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Decision Analysis: Applications in Orthopaedics
Karim A. Meijer, M.D. Joe Hahn, Ph.D., MBA and Jim Dyer, Ph. D.
McCombs School of Business, UT Austin
Decision Analysis: Applications in Orthopaedics Karim A. Meijer, - - PowerPoint PPT Presentation
Decision Analysis: Applications in Orthopaedics Karim A. Meijer, - - PowerPoint PPT Presentation
Decision Analysis: Applications in Orthopaedics Karim A. Meijer, M.D. Joe Hahn, Ph.D., MBA and Jim Dyer, Ph. D. McCombs School of Business, UT Austin Analysis of Orthopaedic Treatment Decisions Three Applications: Patellar Resurfacing in
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Analysis of Orthopaedic Treatment Decisions
§ Gameplan
§ Introduction and Anatomy § Medical Literature Review and Data
§ Cost Estimates & Probabilities
§ Analysis and Results
§ Decision Tree and Sensitivity Analysis § PAYER PERSPECTIVE
§ Discussion/Questions
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Total Knee Replacement
§ Total Knee Arthroplasty (TKA) is a high volume procedure § Estimated to be 3.48 million per year in 2030 Kurtz et JBJS 2007 § ~600,000 performed in 2007 with costs exceeding $11 billon
Arch Intern Med. 2009
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Patellar Resurfacing
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Patella Resurfacing with TKA?
Physician (Provider): Government (Payer):
“Always, Sometimes, Never.”
27447 470
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TKA Resurfaced Patella Nonresurfaced Patella
Decision Tree Model
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Decision Tree Model
Resurfaced Patella Reoperations Instability Aseptic Loosening Fracture Ruptured Extensor Mechanism Other No Reoperations
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Decision Tree Model
Nonresurfaced Patella Reoperations Anterior Knee Pain Osteonecrosis Other No Further Operations
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Decision Tree Analysis
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Results
Resurfaced Nonresurfaced 5 Year Expected Cost $13,788.48 $14,016.41 Secondary Surgery 0.71% 3.34%
Cost Savings of $228 per knee More likely ~$750/knee
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No Resurface Resurface
Revision rates shown in Figure 1 .05 .1 .15 .2 .05 .1 .15 .2 Chance of Revision for not-Resurfaced
Two-way Sensitivity Analysis
Chance of Revision for Resurfaced
Sensitivity Analysis
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Discussion
§ Potential Savings
§ 15% Do not routinely resurface
§ AAHKS 2010 Survey
§ 2007 à $20,500,000/year § 2030 à $175,000,000/year (Medicare data)
§ Remember Payer’s Perspective!
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Clavicle “Collar Bone” Fractures
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Treatment of Clavicle Fractures
§ Background Data
§ 3-4% of all adult fractures § 80% occur in the middle 1/3 § Peak incidence in males under 30
§ Traditionally treated non-op
§ Retrospective data from 1960s
§ Low rates of nonunion (1%) § Included adolescents McKee et al. JBJS Am 2006 Neer JAMA 1960 Rowe CORR 1968
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Clavicle Fractures
§ New Study Results
§ Higher rates of nonunion (up to 15%) § Decreased patient satisfaction
§ Biomechanics § Advantages & Disadvantages § Trends
§ Synthes - domestic clavicle plate sales
§ 2009 - 11,630 Units § 2010 - 15,640 U (34% inc) § 2011 - 17,430 U (12% inc) § 2012 - 18,180 U (4.5% inc)
§ 2012- 56% inc over 2009
Hill et al. JBJS Br 1997 Ledger et al. JSES 2005
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Displaced Midshaft Clavicle Fracture Operative Treatment Nonoperative Treatment
Decision Tree Model
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Decision Tree Model
Operative Treatment Reoperations HWR HWR with I&D Revision ORIF Nonunion No Reoperations
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Decision Tree Model
Nonoperative Treatment Delayed Operative Procedure ORIF ORIF Malunion ORIF Nonunion No Further Operations
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Decision Tree Model
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Results
§ Decision tree analysis expected costs
§ Operative treatment- $14,763.21 § Nonoperative treatment- $3,112.65
§ Projected cost savings of $11,650.56/clavicle fracture
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Results
§ Sensitivity Analysis
§ 2-way analysis varying rates of reoperation and delayed operative treatment § Model remained stable over a wide range of probabilities
Non-OP treatment OP treatment x=.1871 y=.2348 .05 .1 .15 .2 .25 .2 .4 .6 .8 1 Probability of Delayed Surgery after non-OP Treatment
Two-way Sensitivity Analysis, Medicare Costs
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Discussion
§ Potential Savings
§ $11,650 per fracture
§ How many fractures are there?
§ Incidence 24-71 fractures / 100,000 population
§ Mueller J Trauma 2008 § Robison JBJS 1998
§ Let’s do the math…
§ US ~325,000,000 § 78,000 – 230,750 / per year § 80% occur in the midshaft § 62,400 – 184,600 fractures/year § $727 Million – $ 2.15 Billion in healthcare savings
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Lisfranc Injuries
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§ What’s the Big Deal?
§ Imperative to maintain normal foot biomechanics and function § Untreated injuries
§ Persistent pain § Progressive deformity § Prolonged disability
Lisfranc Injuries
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§ Surgery
§ Two Options
- 1. Open Reduction Internal Fixation
(ORIF)
- 2. Primary Arthrodesis
Lisfranc Injuries
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Surgical Treatment of Lisfranc Injuries
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Cost Estimation
§ Where you have your surgery matters!!!
§ Two decision tree models
§ Outpatient Hospital (APC) § Outpatient Ambulatory Surgery Center (ASC)
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Data
§ What Does the Literature Say?
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§ APC Expected Costs:
§ ORIF
§ $18,613
§ PA
§ $19,803
§ Expected Savings
§ $1,190
Basic Decision Tree Analysis
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§ ASC Expected Costs:
§ ORIF
§ $11,652
§ PA
§ $11,703
§ Expected Savings
§ $51
Basic Decision Tree Analysis
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Table 3 One-way Sensitivity Analysis Intersection Points Initial Cost/Percentage Indifference Point Percent Change
ORIF Cost APC $13,611.29 $14,801.80 (+) 8.7% ORIF Cost ASC $8,335.59 $8,387.12 (+) 0.62% Primary Arthrodesis Cost APC $18,165.50 $16,974.99 (-) 6.55% Primary Arthrodesis Cost ASC $10,662.66 $10,611.13 (-) 0.48% Probability of HWR after ORIF APC 60% 74% (+) 23.33% Probability of HWR after ORIF ASC 60% 61% (+) 1.67% HWR Cost ASC $3,394.82 $3,497.48 (+) 3.02% Probability of Secondary Surgery after PA ASC 17.65% 16.78% (-) 4.92%
Results
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Sensitivity Analysis: Costs
(+) $1,190.51 (+8.7%)
15000 16000 17000 18000 19000 20000 21000 22000 23000 $10,000.00 $11,000.00 $12,000.00 $13,000.00 $14,000.00 $15,000.00 $16,000.00 $17,000.00 $18,000.00
Expected Value
ORIF Cost
APC - ORIF Cost Variation
ORIF Primary Arthrodesis
PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin
15000 16000 17000 18000 19000 20000 21000 22000 23000 24000 25000 $13,000.00 $14,000.00 $15,000.00 $16,000.00 $17,000.00 $18,000.00 $19,000.00 $20,000.00 $21,000.00 $22,000.00 $23,000.00
Expected Value
Primary Arthrodesis Cost
APC - Primary Arthrodesis Cost Variation
ORIF Primary Arthrodesis
(-) $1,190.51 (-6.55%)
(+) $102.66 (+3.02%)
11000 11200 11400 11600 11800 12000 12200 $2,400.00 $2,600.00 $2,800.00 $3,000.00 $3,200.00 $3,400.00 $3,600.00 $3,800.00 $4,000.00 $4,200.00 $4,400.00
Expected Value
HWR Cost
ASC - HWR Cost Variation
ORIF Primary Arthrodesis
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Sensitivity Analysis: Probabilities
15000 16000 17000 18000 19000 20000 21000 22000 23000 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110%
Expected Value Rate of HWR after ORIF
APC - Rate of HWR after ORIF
ORIF Primary Arthrodesis
60% à 74% (△ 23.33%) 17.65% à 16.78% (△ -4.92%)
11000 11200 11400 11600 11800 12000 12200 12400 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%
Expected Value Rate of Secondary Surgery after Primary Arthrodesis
Rate of Secondary Surgery after Primary Arthrodesis
ORIF Primary Arthrodesis
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Two-Way Sensitivities
20% 30% 40% 50% 60% 70% 80% 90% 100% $10,000.00 $11,000.00 $12,000.00 $13,000.00 $14,000.00 $15,000.00 $16,000.00 $17,000.00 $18,000.00Rate of HWR after ORIF
ORIF Cost
APC: ORIF Cost vs Rate of HWR after ORIF
ORIF Primary ArthrodesisPrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin
20% 30% 40% 50% 60% 70% 80% 90% 100% $6,000.00 $6,500.00 $7,000.00 $7,500.00 $8,000.00 $8,500.00 $9,000.00 $9,500.00 $10,000.00 $10,500.00Rate of HWR after ORIF
ORIF Cost
ASC: ORIF Cost vs Rate of HWR after ORIF
ORIF Primary ArthrodesisPrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin
20% 30% 40% 50% 60% 70% 80% 90% 100% $7,000.00 $8,000.00 $9,000.00 $10,000.00 $11,000.00 $12,000.00 $13,000.00 $14,000.00Rate of HWR after ORIF
Primary Arthrodesis Cost
ASC: Primary Arthrodesis Cost vs Rate of HWR after ORIF
ORIF Primary ArthrodesisPrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin PrecisionTree Course Version University of Texas Austin
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§ Sensitivity analyses reveals which inputs influence the decision policy § Outcomes can change with small differences in costs or probabilities
Lisfranc Treatment Analysis - Results
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Analysis of Orthopaedic Treatment Decisions
§ Three Applications:
§ Patellar Resurfacing in Total Knee Replacements § Treatment of Clavicle “Collar Bone” Fractures § Surgical Treatment of Lisfranc Injuries
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Conclusions
- 1. Patella resurfacing during
primary TKA is the optimal financial strategy from a Medicare perspective over a mid term period.
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Conclusions
- 2. Initial nonoperative management
- f mid shaft clavicle fractures is
the optimal financial strategy from the payer perspective
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Conclusions
- 3. Surgeon discretion is
the optimal surgical solution for each unique Lisfranc injury pattern
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Publications
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DISCUSSION & QUESTIONS
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Decision Analysis: Applications in Orthopaedics
Karim A. Meijer, M.D. kam@tsmog.com Joe Hahn, Ph.D, MBA and Jim Dyer, Ph.D.
McCombs School of Business, UT Austin