title: The Cost and Outcome Effectiveness of Total Hip Replacement: Technique Choice and Volume-Output Effects Matter.
abstract: BACKGROUND
  Total hip replacement (THR) must be managed in a more sustainable manner. More cost-effective surgical techniques and the centralization/regionalization of services are two solutions. The former requires an assessment of newer minimally invasive and muscle-sparing surgical techniques. The latter necessitates an effective volume-outcome (VO) relationship. Prior studies have failed to evaluate and control for the VO relation.
  
  
  OBJECTIVE
  The objective of this study was to evaluate the relative cost and outcome effectiveness of two minimally invasive and one muscle-sparing techniques while evaluating and controlling for a potentially endogenous VO relation.
  
  
  METHODS
  An all payer claims database for all THR performed in Maine in 2011 was used. The cost and outcome effectiveness of newer minimally invasive (modified Hardinge) and muscle-sparing (modified Watson-Jones) techniques were compared with the standard bearer posterior minimally invasive method. Using regression analysis, the outcomes analyzed were as follows: total costs, length of hospital stay, nursing care and home discharges, and use of physical therapy. Regression analysis was also used to evaluate and control for VO effects.
  
  
  RESULTS
  (1) Newer muscle-sparing and minimally invasive approaches are substantially more effective; (2) irrespective of technique, higher volume surgeons are more effective; (3) technique-specific VO effects for more complex techniques exist and show substantial savings when yearly volume exceeds 30-50; and (4) the anterolateral muscle-sparing technique is accessible to the average surgeon.
  
  
  CONCLUSIONS
  Reliance on newer surgical techniques and centralization/regionalization of THR services can reduce costs.
authors.affiliation: Department of Economics, Bowdoin College, 9700 College Station, Brunswick, ME, 04011, USA. jgoldste@bowdoin.edu.
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Goldstein
authors.affiliation: Department of Surgery, Division of Joint Replacement Maine Medical Center, Portland, ME, USA.|, 5 Bucknam Rd., Suite 1D, Falmouth, ME, 04105, USA.
authors.forename: George M
authors.initials: GM
authors.lastname: Babikian
authors.affiliation: Department of Surgery, Division of Joint Replacement Maine Medical Center, Portland, ME, USA.|, 5 Bucknam Rd., Suite 1D, Falmouth, ME, 04105, USA.
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Rana
authors.affiliation: Department of Surgery, Division of Joint Replacement Maine Medical Center, Portland, ME, USA.|, 5 Bucknam Rd., Suite 1D, Falmouth, ME, 04105, USA.
authors.forename: Johanna A
authors.initials: JA
authors.lastname: Mackenzie
authors.affiliation: Department of Economics, Bowdoin College, 9700 College Station, Brunswick, ME, 04011, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Millar
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000191:economics* / Q000379:methods; D014487:Centers for Medicare and Medicaid Services, U.S. / Q000191:economics* / Q000592:standards; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D007345:Insurance Claim Review; D008281:Maine; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000191:economics / Q000379:methods; D010043:Outcome and Process Assessment, Health Care / Q000191:economics* / Q000706:statistics & numerical data; D012044:Regression Analysis; D014481:United States