The Scope of Musculoskeletal Disease Treatment and Costs

The Scope of Musculoskeletal Disease Treatment and Costs Prof Stephen Graves University of Melbourne

Is the maintenance of musculoskeletal well being the most important system specific health issue today?

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

The Facts Most common cause of disability • Most common cause of time off work • 80% of Trauma is musculoskeletal injury • 40 -50% over 60 yrs 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 •

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

Changing rates of intervention It is unusual for any intervention to change more than 3% in any one year

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

Australian Joint Replacement Registry

Percentage Change in Joint Replacement Surgery

Change in Incidence and Acute Care Costs Procedure/year Number Hips 1999 -2000 -2001 -2002 22, 717 24, 285 26, 689 Knees 1999 -2000 -2001 -2002 19. 936 22, 252 26, 099 % Change Costs (constant $) (mil) % Change 6. 9% 9. 9% 349. 1 353. 1 417. 5 1. 1% 18. 2% 11. 6% 17. 3% 305. 1 304. 5 398. 1 -0. 2% 30. 7%

Change in Incidence and Acute Care Costs for Hips Public v’s Private System/year Number Public 1999 -2000 -2001 -2002 11, 493 11, 510 12, 149 Private 1999 -2000 -2001 -2002 11, 224 12, 664 14, 449 % Change Costs (constant $) (mil) % Change 0. 1% 5. 5% 170. 6 170. 3 186. 8 -0. 2% 9. 7% 12. 8% 14. 1% 178. 5 182. 8 230. 7 2. 4% 26. 2%

Change in Incidence and Acute Care Costs for Knees Public v’s Private System/year Number Public 1999 -2000 -2001 -2002 7, 700 7, 570 8, 521 Private 1999 -2000 -2001 -2002 12, 236 13, 995 16, 798 % Change Costs (constant $) (mil) % Change -1. 7% 12. 6% 110. 4 107. 9 125. 6 -2. 3% 16. 4% 14. 4% 20. 0% 194. 7 196. 6 272. 5 1. 0% 38. 6%

Prostheses Costs as a Percentage of Total Costs (Public v’s private) 2001 -2002 Total Cost Total Prostheses as % of cost 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%

Change in Prostheses Costs (Public v’s private) Procedure 1999 -2000 -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%)

Changing Costs n n n 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

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

Change in Survival with Age Male Patients with OA

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.

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

How to address the issue? n n n Quality Data Identify both the best and worse types of prostheses Identify best surgical techniques Most importantly n n Identify predisposing/exacerbating factors Optimize early management

Australian Orthopaedic Association National Joint Replacement Registry n A Registry is the most effective method for determining the most successful prostheses and surgical technique in different clinical situations n Post market surveillance is critical

Australian Joint Replacement Registry n Collect Australian wide information n Provide data to surgeons and hospitals for audit n Education surgeons, hospitals, Governments, health industry and community

Australian Joint Replacement Registry n All Government and Private Hospitals in Australia n 296 hospitals n Commenced September 1999 n Introduced progressively in all States & Territories n Fully implemented in 2002

Austin Moore and Thompson Hemi-arthroplasty

Australian Joint Replacement Registry

New surgical technologies Unispacer Preservation Unicompartment Knee Oxinium Knee Resurfacing THR

Unispacer Knee Replacement

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)

Preservation Unicompartment Knee Replacement

Preservation Mobile

Preservation Fixed

Oxinium Knee Replacement

Genesis II Cementless Oxinium

Resurfacing Hip Replacement

Resurfacing compared to Conventional (OA only)

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 4 x risk of fracture P<. 0001 HR=3. 8, 95%CI (2. 16, 6. 72) § Females fracture at a significantly higher rate than males P<0. 0001 HR=2. 190, 95%CI (1. 52, 3. 16)

Resurfacing compared to Conventional (OA only)

Trends in Prosthesis Fixation Conventional Primary THR

Improve surgical technique To be implemented must be cost effective Computer assisted surgery Minimally invasive surgery

Clinical Evaluation and Results p<0. 05 Navigation (n=65) Conventional (n=50)

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

Orthopaedic biological solutions Be afraid very afraid 2003 n Prostheses US $40 billion n Biologics US $ 4 billion 2010 (estimate) n Prostheses US $120 billion n Biologics US $ 80 billion

Intelligent analysis of quality data and develop appropriate research strategies • Know best practice • Collect the right data • Appropriate analysis • Identify problems • Develop solutions

Prevention Identify predisposing factors n Identify exacerbating factors n Data mining n Database integration and cross referencing n

Optimize early management Patient education n Physical therapy n Drug treatment n Appropriate use of surgical procedures and techniques n

Prevention of fractures secondary to osteoporosis Best practice not implemented n Drug treatment very effective n First fracture patients are identifiable n need to ensure drug treatment availability n Do the numbers n

Some important strategies n n n n 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

Thank you