The Scope of The Scope of Musculoskeletal Musculoskeletal

DiseaseDisease

Treatment and Treatment and CostsCosts

Prof Stephen GravesProf Stephen Graves

University of MelbourneUniversity of Melbourne

Is the maintenance of Is the maintenance of musculoskeletal well musculoskeletal well

being the most being the most important system important system

specific health issue specific health issue today?today?

National and National and International International SignificanceSignificance

• National priority listingNational priority listing• Bone and Joint decadeBone and Joint decade• WHO immobility is the WHO immobility is the greatest healthgreatest health concernconcern

The FactsThe Facts• Most common cause of disabilityMost common cause of disability• Most common cause of time off workMost common cause of time off work• 80% of Trauma is musculoskeletal injury80% of Trauma is musculoskeletal injury• 40-50% over 60yrs have Osteoarthritis40-50% over 60yrs have Osteoarthritis• Inflammatory Arthritis, Osteoporosis, Inflammatory Arthritis, Osteoporosis, Back pain are common and expensive to Back pain are common and expensive to managemanage• Old estimates where that disease burden Old estimates where that disease burden expected to at least expected to at least double by 2020?double by 2020?• Current cost for acute care $16.5 billionCurrent cost for acute care $16.5 billion• Costs per episode of care increasing faster Costs per episode of care increasing faster than rate of than rate of increase in diseaseincrease in disease

Social and Other Social and Other CostsCosts

• Inability to exerciseInability to exercise• Loss of independenceLoss of independence• Inability to self careInability to self care• Reduced quality of lifeReduced quality of life• Dependence on Dependence on family/friends/neighborsfamily/friends/neighbors• Loss of self esteemLoss of self esteem• Reduced health statusReduced health status

Changing rates of Changing rates of intervention intervention

It is unusual for any It is unusual for any intervention to change intervention to change

more than 3% in any one more than 3% in any one yearyear

Joint Replacement Joint Replacement SurgerySurgery

• End stage disease particularly OA End stage disease particularly OA • Most cost effective surgeryMost cost effective surgery• Reduces pain and maintains Reduces pain and maintains independenceindependence• Just over 60,000 procedures in 2004Just over 60,000 procedures in 2004• Total acute care cost this year will Total acute care cost this year will approachapproach $ 1 billion$ 1 billion• Most will be in the private systemMost will be in the private system

Australian Joint Replacement Australian Joint Replacement RegistryRegistry

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

1995-1996

1996-1997

1997-1998

1998-1999

1999-2000

2000-2001

2001-2002

2002-2003

2003-2004

years

hips knees

Percentage Change in Joint Percentage Change in Joint Replacement SurgeryReplacement Surgery

0

2

4

68

10

12

14

16

18

1995-1996

1997-1998

1999-2000

2001-2002

HipsKneesTotal

Change in Incidence Change in Incidence and Acute Care Costsand Acute Care Costs

Procedure/yearProcedure/year NumberNumber %%

ChangChangee

Costs Costs (constant (constant

$)$)

(mil)(mil)

%%

ChangChangee

HipsHips

1999-20001999-2000

2000-20012000-2001

2001-20022001-2002

22,71722,717

24,28524,285

26,68926,6896.9%6.9%

9.9%9.9%

349.1349.1

353.1353.1

417.5417.51.1%1.1%

18.2%18.2%

KneesKnees

1999-20001999-2000

2000-20012000-2001

2001-20022001-2002

19.93619.936

22,25222,252

26,09926,09911.6%11.6%

17.3%17.3%

305.1305.1

304.5304.5

398.1398.1-0.2%-0.2%

30.7%30.7%

Change in Incidence Change in Incidence and Acute Care Costs and Acute Care Costs

for Hipsfor HipsPublic v’s PrivatePublic v’s Private

System/yearSystem/year NumberNumber %%

ChangChangee

Costs Costs (constant (constant

$)$)

(mil)(mil)

%%

ChangChangee

PublicPublic

1999-20001999-2000

2000-20012000-2001

2001-20022001-2002

11,49311,493

11,51011,510

12,14912,1490.1%0.1%

5.5%5.5%

170.6170.6

170.3170.3

186.8186.8-0.2%-0.2%

9.7%9.7%

PrivatePrivate

1999-20001999-2000

2000-20012000-2001

2001-20022001-2002

11,22411,224

12,66412,664

14,44914,44912.8%12.8%

14.1%14.1%

178.5178.5

182.8182.8

230.7230.72.4%2.4%

26.2%26.2%

Change in Incidence Change in Incidence and Acute Care Costs and Acute Care Costs

for Kneesfor KneesPublic v’s PrivatePublic v’s Private

System/yearSystem/year NumberNumber %%

ChangChangee

Costs Costs (constant (constant

$)$)

(mil)(mil)

%%

ChangChangee

PublicPublic

1999-20001999-2000

2000-20012000-2001

2001-20022001-2002

7,7007,700

7,5707,570

8,5218,521-1.7%-1.7%

12.6%12.6%

110.4110.4

107.9107.9

125.6125.6-2.3%-2.3%

16.4%16.4%

PrivatePrivate

1999-20001999-2000

2000-20012000-2001

2001-20022001-2002

12,23612,236

13,99513,995

16,79816,79814.4%14.4%

20.0%20.0%

194.7194.7

196.6196.6

272.5272.51.0%1.0%

38.6%38.6%

Prostheses Costs as a Prostheses Costs as a PercentagePercentage

of Total Costs (Public v’s of Total Costs (Public v’s private)private) 2001-20022001-2002 Total CostTotal Cost Total Total

Prostheses Prostheses costcost

Prostheses Prostheses as % of total as % of total

costcost

HipsHips

PublicPublic

PrivatePrivate

TotalTotal

186.8186.8

230.7230.7

417.5417.5

40.940.9

85.685.6

126.5126.5

21.9%21.9%

37.7%37.7%

30.3%30.3%

KneesKnees

Public Public

PrivatePrivate

TotalTotal

125.6125.6

272.5272.5

398.1398.1

34.534.5

112.3112.3

146.7146.7

27.4%27.4%

41.2%41.2%

36.9%36.9%

TotalTotal 815.6815.6 273.2273.2 33.5%33.5%

Change in Prostheses Costs Change in Prostheses Costs (Public v’s private) (Public v’s private)

ProcedureProcedure 1999-20001999-2000 2000-20012000-2001 2001-20022001-2002

HipsHips

PublicPublic

PrivatePrivate

Total HipTotal Hip

31.831.8

55.255.2

87.087.0

36.3 (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%)

126.5 (31.0%)126.5 (31.0%)

KneesKnees

Public Public

PrivatePrivate

Total KneeTotal Knee

24.624.6

64.364.3

88.988.9

30.1 (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%)

112.3 (67.4%)112.3 (67.4%)

146.7 (51.0%)146.7 (51.0%)

TotalTotal 175.9175.9 193.7 (10.1%)193.7 (10.1%) 273.2 (41.1%)273.2 (41.1%)

Changing CostsChanging Costs

Cost increase more apparent in KneesCost 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) downAcute care (prostheses independent) down The introduction of the new prosthesis The introduction of the new prosthesis

funding arrangements will only partially funding arrangements will only partially helphelp

Real improvement will only come by Real improvement will only come by relating expenditure to outcomerelating expenditure to outcome

Joint Replacement Joint Replacement SurgerySurgery

• Increasing at 5-10% pa each year for the Increasing at 5-10% pa each year for the last 10last 10

yearsyears• Aging of the population Aging of the population • Knee replacement increasing in under Knee replacement increasing in under 55 yr olds55 yr olds

at 30% paat 30% pa• Australia underperforms with respect to Australia underperforms with respect to meetingmeeting

demanddemand

Change in Survival with Change in Survival with AgeAge

Male Patients with OAMale Patients with OA

70.00

75.00

80.00

85.00

90.00

95.00

100.00

0 2 4 6 8 10 12 14 16 18

years postoperatively

perc

ent

not

revi

sed

All AgesUnder 55

Australian Joint Australian Joint Replacement RegistryReplacement Registry In Australia 14% of Hip replacements are In Australia 14% of Hip replacements are

revisions revisions This does not equate to the revision rateThis does not equate to the revision rate

Australia 20-25% (estimated)Australia 20-25% (estimated)SwedenSweden 7-8%7-8%

Reducing rate of revision by 1% decreases Reducing rate of revision by 1% decreases revision procedures by 600 p.a. and saves revision procedures by 600 p.a. and saves

$ 15.5 million p.a.$ 15.5 million p.a.

Prostheses usage in Prostheses usage in AustraliaAustralia

More than 130 different hip More than 130 different hip prosthesesprostheses

Greater than 60 different knee Greater than 60 different knee prosthesesprostheses

Over 17,000 different sizes and Over 17,000 different sizes and types of components used in the types of components used in the 20032003

How to address the How to address the issue?issue?

Quality Data Quality Data Identify both the best and worse types of Identify both the best and worse types of

prosthesesprostheses Identify best surgical techniques Identify best surgical techniques

Most importantlyMost importantly Identify predisposing/exacerbating factorsIdentify predisposing/exacerbating factors Optimize early managementOptimize early management

Australian Orthopaedic Australian Orthopaedic Association National Association National Joint Replacement Joint Replacement

RegistryRegistry A Registry is the most effective A Registry is the most effective

method for determining the method for determining the most successful prostheses and most successful prostheses and surgical technique in different surgical technique in different clinical situationsclinical situations

Post market surveillance is Post market surveillance is criticalcritical

Australian Joint Australian Joint Replacement RegistryReplacement Registry

Collect Australian wide Collect Australian wide information information

Provide data to surgeons and Provide data to surgeons and hospitals for audit hospitals for audit

Education surgeons, Education surgeons, hospitals, Governments, hospitals, Governments, health industry and health industry and community community

Australian Joint Australian Joint Replacement RegistryReplacement Registry

All Government and Private All Government and Private Hospitals in AustraliaHospitals in Australia

296 hospitals296 hospitals

Commenced September 1999Commenced September 1999 Introduced progressively in all States & Introduced progressively in all States &

TerritoriesTerritories Fully implemented in 2002Fully implemented in 2002

Austin Moore and Austin Moore and Thompson Thompson

Hemi-arthroplastyHemi-arthroplasty

Australian Joint Australian Joint Replacement RegistryReplacement Registry

New surgical New surgical technologiestechnologies

UnispacerUnispacerPreservation Unicompartment Preservation Unicompartment

KneeKneeOxinium KneeOxinium Knee

Resurfacing THRResurfacing THR

Unispacer Knee Unispacer Knee ReplacementReplacement

Unispacer Knee Unispacer Knee ReplacementReplacement

UnispaceUnispacerr

Number Number revisedrevised

Total Total NumberNumber

% % RevisedRevised

Observed Observed 'compone'component' yearsnt' years

Revisions Revisions per 100 per 100 observed observed 'compone'component' yearsnt' years

UnispaceUnispacerr

1111 2727 40.740.7 2222 50.050.0

Exact 95% CI(24.96, 89.47)

Preservation Preservation Unicompartment Knee Unicompartment Knee

ReplacementReplacement

Preservation Mobile

Preservation Fixed

Oxinium Knee Oxinium Knee ReplacementReplacement

Genesis II Cementless Oxinium

 

Resurfacing Hip Resurfacing Hip ReplacementReplacement

Resurfacing Resurfacing compared to compared to

Conventional (OA Conventional (OA only)only)

Resurfacing compared Resurfacing compared to Conventional THR to Conventional THR

(OA)(OA)

Resurfacing has a significantly greater risk of Resurfacing has a significantly greater risk of early revision compared to conventional hip early revision compared to conventional hip replacement replacement

This is due to an increased risk of fractureThis is due to an increased risk of fracture Males over 65 yrs old have almost a 4x risk Males over 65 yrs old have almost a 4x risk of fracture of fracture P<.0001 HR=3.8, 95%CI (2.16, 6.72)

Females fracture at a significantly higher rate Females fracture at a significantly higher rate than males than males PP<0.0001 HR=2.190, 95%CI (1.52, 3.16)

Resurfacing Resurfacing compared to compared to

Conventional (OA Conventional (OA only)only)

Trends in Prosthesis Trends in Prosthesis Fixation Conventional Fixation Conventional

Primary THRPrimary THR

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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

1999

2000

2001

2002

2003

2004

1999

2000

2001

2002

2003

2004

1999

2000

2001

2002

2003

2004

AUST NSW VIC QLD WA SA TAS ACT/NT

Cemented Hybrid Cementless

Improve surgical Improve surgical techniquetechnique

To be implemented must To be implemented must be cost effectivebe cost effective

Computer assisted surgeryComputer assisted surgery

Minimally invasive surgeryMinimally invasive surgery

Clinical Evaluation and Clinical Evaluation and ResultsResults

3%

97%

Axis: 0-3° Axis: 4-5°

74%

20%6%

Axis: 0-3° Axis: 4-5° Axis >5°

Conventional (n=50)

Navigation (n=65)

p<0.05

Minimally invasive surgery Minimally invasive surgery

Entirely new approachEntirely new approach Hip and Knee replacement Hip and Knee replacement Same day discharge possibleSame day discharge possible Approach made more feasible Approach made more feasible

by Computer assisted surgeryby Computer assisted surgery Outcomes to be determinedOutcomes to be determined

Orthopaedic biological solutionsOrthopaedic biological solutionsBe afraid very afraidBe afraid very afraid

20032003 Prostheses US $40 billionProstheses US $40 billion Biologics US $ 4 billionBiologics US $ 4 billion

2010 (estimate)2010 (estimate) Prostheses US $120 billionProstheses US $120 billion Biologics US $ 80 billionBiologics US $ 80 billion

Intelligent analysis of Intelligent analysis of quality data and develop quality data and develop

appropriate research appropriate research strategiesstrategies

• Know best practiceKnow best practice• Collect the right dataCollect the right data• Appropriate analysis Appropriate analysis • Identify problems Identify problems • Develop solutionsDevelop solutions

PreventionPrevention

Identify predisposing factorsIdentify predisposing factors Identify exacerbating factorsIdentify exacerbating factors Data miningData mining Database integration and cross Database integration and cross

referencingreferencing

Optimize early managementOptimize early management

Patient education Patient education Physical therapyPhysical therapy Drug treatmentDrug treatment Appropriate use of surgical Appropriate use of surgical

procedures and techniquesprocedures and techniques

Prevention of fractures Prevention of fractures secondary to osteoporosis secondary to osteoporosis

Best practice not implementedBest practice not implemented Drug treatment very effectiveDrug treatment very effective First fracture patients are First fracture patients are

identifiableidentifiable need to ensure drug treatment need to ensure drug treatment

availabilityavailability Do the numbersDo the numbers

Some important strategiesSome important strategies

Do not take a passive role in health care Do not take a passive role in health care delivery delivery

Effectively utilize the information you haveEffectively utilize the information you have Access available quality informationAccess available quality information Identify where best practice not Identify where best practice not

implemented and ensure that it isimplemented and ensure that it is Consider involvement in changing clinician Consider involvement in changing clinician

practice practice Identify critical areas of future expenditureIdentify critical areas of future expenditure Contract research to develop targeted Contract research to develop targeted

strategies to minimize costs and maximize strategies to minimize costs and maximize patient benefit patient benefit

Thank youThank you