This study analyzed the total economic costs of revision total joint replacement surgery in the United States using a database of 7,034 revision total hip arthroplasty and revision total knee arthroplasty procedures performed between 2003-2006. The results found that the mean total costs per patient across all payers was $128,223 for revision total hip arthroplasty and $67,095 for revision total knee arthroplasty. Projections estimate substantial growth in the number of revision procedures between 2007-2013, with a 32% increase in knee procedures and a 23% increase in hip revisions. This study provides data on the actual economic burden to Medicare and commercial insurers from revision total joint replacement surgeries in the US.

1. The Total “Economic Cost” of Revision Total Joint Replacement Surgery in the United States
Ryan M. Graver, MPH; Lisa Da Deppo, PharmD, MPH, MSc; Erik M. Harris, MHA; Shamiram R. Feinglass, MD, MPH, Zimmer, Inc.
Introduction Results Figure 2. Growth in Aggregate National RTHA Annual Costs Table 1. Mean Costs
$600 25.0K
Revision surgeries impose a burden on the clinical team and patient in the form of patient management A total of 7,034 patient records of RTHA and RTKA performed from January 1, 2003 and December 21, 3rd 2nd 1st 1st 2nd 3rd
CAGR* = 7.07%
and additional hospital stays, respectively. Recent estimates indicate that substantial growth in the 2006 were qualified for analysis. year pre year pre year pre year post year post year post Total
$570 CAGR* = -0.30% 22.5K
National procedureA procedureA procedureA procedureB procedureB procedureB
number of revision procedures in the US will continue between 2007 and 2013; with a 32% increase Commercial
in knee procedures and a 23% increase in hip revisions projected during this period.1 • ,326 patients underwent revision hip replacement surgery, and 3,708 patients underwent
3 $540 20.0K Cost Commercial
revision knee replacement surgery. National Revision THA Cohort
$510 17.5K
Commercial All Causes $14,912 $16,371 $18,154 $47,263 $17,132 $14,386 $128,223
Study Objective • emales comprised the majority of patients undergoing revision total joint replacement (55.2%
F Volume
Cost in Millions
$480 15.0K
hip replacement, 56.8% knee replacement). The mean age was 68.3 (± 12.5) years at the time Orthopedic Related $6,804 $6,555 $6,913 $35,018 $6,741 $5,063 $67,095
National
Volume
The objective was to report the actual economic burden to Medicare and commercial insurance of RTHA and 67.8 (± 10.4) years at the time of the RTKA. $450 12.5K Medicare
Revision TKA Cohort
associated with the treatment of patients who require revision total hip (RTHA) and knee Arthroplasty
Cost All Causes $19,604 $25,291 $22,244 $25,814 $19,011 $27,410 $139,374
• xamining the mean combined costs and utilization during the first year post-procedure we
E $420 10.0K
(RTKA) procedures. This research explores the direct economic costs and related healthcare utilization CAGR* = 1.84% National Orthopedic Related $11,101 $12,923 $7,087 $32,124 $6,923 $9,546 $79,704
observed the following: Medicare
in the United States among the 62% Medicare and 30% commercial insurance patient populations $390 7.5K
Volume
°° Average hospital length of stay was 4.48 days for RTHA and 3.93 days for RTKA. Medicare
undergoing primary RTHA and RTKA.2 *Compound Annual Growth
$360 5.0K Revision THA Cohort
°° uring the entire study period, the total inpatient hospitalization cost for all reasons was
D CAGR* = 0.08% Rate (CAGR); the geometric
mean growth rate on an
annualized basis All Causes $11,951 $13,366 $16,187 $33,181 $15,238 $14,800 $104,722
$35,164 for RTHA and $36,913 for RTKA (Figure 1).
Materials and Methods
$330 2.5K
Orthopedic Related $3,391 $4,747 $5,384 $21,214 $4,419 $3,557 $42,712
°° ealthcare utilization and expenditure increased dramatically in the 1-year post-surgery
H $310 0 Revision TKA Cohort
Data Source. This study is a retrospective, longitudinal database audit with data derived from the period due to arthroplasty and arthroplasty-related costs (Table 1). 2003 Cohort 2004 Cohort 2005 Cohort 2006 Cohort
All Causes $12,776 $15,136 $14,925 $31,336 $15,288 $15,551 $105,012
Thomson Reuters MarketScan® Commercial Claims and Encounters Database (Commercial Database) °° he mean orthopaedic related hospitalization cost was $24,878 for RTHA and $25,844 for
T
Orthopedic Related $3,977 $5,693 $4,579 $19,937 $4,143 $3,682 $42,012
and Medicare Supplemental and Coordination of Benefits Database (Medicare Database) from January RTKA cohorts or 71% and 70% of total costs, respectively. Figure 3. Growth in Aggregate National RTKA Annual Costs A
Includes costs of services rendered prior to the index procedure, for any medcal reason.
1, 2000 through December 31, 2007. °° otal pharmaceutical costs were $23,127 for RTHA and $25,411 for RTKA; of which approx-
T B
Includes costs of services rendered following and including the index procedure, for any medical reason.
$550 25.0K
imately $3,397 or 15% was orthopaedic related for RTHA and $3,981 or 16% for RTKA. CAGR* = 4.54%
Claims were selected for patients who underwent arthroplasty procedures, identified using the $520 CAGR* = 9.74% 22.5K
ICD-9 procedure codes, 00.70, 00.71, 00.72, 00.73, 81.53 for RTHA and 00.80, 00.81, 00.82, 00.83, National
• he total national aggregate direct cost of illness for revision RTHA and RTKA in the year of the index
T Commercial the same category of orthopaedic-related hospitalization costs appeared to drive the post-operative
00.84, 81.55 for RTKA. procedure by payer type is represented in Figure 2 and Figure 3. Costs were adjusted to 2007 dollars. $490 20.0K Cost
costs for primary joint replacement. This analysis was subject to a number of limitations. The results
In both RTHA and RTKA Medicare cohorts, increases in costs are likely due to increases in annual $460 17.5K National shown were all unadjusted for potential confounders such as age, seriousness of the morbidity status
Study Population and Sample Selection. For this analysis, patients undergoing revision total joint reimbursement, however roughly half of the RTKA increase also did appear to be related to volume. Commercial
replacement procedures were examined. Volume
and co-morbidities. Classification error is possible when relying on diagnosis coding of administrative
In the commercial cohorts, RTHA costs were flat despite a slight increase in volume. Commercial
Cost in Millions
$430 CAGR* = 12.98% 15.0K
claims data.
RTKA demonstrated the largest CAGR, of which approximately 70% was driven by increases in volume. National
Volume
• This is an episode-based analysis and a patient could be included in more than one cohort. $400 CAGR* = 8.89% 12.5K Medicare
Cost This analysis represents the first truly population-based examination of orthopaedic expenditure in the
• t is estimated that the aggregate national direct cost of orthopaedic related care in the year
I
• nly adult patients in the databases who had at least 12-months of continuous health plan
O $370 10.0K Medicare and commercial insurance populations. With increasing budgetary pressure and increasing
patients underwent RTHA increased from $800 million in 2003 to approximately $941 million National
enrollment in the pre- and post-arthroplasty period, and did not have any diagnosis for bone Medicare numbers of elderly patients who may be seeking these surgeries to relieve their hip and knee problems,
in 2006 and from $630 million in 2003 to $961million in 2006 for RTKA. The inpatient hospital $340 7.5K
cancers, were included in this analysis. Volume reliable and objective quantification of the economic and epidemiologic characteristics of these
portion during the year of the index procedure averaged 66% for RTHA and 72% for RTKA,
$310 5.0K *Compound Annual Growth surgeries is critically needed.
• Patients with more than one type of arthroplasty procedure on the index date were excluded. respectively, of the total estimated aggregate costs for each procedure cohort. Rate (CAGR); the geometric
mean growth rate on an
annualized basis
$280 2.5K
• or the cost and utilization analysis, episodes were assigned to cohorts depending on the year
F
of the index arthoplasty, 2003-2006. Figure 1. Combined Medicare Commercial Direct Costs During Study Period
$250 0
Bibliography
RTHA RTKA 2003 Cohort 2004 Cohort 2005 Cohort 2006 Cohort 1
Millennium Research Group. US markets for large-joint reconstructive implants, 2009.
Cost and Utilization Variables. The data endpoints were segmented into orthopaedic-related vs. non- $120,000 $120,000 2
A
gency for Healthcare Research and Quality. National and state statistics on hospital stays by payer –Medicare, Medicaid, private, uninsured. http://hcupnet.ahrq.gov/.
orthopaedic-related care for both inpatient and outpatient claims. Cost variables analyzed include: Total $113,954
Accessed 2009 Mar 1.
3
C
onsumer Price Index Detailed Reports 2000-2007, http://www.bls.gov/cpi/cpi_dr.htm (Medical CPI Averages, 2000 – 4.1%,2001 – 4.6%, 2002 – 4.7%, 2003 – 4.0%,
hospital access, in-patient hospital stay, orthopaedic procedures, medications, outpatient drug
utilization, specialty provider’s visits and contacts with medical specialty in the 3-year pre-surgery or Total $104,719 Discussions/Conclusions 4
2004 – 4.4%, 2005 – 4.2%, 2006 – 4.0%, 2007 - 4.4%)
Kim S. Changes in surgical loads and economic burden of hip and knee replacements in the US: 1997-2004.Arthritis Rheum 2008 Apr 15;59 (4):481-8.
3-year post-surgery period. K
urtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007
5
Hospital+ $36,913 In 2006, major joint replacements ranked No. 3 in Medicare discharges for all short-stay hospitals.4 Apr; 89(4):780-5.
Hospital+ $35,164 The economic burden of revision joint replacements is projected to increase substantially over the next
Costs were extrapolated as reimbursement payment requests made by institution and provider to
third party Medicare and commercial payers. Costs were adjusted to December 2007 dollars by Rehabilitation 5 years.4,5 Accordingly, greater insight into the longitudinal costs associated with treatment of these Acknowledgments
multiplying each year’s cost by the Medical Care Consumer Price Index.3 Rehabilitation
$1,729 patients should help to inform strategies aimed at cost management.
$1,219 MD $12,023 Dan Huse, PhD, Vice President, Health Care Division, Thomson Reuters, Inc.
MD $11,623 When comparing costs, this analysis demonstrated patients undergoing revision arthroplasty procedures
MarketScan® is a trademark of Thomson Reuters (Healthcare) Inc.
represented an increase in all costs of 23% for both hip and knee. The index procedure represented a
Drugs $25,411 22% increase in cost of RTHA and a 28% increase in cost for RTKA.
Drugs $23,127
Costs observed in the 2- to 3-year post-surgery period were lower than in the three years prior
to the revision joint replacement procedure. This is a different trend than observed in our primary
+ Implant related costs included in Hospital costs for both THA TKA. joint arthroplasty analysis (see AAOS poster 271). In revision cohorts, declining orthopaedic-related
¨ Other costs include all medical expenses reimbursed by insurance not categorized in Figure 1, including but not limited to; x-ray, MRI, chiropractic care, etc. Other¨ $33,586 Other¨ $37,878 hospitalization costs during the 2- to 3-year post revision surgery period were observed. In contrast,
$0 $0
© 2010 Zimmer, Inc. 1002-AE11 2/25/2010 LL