The Scope of Musculoskeletal Disease Treatment and Costs

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The Scope of Musculoskeletal DiseaseTreatment
and Costs

• Prof Stephen Graves
• University of Melbourne

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Is the maintenance of musculoskeletal well being
the most important system specific health issue
today?
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National and International Significance

• National priority listing
• Bone and Joint decade
• WHO immobility is the greatest health
• concern

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(No Transcript)
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The Facts

• Most common cause of disability
• Most common cause of time off work
• 80 of Trauma is musculoskeletal injury
• 40-50 over 60yrs have Osteoarthritis
• Inflammatory Arthritis, Osteoporosis,
• Back pain are common and expensive to manage
• Old estimates where that disease burden expected
  to at least
• double by 2020?
• Current cost for acute care 16.5 billion
• Costs per episode of care increasing faster than
  rate of
• increase in disease

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Social and Other Costs

• Inability to exercise
• Loss of independence
• Inability to self care
• Reduced quality of life
• Dependence on family/friends/neighbors
• Loss of self esteem
• Reduced health status

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Changing rates of intervention

• It is unusual for any intervention to change more
  than 3 in any one year

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Joint Replacement Surgery

• End stage disease particularly OA
• Most cost effective surgery
• Reduces pain and maintains independence
• Just over 60,000 procedures in 2004
• Total acute care cost this year will approach
• 1 billion
• Most will be in the private system

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Australian Joint Replacement Registry
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Percentage Change in Joint Replacement Surgery
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Change in Incidence and Acute Care Costs
Procedure/year Number Change Costs (constant ) (mil) Change
Hips 1999-2000 2000-2001 2001-2002 22,717 24,285 26,689 6.9 9.9 349.1 353.1 417.5 1.1 18.2
Knees 1999-2000 2000-2001 2001-2002 19.936 22,252 26,099 11.6 17.3 305.1 304.5 398.1 -0.2 30.7
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Change in Incidence and Acute Care Costs for
HipsPublic vs Private
System/year Number Change Costs (constant ) (mil) Change
Public 1999-2000 2000-2001 2001-2002 11,493 11,510 12,149 0.1 5.5 170.6 170.3 186.8 -0.2 9.7
Private 1999-2000 2000-2001 2001-2002 11,224 12,664 14,449 12.8 14.1 178.5 182.8 230.7 2.4 26.2
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Change in Incidence and Acute Care Costs for
KneesPublic vs Private
System/year Number Change Costs (constant ) (mil) Change
Public 1999-2000 2000-2001 2001-2002 7,700 7,570 8,521 -1.7 12.6 110.4 107.9 125.6 -2.3 16.4
Private 1999-2000 2000-2001 2001-2002 12,236 13,995 16,798 14.4 20.0 194.7 196.6 272.5 1.0 38.6
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Prostheses Costs as a Percentageof Total Costs
(Public vs private)
2001-2002 Total Cost Total Prostheses cost Prostheses as of total cost
Hips Public Private Total 186.8 230.7 417.5 40.9 85.6 126.5 21.9 37.7 30.3
Knees Public Private Total 125.6 272.5 398.1 34.5 112.3 146.7 27.4 41.2 36.9
Total 815.6 273.2 33.5
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Change in Prostheses Costs (Public vs private)
Procedure 1999-2000 2000-2001 2001-2002
Hips Public Private Total Hip 31.8 55.2 87.0 36.3 (14.6) 60.2 ( 9.1) 95.5 (9.8) 40.9 (12.7) 85.5 (42.0) 126.5 (31.0)
Knees Public Private Total Knee 24.6 64.3 88.9 30.1 (22.3) 67.1 (4.4) 97.2 (9.3) 34.5 (14.5) 112.3 (67.4) 146.7 (51.0)
Total 175.9 193.7 (10.1) 273.2 (41.1)
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Changing Costs

• Cost increase more apparent in Knees
• Increased use accounts for well over 50
• Impact greater in Private
• Acute care (prostheses independent) down
• The introduction of the new prosthesis funding
  arrangements will only partially help
• Real improvement will only come by relating
  expenditure to outcome

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Joint Replacement Surgery

• Increasing at 5-10 pa each year for the last 10
• years
• Aging of the population
• Knee replacement increasing in under 55 yr olds
• at 30 pa
• Australia underperforms with respect to meeting
• demand

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Change in Survival with AgeMale Patients with OA
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Australian Joint Replacement Registry

• In Australia 14 of Hip replacements are
  revisions
• This does not equate to the revision rate
• Australia 20-25 (estimated)
• Sweden 7-8
• Reducing rate of revision by 1 decreases
  revision procedures by 600 p.a. and saves
• 15.5 million p.a.

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Prostheses usage in Australia

• More than 130 different hip prostheses
• Greater than 60 different knee prostheses
• Over 17,000 different sizes and types of
  components used in the 2003

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How to address the issue?

• Quality Data
• Identify both the best and worse types of
  prostheses
• Identify best surgical techniques
• Most importantly
• Identify predisposing/exacerbating factors
• Optimize early management

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Australian Orthopaedic Association National Joint
Replacement Registry

• A Registry is the most effective method for
  determining the most successful prostheses and
  surgical technique in different clinical
  situations
• Post market surveillance is critical

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Australian Joint Replacement Registry

• Collect Australian wide information
• Provide data to surgeons and hospitals for audit
• Education surgeons, hospitals, Governments,
  health industry and community

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Australian Joint Replacement Registry

• All Government and Private Hospitals in Australia
• 296 hospitals
• Commenced September 1999
• Introduced progressively in all States
  Territories
• Fully implemented in 2002

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Austin Moore and Thompson Hemi-arthroplasty
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Australian Joint Replacement Registry
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New surgical technologies

• Unispacer
• Preservation Unicompartment Knee
• Oxinium Knee
• Resurfacing THR

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Unispacer Knee Replacement
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Unispacer Knee Replacement
Unispacer Number revised Total Number Revised Observed 'component' years Revisions per 100 observed 'component' years
Unispacer 11 27 40.7 22 50.0
Exact 95 CI (24.96, 89.47)
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Preservation Unicompartment Knee Replacement
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Preservation Mobile
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Preservation Fixed
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Oxinium Knee Replacement
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Genesis II Cementless Oxinium
 
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Resurfacing Hip Replacement
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Resurfacing compared to Conventional (OA only)
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Resurfacing compared to Conventional THR (OA)

• Resurfacing has a significantly greater risk of
  early revision compared to conventional hip
  replacement
• This is due to an increased risk of fracture
• Males over 65 yrs old have almost a 4x risk of
  fracture Plt.0001 HR3.8, 95CI (2.16, 6.72)
• Females fracture at a significantly higher rate
  than males Plt0.0001 HR2.190, 95CI (1.52,
  3.16)

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Resurfacing compared to Conventional (OA only)
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Trends in Prosthesis Fixation Conventional
Primary THR
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Improve surgical techniqueTo be implemented
must be cost effective

• Computer assisted surgery
• Minimally invasive surgery

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Clinical Evaluation and Results
plt0.05
Conventional (n50)
Navigation (n65)
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Minimally invasive surgery

• Entirely new approach
• Hip and Knee replacement
• Same day discharge possible
• Approach made more feasible by Computer assisted
  surgery
• Outcomes to be determined

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Orthopaedic biological solutionsBe afraid very
afraid

• 2003
• Prostheses US 40 billion
• Biologics US 4 billion
• 2010 (estimate)
• Prostheses US 120 billion
• Biologics US 80 billion

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Intelligent analysis of quality data and develop
appropriate research strategies

• Know best practice
• Collect the right data
• Appropriate analysis
• Identify problems
• Develop solutions

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Prevention

• Identify predisposing factors
• Identify exacerbating factors
• Data mining
• Database integration and cross referencing

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Optimize early management

• Patient education
• Physical therapy
• Drug treatment
• Appropriate use of surgical procedures and
  techniques

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Prevention of fractures secondary to osteoporosis

• Best practice not implemented
• Drug treatment very effective
• First fracture patients are identifiable
• need to ensure drug treatment availability
• Do the numbers

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Some important strategies

• Do not take a passive role in health care
  delivery
• Effectively utilize the information you have
• Access available quality information
• Identify where best practice not implemented and
  ensure that it is
• Consider involvement in changing clinician
  practice
• Identify critical areas of future expenditure
• Contract research to develop targeted strategies
  to minimize costs and maximize patient benefit

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Thank you