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Hemiarthroplasty and Total Hip Arthroplasty for Treating Primary Intracapsular Fracture of the Hip: A Systematic Review and Cost-Effectiveness Analysis
Health Technology Assessment, No. 15.36
C Carroll, M Stevenson, A Scope, P Evans, and S Buckley.
Author Information and AffiliationsSouthampton (UK): NIHR Journals Library; 2011 Oct.
Abstract
Background:
Hip fracture is a common problem in people aged > 60 years. The treatment options for individuals with high pre-fracture mobility, function and independence are hemiarthroplasty (HA) and total hip arthroplasty (THA).
Objective:
The aim of this report is to assess the clinical effectiveness and cost-effectiveness evidence of THA compared with HA in patients with displaced intracapsular fracture who are cognitively intact with high pre-fracture mobility or function.
Data sources:
A systematic search was made of 11 databases of published and unpublished literature from their inception to December 2010: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Biological Science Citation Index, Social Science Citation Index, Conference Proceedings Citation Index – Science, UK Clinical Trials Research Network and the National Research Register archive, Current Controlled Trials and ClinicalTrials.gov.
Review methods:
A systematic review of randomised controlled trials (RCTs) to assess the effectiveness of THA compared with HA in terms of dislocations, revisions, pain and function, and quality of life. Meta-analysis, independent subgroup analyses and exploratory cost-effectiveness modelling were performed.
Results:
The literature search identified 532 unique citations, of which eight RCTs with almost 1000 participants satisfied the criteria for the effectiveness review. Meta-analysis found a statistically significant increased risk of dislocation for patients treated with THA compared with HA (p = 0.01), but a reduced risk of revision (p = 0.0003). There were no differences in terms of mortality. In all trials, individuals treated with THA reported better function and mobility and less pain than those treated with HA. Four trials reporting utility data found similar trends. Sensitivity analyses indicated that there were no statistically significant differences in outcomes based on follow-up, study quality, surgical approach taken, type of head or the use of cement. Four papers reported a cost–utility analysis or the cost-effectiveness of THA compared with HA. Exploratory modelling was undertaken that showed that THA is likely to be cost-effective compared with HA even when the limitations of the data and methodology are considered.
Limitations:
The costs and disutilities associated with revisions and dislocations were not included in the economic evaluation.
Conclusions:
THA appears to be more cost-effective than HA. It is likely that THA will be associated with increased costs in the initial 2-year period, but lower longer-term costs, owing to potentially lower revision rates. However, these longer-term costs have not been modelled. The capacity and experience of surgeons to perform THA have not been explored and these would need to be addressed at local level were THA to become recommended for active, elderly patients in whom THA is not contraindicated. Further studies examining the impact of surgeon experience on performing the two procedures may offer more robust evidence on outcomes.
Funding:
The National Institute for Health Research Health Technology Assessment programme.
Contents
- NIHR Health Technology Assessment programme
- List of abbreviations
- Executive summary
- 1. Background
- 2. Definition of the decision problem
- 3. Assessment of clinical effectiveness
- 4. Assessment of cost-effectiveness
- 5. Assessment of factors relevant to the NHS and other parties
- 6. Discussion
- 7. Conclusions
- Acknowledgements
- References
- Appendix 1 Literature search strategies
- Appendix 2 Data extraction tables
- Appendix 3 Critical appraisal quality assessment criteria for a surgical randomised controlled trial (based on Parker et al.)
- Appendix 4 Quality assessment of the economic evaluation undertaken by Slover et al. through use of the Drummond et al. checklist
- Appendix 5 Hemiarthroplasty and total-hip arthroplasty for treating primary intracapsular fracture of the hip protocol
- Health Technology Assessment programme
Suggested citation:
Carroll C, Stevenson M, Scope A, Evans P, Buckley S. Hemiarthroplasty and total hip arthroplasty for treating primary intracapsular fracture of the hip: a systematic review and cost-effectiveness analysis. Health Technol Assess 2011;15(36).
Declared competing interests of authors: none
The research reported in this issue of the journal was commissioned by the HTA programme as project number 09/108/02. The contractual start date was in September 2010. The draft report began editorial review in March 2011 and was accepted for publication in May 2011. As the funder, by devising a commissioning brief, the HTA programme specified the research question and study design. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors' report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.
The views expressed in this publication are those of the authors and not necessarily those of the HTA programme or the Department of Health.
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- Hemiarthroplasty and Total Hip Arthroplasty for Treating Primary Intracapsular F...Hemiarthroplasty and Total Hip Arthroplasty for Treating Primary Intracapsular Fracture of the Hip: A Systematic Review and Cost-Effectiveness Analysis
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