SLR - March 2016 - Nicholas Posge

Title: Management of End-Stage Ankle Arthritis: Cost-Utility Analysis Using Direct and Indirect Costs

Reference: Nwachukwu BU, McLawhorn AS, Simon MS, Hamid KS, Demetracopoulos CA, Deland JT, Ellis SJ. Management of End-Stage Ankle Arthritis: Cost-Utility Analysis Using Direct and Indirect Costs. J Bone Joint Surg Am. 2015 Jul 15; 97(14): 1159-72.

Scientific Literature Review

Reviewed By: Nicholas Posge, DPM
Residency Program: The Christ Hospital

Podiatric Relevance: This article is pertinent to the podiatric physician because it discusses pathology that is commonly seen in a foot and ankle surgeon’s practice. It is of significant relevance in that it discusses the three most common treatment modalities for end stage ankle arthritis and how they vary cost-wise for a patient. Their cost analysis was made using estimates comparing both direct and indirect costs.

Methods: The study was aimed to compare the direct and indirect costs of three management therapies for end-stage ankle arthritis. The three modalities investigated were: Total Ankle Replacement, Ankle Fusion, and Conservative management. Direct costs were obtained from a Nationwide Inpatient Sample. Indirect costs were derived from missed work productivity calculations and based on the average number of working days in a calendar year compared to the average daily income. The effectiveness was expressed as quality-adjusted life years (QALY), and the outcome was measured in incremental cost-effectiveness ratio (ICER). Comparing the ICER per QALY was used to determine which modality got the most success and cost the least. With the surgical options, various outcomes, including failures and revisions, were taken into consideration.

Results: When the indirect costs were taken into consideration, total ankle replacement was more effective and more cost efficient than both ankle fusion and ankle arthritis conservative care. The lifetime savings when doing a total ankle replacement was $5,900 when compared to conservative care and $800 when compared to ankle fusion. The total ankle replacement was also the preferred modality in 83 percent of the analysis. Patient age was a large factor in cost-effectiveness of the surgical procedure, and in the elderly ankle fusion was actually the preferred modality.

Conclusions: When dealing with end-stage ankle arthritis, with proper patient selection, surgical correction will often end up being more cost-effective than treating with conservative means. This takes into account the indirect cost of lost working days as well as the direct costs of the treatment. With choosing a surgical procedure, age was a dominant factor but generally a total ankle replacement was the most cost-effective treatment. While much of the data is carefully estimated and speculation, the article brings up a lot of interesting aspects to consider. Physicians need to be most concerned about what is best for the patient, and this can and should include the ability of the patient to handle the costs of treatment.

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