‘Worse than death’ and waiting for a joint arthroplasty

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Abstract

Aims

The EuroQol five-dimension (EQ-5D) questionnaire is a widely used multiattribute general health questionnaire where an EQ-5D < 0 defines a state ‘worse than death’ (WTD). The aim of this study was to determine the proportion of patients awaiting total hip arthroplasty (THA) or total knee arthroplasty (TKA) in a health state WTD and to identify associations with this state. Secondary aims were to examine the effect of WTD status on one-year outcomes.

Patients and Methods

A cross-sectional analysis of 2073 patients undergoing 2073 THAs (mean age 67.4 years ( sd 11.6; 14 to 95); mean body mass index (BMI) 28.5 kg/m ² ( sd 5.7; 15 to 72); 1253 female (60%)) and 2168 patients undergoing 2168 TKAs (mean age 69.3 years ( sd 9.6; 22 to 91); BMI 30.8 kg/m ² ( sd 5.8; 13 to 57); 1244 female (57%)) were recorded. Univariate analysis was used to identify variables associated with an EQ-5D score < 0: age, BMI, sex, deprivation quintile, comorbidities, and joint-specific function measured using the Oxford Hip Score (OHS) or Oxford Knee Score (OKS). Multivariate logistic regression was performed. EQ-5D and OHS/OKS were repeated one year following surgery in 1555 THAs and 1700 TKAs.

Results

Preoperatively, 391 THA patients (19%) and 263 TKA patients (12%) were WTD. Multivariate analysis identified preoperative OHS, deprivation, and chronic obstructive pulmonary disease in THA, and OKS, peripheral arterial disease, and inflammatory arthropathy in TKA as independently associated with WTD status (p < 0.05). One year following arthroplasty EQ-5D scores improved significantly (p < 0.001) and WTD rates reduced to 35 (2%) following THA and 53 (3%) following TKA. Patients who were WTD preoperatively achieved significantly (p < 0.001) worse joint-specific Oxford scores and satisfaction rates one year following joint arthroplasty, compared with those not WTD preoperatively.

Conclusion

In total, 19% of patients awaiting THA and 12% awaiting TKA for degenerative joint disease are in a health state WTD. Although specific comorbidities contribute to this, hip- or knee-specific function, mainly pain, appear key determinants and can be reliably reversed with an arthroplasty.

Cite this article: Bone Joint J 2019;101-B:941–950.

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Most cited references 16

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Meaningful changes for the Oxford hip and knee scores after joint replacement surgery

David Beard, Kristina Doing-Harris, Jill Dawson … (2015)

Objectives To present estimates of clinically meaningful or minimal important changes for the Oxford Hip Score (OHS) and the Oxford Knee Score (OKS) after joint replacement surgery. Study Design and Setting Secondary data analysis of the NHS patient-reported outcome measures data set that included 82,415 patients listed for hip replacement surgery and 94,015 patients listed for knee replacement surgery was performed. Results Anchor-based methods revealed that meaningful change indices at the group level [minimal important change (MIC)], for example in cohort studies, were ∼11 points for the OHS and ∼9 points for the OKS. For assessment of individual patients, receiver operating characteristic analysis produced MICs of 8 and 7 points for OHS and OKS, respectively. Additionally, the between group minimal important difference (MID), which allows the estimation of a clinically relevant difference in change scores from baseline when comparing two groups, that is, for clinical trials, was estimated to be ∼5 points for both the OKS and the OHS. The distribution-based minimal detectable change (MDC90) estimates for the OKS and OHS were 4 and 5 points, respectively. Conclusion This study has produced and discussed estimates of minimal important change/difference for the OKS/OHS. These estimates should be used in the power calculations and the interpretation of studies using the OKS and OHS. The MDC90 (∼4 points OKS and ∼5 points OHS) represents the smallest possible detectable change for each of these instruments, thus indicating that any lower value would fall within measurement error.

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Questionnaire on the perceptions of patients about total knee replacement

Jill Dawson, Ray Fitzpatrick, David Murray … (1998)

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Predicting the cost-effectiveness of total hip and knee replacement: a health economic analysis.

P. Jenkins, P Gaston, Yuri N Clement … (2012)

The aim of this study was to perform a cost-utility analysis of total hip (THR) and knee replacement (TKR). Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine of the modern era, has recently come under scrutiny. The National Health Service (NHS) has competing demands, and resource allocation is challenging in times of economic restraint. Patients who underwent THR (n = 348) or TKR (n = 323) between January and July 2010 in one Scottish region were entered into a prospective arthroplasty database. A health-utility score was derived from the EuroQol (EQ-5D) score pre-operatively and at one year, and was combined with individual life expectancy to derive the quality-adjusted life years (QALYs) gained. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher after THR than after TKR (6.5 vs 4.0 years, p < 0.001). The cost per QALY for THR was £1372 compared with £2101 for TKR. The predictors of an increase in QALYs gained were poorer health before surgery (p < 0.001) and younger age (p < 0.001). General health (EQ-5D VAS) showed greater improvement after THR than after TKR (p < 0.001). This study provides up-to-date cost-effectiveness data for total joint replacement. THR and TKR are extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.

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Author and article information

Contributors

C. E. H. Scott: Role: Consultant Orthopaedic Surgeon and NRS Clinical Research Fellow

D. J. MacDonald: Role: Research Associate

C. R. Howie: Role: Professor of Orthopaedics

Journal

Journal ID (nlm-ta): Bone Joint J

Journal ID (iso-abbrev): Bone Joint J

Journal ID (publisher-id): Bjj

Title: The Bone & Joint Journal

Publisher: The British Editorial Society of Bone & Joint Surgery (London )

ISSN (Print): 2049-4394

ISSN (Electronic): 2049-4408

Publication date (Print): August 2019

Publication date (Electronic): 31 July 2019

Volume: 101-B

Issue: 8

Pages: 941-950

Affiliations

[1 ]Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.

[2 ]Department of Orthopaedics, University of Edinburgh, Edinburgh, UK.

Author notes

Correspondence should be sent to C. E. H. Scott; email: chloe.scott@ 123456nhslothian.scot.nhs.uk

Article

Publisher ID: BJJ-101B-941

DOI: 10.1302/0301-620X.101B8.BJJ-2019-0116.R1

PMC ID: 6681678

PubMed ID: 31362549

SO-VID: 80f76f57-f2f3-4c48-8a65-5e337ada3af8

License:

This is an open-access article distributed under the terms of the Creative Commons Attributions licence (CC-BY-NC), which permits unrestricted use, distribution, and reproduction in any medium, but not for commercial gain, provided the original author and source are credited.

History

Custom metadata

odf2nlm-version 2.0

price $2.00

principal-institution Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

article-type Arthroplasty

coi-statement C. E. H. Scott reports personal consultancy fees from Stryker not related to this study. C. E. H. Scott and C. R. Howie report an institutional grant paid to the Royal Infirmary of Edinburgh (Edinburgh, United Kingdom) by Stryker not related to this study.

Keywords: hip arthroplasty,knee arthroplasty,health-related quality of life

Data availability:

Keywords: hip arthroplasty, knee arthroplasty, health-related quality of life