title: Current status of cost utility analyses in total joint arthroplasty: a systematic review.
abstract: BACKGROUND
  Total joint arthroplasty (TJA), although considered to be highly beneficial, is associated with substantial costs to the US healthcare system. Cost utility analysis has become an increasingly important means to objectively evaluate the value of a healthcare intervention from the perspective of both extending the quantity and improving the quality of life. Relatively little is known about the overall cost utility analysis evidence base in TJA.
  
  
  OBJECTIVE
  The goals of this review were to (1) determine the cost utility of TJA interventions; (2) critically assess the quality of published US-based cost utility analyses using the Quality of Health Economic Studies instrument; and (3) determine what characteristics were common among studies receiving a high quality score.
  
  
  METHODS
  A systematic review of the literature using the MEDLINE database was performed to compile findings and critically appraise US-based cost utility analysis studies for total hip and knee arthroplasty. Based on review of 676 identified articles, 23 studies were included. We used the Quality of Health Economic Studies instrument to assess study quality and one-sided Fisher's exact tests were applied to analyze the predictors of high-quality cost utility analysis.
  
  
  RESULTS
  Very few studies compare the cost utility of TJA versus nonoperative intervention; however, the available evidence suggests that TJA can be cost-saving and is highly cost-effective compared with conservative management of end-stage arthritis. The majority of identified studies are focused on the cost utility of new implant technologies or comparisons among surgical alternatives. These studies suggest that the upfront costs associated with new technologies are cost-effective when there is a major reduction in a future cost. The quality of identified studies is quite high (Quality of Health Economic Studies Instrument score: mean 86.5; range, 63-100). National funding source (p = 0.095) and lifetime horizon for analysis (p = 0.07) correlate with high-quality evidence but do not reach significance.
  
  
  CONCLUSIONS
  Over the past 15 years, there has been a major increase in the volume of cost utility analyses published in total hip and knee arthroplasty. The quality of cost utility analyses published during that period is good. As increasing attention is paid to value in US health care, more attention should be paid to understanding the cost utility of TJA compared with nonoperative treatment modalities. Future studies may also look to incorporate patient willingness to pay.
authors.affiliation: Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA, nwachukwub@hss.edu.
authors.forename: Benedict U
authors.initials: BU
authors.lastname: Nwachukwu
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Bozic
authors.forename: William W
authors.initials: WW
authors.lastname: Schairer
authors.forename: Jaime L
authors.initials: JL
authors.lastname: Bernstein
authors.forename: David S
authors.initials: DS
authors.lastname: Jevsevar
authors.forename: Robert G
authors.initials: RG
authors.lastname: Marx
authors.forename: Douglas E
authors.initials: DE
authors.lastname: Padgett
mesh_terms: D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D017048:Health Care Costs; D006622:Hip Prosthesis / Q000191:economics; D006801:Humans; D007720:Knee Prosthesis / Q000191:economics; D016017:Odds Ratio; D016896:Treatment Outcome