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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.

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a. Total hip replacement: Sensitivity analyses cost-effectiveness planes and cost-acceptability curves. b. Total knee replacement: Sensitivity analyses cost-effectiveness planes and cost-acceptability curves
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Fig2: a. Total hip replacement: Sensitivity analyses cost-effectiveness planes and cost-acceptability curves. b. Total knee replacement: Sensitivity analyses cost-effectiveness planes and cost-acceptability curves

Mentions: Our results in THR (Table 6) are robust to costing method of medication use, with an INMB statistic at the £20,000 per QALY threshold only slightly higher than base case. Varying local trust cost estimates during the initial patient stay by a factor of 50 % higher or lower did not alter our results, whereby the intervention is still dominant in both surgeries. In THR, the INMB statistics range from £1,051, using lower local costs, to £1,151, when higher local costs were used, compared with £1,125 in the base case. In TKR (Table 7), the respective figures are £253 and £159, compared with £264 in the base case. Due to changes in the components of the imputation model, QALY estimates vary slightly, particularly in TKR for these scenarios. In the scenario where we drop two high cost patients in THR, LAI is also the dominant treatment option with an INMB statistic of £1,121 (λ = 20,000; 95 % CI, £215 to £2,026). Figure 2a portrays the cost-effectiveness planes and CEACs for the scenarios, displaying probabilities of LAI being the cost-effective treatment option of over 98 % at the £20,000 per QALY threshold in THR. For TKR (Fig. 2b), sensitivity analysis results are consistent with base case results with just over 60 % probability of LAI being cost-effective at the £20,000 threshold.Fig. 2


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: Sensitivity analyses cost-effectiveness planes and cost-acceptability curves. b. Total knee replacement: Sensitivity analyses cost-effectiveness planes and cost-acceptability curves
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Fig2: a. Total hip replacement: Sensitivity analyses cost-effectiveness planes and cost-acceptability curves. b. Total knee replacement: Sensitivity analyses cost-effectiveness planes and cost-acceptability curves
Mentions: Our results in THR (Table 6) are robust to costing method of medication use, with an INMB statistic at the £20,000 per QALY threshold only slightly higher than base case. Varying local trust cost estimates during the initial patient stay by a factor of 50 % higher or lower did not alter our results, whereby the intervention is still dominant in both surgeries. In THR, the INMB statistics range from £1,051, using lower local costs, to £1,151, when higher local costs were used, compared with £1,125 in the base case. In TKR (Table 7), the respective figures are £253 and £159, compared with £264 in the base case. Due to changes in the components of the imputation model, QALY estimates vary slightly, particularly in TKR for these scenarios. In the scenario where we drop two high cost patients in THR, LAI is also the dominant treatment option with an INMB statistic of £1,121 (λ = 20,000; 95 % CI, £215 to £2,026). Figure 2a portrays the cost-effectiveness planes and CEACs for the scenarios, displaying probabilities of LAI being the cost-effective treatment option of over 98 % at the £20,000 per QALY threshold in THR. For TKR (Fig. 2b), sensitivity analysis results are consistent with base case results with just over 60 % probability of LAI being cost-effective at the £20,000 threshold.Fig. 2

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