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

Abstract

ObjectivesTo 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.DesignSystematic review of cost–utility analyses.Data sourcesOvid MEDLINE, Embase, the National Health Service Economic Evaluations Database and EconLit, January 2000 to August 2019.Eligibility criteriaEnglish-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 synthesisData 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.ResultsWe 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.ConclusionsConsistent 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 numberCRD42017059473.

Introduction of an enhanced recovery programme for total shoulder arthroplasty: report of a novel pathway

“…Findings are in keeping with the results of a recent systematic review in to the cost effectiveness of ER programmes with TKA and THA. 12 On the whole, ER programmes were regarded to be cost-effective, with the AMSTAR tool 8 suggesting moderate confidence in these results. This has justified the programme’s sustainability long term.…”

The Impact of Enhanced Recovery After Surgery on Total Joint Arthroplasty: Protocol for a Systematic Review and Meta-analysis

“…Recent systematic reviews by Zhu et al [ 11 ] and Deng et al [ 12 ] found ERAS programs reduced both LOS and incidence of complications in the 30 days following THA and TKA, without driving a commensurate increase in re-admission following discharge. In addition, one previous review on the cost-effectiveness of ERAS pathways found ERAS surgery to be dominant compared with conventional treatment [ 17 ]. To date, available systematic reviews have yet to explore the evidence relating to other post-acute care outcomes such as emergency department visits, postoperative primary care visits, and revision surgery.…”

“…Finally, the previously published systematic reviews have not assessed the impact of the number of type of items that may be combined as part of a particular ERAS program. Rather, they have focused only on comparing cohorts undergoing surgery informed by ERAS principles and those without [ 11 , 12 , 17 ].…”

The Impact of Enhanced Recovery After Surgery on Total Joint Arthroplasty: Protocol for a Systematic Review and Meta-analysis (Preprint)

“…Recent systematic reviews by Zhu et al [11] and Deng et al [12] found ERAS programs reduced both LOS and incidence of complications in the 30 days following THA and TKA, without driving a commensurate increase in re-admission following discharge. In addition, one previous review on the cost-effectiveness of ERAS pathways found ERAS surgery to be dominant compared with conventional treatment [17]. To date, available systematic reviews have yet to explore the evidence relating to other post-acute care outcomes such as emergency department visits, postoperative primary care visits, and revision surgery.…”

“…Finally, the previously published systematic reviews have not assessed the impact of the number of type of items that may be combined as part of a particular ERAS program. Rather, they have focused only on comparing cohorts undergoing surgery informed by ERAS principles and those without [11,12,17].…”