Transcript Musculoskeletal Health Walking into the future

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 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
•
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
18
16
14
12
10
8
6
4
2
0
Hips
Knees
Total
19951996
19971998
19992000
20012002
Change in Incidence and
Acute Care Costs
Procedure/year
Number
Hips
1999-2000
2000-2001
2001-2002
22,717
24,285
26,689
Knees
1999-2000
2000-2001
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
2000-2001
2001-2002
11,493
11,510
12,149
Private
1999-2000
2000-2001
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
2000-2001
2001-2002
7,700
7,570
8,521
Private
1999-2000
2000-2001
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
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%
Change in Prostheses Costs (Public
v’s 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%)
Changing Costs
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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
percent not revised
100.00
95.00
90.00
All Ages
Under 55
85.00
80.00
75.00
70.00
0
2
4
6
8
10
12
14
years postoperatively
16
18
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
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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
How to address the issue?
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Quality Data
Identify both the best and worse types of
prostheses
Identify best surgical techniques
Most importantly
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Identify predisposing/exacerbating factors
Optimize early management
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
Australian Joint Replacement
Registry
 Collect
Australian wide
information
 Provide data to surgeons and
hospitals for audit
 Education surgeons, hospitals,
Governments, health industry
and community
Australian Joint Replacement
Registry

All Government and Private Hospitals in
Australia
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296 hospitals
Commenced September 1999

Introduced progressively in all States & Territories

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 4x 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)
AUST
NSW
VIC
Cemented
WA
SA
Hybrid
TAS
Cementless
1999
2000
2001
2002
2003
2004
1999
2000
2001
2002
2003
2004
1999
2000
2001
2002
2003
2004
QLD
1999
2000
2001
2002
2003
2004
1999
2000
2001
2002
2003
2004
1999
2000
2001
2002
2003
2004
1999
2000
2001
2002
2003
2004
1999
2000
2001
2002
2003
2004
Trends in Prosthesis Fixation
Conventional Primary THR
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ACT/NT
Improve surgical technique
To be implemented must be cost
effective
Computer assisted surgery
Minimally invasive surgery
Clinical Evaluation and Results
97%
p<0.05
74%
20%
3%
Axis: 0-3°
Axis: 4-5°
Navigation (n=65)
6%
Axis: 0-3°
Axis: 4-5°
Axis >5°
Conventional (n=50)
Minimally invasive surgery
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Entirely new approach
Hip and Knee replacement
Same day discharge possible
Approach made more feasible by
Computer assisted surgery
Outcomes to be determined
Orthopaedic biological solutions
Be afraid very afraid
2003
 Prostheses US $40 billion
 Biologics US $ 4 billion
2010 (estimate)
 Prostheses US $120 billion
 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
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Identify predisposing factors
Identify exacerbating factors
Data mining
Database integration and cross referencing
Optimize early management
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Patient education
Physical therapy
Drug treatment
Appropriate use of surgical procedures and
techniques
Prevention of fractures
secondary to osteoporosis
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Best practice not implemented
Drug treatment very effective
First fracture patients are identifiable
need to ensure drug treatment availability
Do the numbers
Some important strategies
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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