Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence

Abstract

Objectives: To assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work.

Design: Systematic review of cost-utility analyses.

Data sources: Ovid MEDLINE, Embase, the National Health Service Economic Evaluations Database and EconLit, January 2000 to August 2019.

Eligibility criteria: English-language peer-reviewed cost-utility analyses of enhanced recovery pathways, or components of one, compared with usual care, in patients having total hip or knee arthroplasties for osteoarthritis.

Data extraction and synthesis: Data extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria list, the International Society for Pharmacoeconomics and Outcomes Research and Assessment of the Validation Status of Health-Economic decision models tools; for trial-based studies the Cochrane Collaboration's tool to assess risk of bias. No quantitative synthesis was undertaken.

Results: We identified 17 studies: five trial-based and 12 model-based studies. Two analyses evaluated entire enhanced recovery pathways and reported them to be cost-effective compared with usual care. Ten pathway components were more effective and cost-saving compared with usual care, three were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation.

Conclusions: Consistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies.

Prospero registration number: CRD42017059473.

Keywords: cost-effectiveness; economic evaluation; hip replacement; knee replacement; osteoarthritis; systematic review.

Figure 1

Flow diagram of studies included in this review and reasons for exclusion, modified from Moher et al. NHS EED, National Health Service Economic Evaluations Database; QALY, quality-adjusted life year.

Figure 2

Assessments of study quality based on tools from (A) Consensus on Health Economic Criteria, (B) International Society for Pharmacoeconomics and Outcomes Research, (C) assessment of the validation status of Health-Economic decision models tool and (D) Cochrane Collaboration. Note that the study by Brunenberg and colleagues was a non-randomised before and after trial and we have included it in panel (D) for completeness.