title: 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.
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.
  
  
  BACKGROUND
  ISRCTN96095682 , 29/04/2010.
authors.affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. e.marques@bristol.ac.uk.
authors.forename: Elsa Mr
authors.initials: EM
authors.lastname: Marques
authors.affiliation: Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK. ashley.blom@bristol.ac.uk.
authors.forename: Ashley W
authors.initials: AW
authors.lastname: Blom
authors.affiliation: Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK. erik.lenguerrand@bristol.ac.uk.
authors.forename: Erik
authors.initials: E
authors.lastname: Lenguerrand
authors.affiliation: Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK. v.wylde@bristol.ac.uk.
authors.forename: Vikki
authors.initials: V
authors.lastname: Wylde
authors.affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. s.m.noble@bristol.ac.uk.
authors.forename: Sian M
authors.initials: SM
authors.lastname: Noble
mesh_terms: D000368:Aged; D000772:Anesthesia, Local / Q000379:methods; D000779:Anesthetics, Local / Q000627:therapeutic use; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D017063:Outcome Assessment, Health Care; D059408:Pain Management / Q000191:economics* / Q000379:methods; D010149:Postoperative Pain / Q000517:prevention & control*; D019057:Quality-Adjusted Life Years; D011795:Surveys and Questionnaires; D058106:Wound Closure Techniques / Q000191:economics*
chemical_list: D000779:Anesthetics, Local