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

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

Social and Other Costs Inability to exercise Inability to exercise Loss of independence Loss of independence Inability to self care Inability to self care Reduced quality of life Reduced quality of life Dependence on family/friends/neighbors Dependence on family/friends/neighbors Loss of self esteem Loss of self esteem Reduced health status 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 End stage disease particularly OA Most cost effective surgery Most cost effective surgery Reduces pain and maintains independence Reduces pain and maintains independence Just over 60,000 procedures in 2004 Just over 60,000 procedures in 2004 Total acute care cost this year will approach Total acute care cost this year will approach $ 1 billion $ 1 billion Most will be in the private system 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/yearNumber%Change Costs (constant $) (mil)%Change Hips ,71724,28526,6896.9%9.9% %18.2% Knees ,25226, %17.3% %30.7%

Change in Incidence and Acute Care Costs for Hips Public v’s Private System/yearNumber%Change Costs (constant $) (mil)%Change Public ,49311,51012,1490.1%5.5% %9.7% Private ,22412,66414, %14.1% %26.2%

Change in Incidence and Acute Care Costs for Knees Public v’s Private System/yearNumber%Change Costs (constant $) (mil)%Change Public ,7007,5708, %12.6% %16.4% Private ,23613,99516, %20.0% %38.6%

Prostheses Costs as a Percentage of Total Costs (Public v’s private) Total Cost Total Prostheses cost Prostheses as % of total cost HipsPublicPrivateTotal %37.7%30.3% KneesPublicPrivateTotal %41.2%36.9% Total %

Change in Prostheses Costs (Public v’s private) Procedure HipsPublicPrivate Total Hip (14.6%) 36.3 (14.6%) 60.2 ( 9.1%) 60.2 ( 9.1%) 95.5 (9.8%) 95.5 (9.8%) 40.9 (12.7%) 40.9 (12.7%) 85.5 (42.0%) 85.5 (42.0%) (31.0%) (31.0%) KneesPublicPrivate Total Knee (22.3%) 30.1 (22.3%) 67.1 (4.4%) 67.1 (4.4%) 97.2 (9.3%) 97.2 (9.3%) 34.5 (14.5%) 34.5 (14.5%) (67.4%) (67.4%) (51.0%) (51.0%) Total (10.1%) (10.1%) (41.1%) (41.1%)

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

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

Change in Survival with Age Male Patients with OA

Australian Joint Replacement Registry In Australia 14% of Hip replacements are revisions In Australia 14% of Hip replacements are revisions This does not equate to the revision rate Australia 20-25% (estimated) Sweden7-8% 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 More than 130 different hip prostheses Greater than 60 different knee prostheses Greater than 60 different knee prostheses Over 17,000 different sizes and types of components used in the 2003 Over 17,000 different sizes and types of components used in the 2003

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

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

Australian Joint Replacement Registry All Government and Private Hospitals in Australia All Government and Private Hospitals in Australia 296 hospitals 296 hospitals Commenced September 1999 Commenced September 1999 Introduced progressively in all States & Territories Introduced progressively in all States & Territories Fully implemented in 2002 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 Number revised Total Number % Revised Observed 'component' years Revisions per 100 observed 'component' years Unispacer 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  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  Females fracture at a significantly higher rate than males P< 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 Conventional (n=50)Navigation (n=65) p<0.05

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

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

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

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

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

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

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

Thank you