-months follow-up. Resource use was collected from hospital records and patient-completed postal questionnaires, and valued using unit cost estimates from local NHS Trust finance department and national tariffs. Missing data were addressed using multiple imputation chained equations. Costs and outcomes were compared per trial arm and plotted in cost-effectiveness planes. If no arm was dominant (i.e., more effective and less expensive than the other), incremental cost-effectiveness ratios were estimated. The economic results were bootstrapped incremental net monetary benefit statistics (INMB) and cost-effectiveness acceptability curves. One-way deterministic sensitivity analyses explored any methodological uncertainty.

Results: In both the THR and TKR trials, LAI was the dominant treatment: cost-saving and more effective than standard care, in relation to QALYs and WOMAC Pain. Using the £20,000 per QALY threshold, in THR, the INMB was £1,125 (95 % BCI, £183 to £2,067) and the probability of being cost-effective was over 98 %. In TKR, the INMB was £264 (95 % BCI, -£710 to £1,238), but there was only 62 % probability of being cost-effective. When considering an NHS perspective only, LAI was no longer dominant in THR, but still highly cost-effective, with an INMB of £961 (95 % BCI, £50 to £1,873).

Conclusions: Administering LAI is a cost-effective treatment option in THR and TKR surgeries. The evidence, because of larger QALY gain, is stronger for THR. In TKR, there is more uncertainty around the economic result, and smaller QALY gains. Results, however, point to LAI being cheaper than standard analgesia, which includes a femoral nerve block.

Trial registration: ISRCTN96095682 , 29/04/2010.

Show MeSH