The authors point out that the average implant cost per case varied by over 600% ($1797 to $12093) for total knee replacement procedures and by over 400% ($2392 to $12651) for total hip replacement procedures. These wide variances could not be explained by differences in patient characteristics. The ratio of device cost to total surgical cost for knee and hip arthroplasty can be as high as 87%, with the median ratio being 43%.
The authors point out that data are currently lacking to support the belief that higher cost devices are associated with better outcomes. This is an important article, especially when viewed in the light of the survivorship of some of the more expensive and 'more modern' implants as also shown here. On this basis some have advocated device regulation to assure that new technology is optimally applied.
While we are not aware of similar data for shoulder implants, it is logical to assume that the same phenomenon exists there. We have also seen that the results with newer shoulder implants may not justify the associated expense. Determination of differences in outcome may require quite long term followup.
An interesting commentary on this article was offered: Joint Replacement Costs in the Era of Healthcare Reform: Commentary on an article by James C. Robinson, PhD, MPH, et al.: “Variability in Costs Associated with Total Hip and Knee Replacement Implants” The author of this commentary reminded that orthopaedic implants and procedures are major contributors to the rising cost of healthcare. In spite of the rising number of these procedures performed each year, the cost of these procedures is not following 'economies of scale principles' in which the implant cost per case would drop as the number of cases increased. The author of the commentary suggests several possible approaches to reducing these costs: (1) collective bargaining by Medicare with the implant manufacturers, (2) defining standards on the impact of new devices on cost and outcomes before they come to market, opining that 'there is little evidence that newer and more expensive devices are associated with better functional outcomes', (3) lack of 'gain-sharing' between medical centers and surgeons, which could incentivize surgeons to cut costs without compromising outcomes, and (4) lack of a national joint registry, such as those that exist in other countries, that would provide cost and outcomes data that could inform future decisions on implant selection for particular categories of patients.
The bottom line is that in future we need to pay more attention to the value equation: how much better are the documented results with the new implant divided by how much more it costs than the existing device? If a country wanted to curb the rising cost of joint arthroplasty, would it be better for it to reduce the cost of implants or to reduce the payments to the surgeons implanting them? That choice may be on us sooner rather than later.
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