Healthcare costs in knee replacement surgery
Creators: name: Chen, Alvin Mingguang
Publisher: name: Imperial College London
Year: 2015

description: The fundamental questions behind this thesis are: Can we save money in the surgical treatment of osteoarthritis in the knee? And if so, what areas should we be looking at and how can we do it? Osteoarthritis represents a considerable cost to the UK economy. A review of the economic costs of osteoarthritis was performed as part of this thesis. While estimates of economic costs can be made, one conclusion from the studies does seem clear: that these costs are very significant and are continuing to rise. Based on data from the UK National Joint Registry (NJR), there has been a substantial increase in the number, and hence the costs of knee replacements to the NHS over the last 10 years. At the time this thesis started in 2011, the NHS had also begun a previously unprecedented slowdown. This resulted in a significant funding gap. The estimated shortfall in funding, in order for the NHS to cope with events such as increasing numbers of aging population or the cost of increases in new medical technology, has been calculated as £20 billion by 2014, with an additional, further funding shortfall of an estimated £30 billion by 2020. As a result, an intensive programme targeting productivity improvement was instituted with a view to solving this deficit through improvements in efficiency.It is well known amongst accounting circles that what cannot be accurately measured, cannot be controlled. One of the aims of this thesis was to improve on the existing costing methodology utilised for knee replacement surgery. In order to better control costs, and understand where the cost drivers in such surgery lay, the patient pathway for total knee replacement was prospectively mapped utilising a Time driven Activity based costing model. Timings were prospectively collected as the patient was followed through the TKR pathway. All costs for the patient pathway from admission through to discharge, as well as pre-operative assessment clinic and joint school, were analysed. The major cost drivers involved in the Total Knee Replacement pathway were identified as a result of this study. This data was then subsequently utilised at our institution to implement further cost reduction strategies in knee replacement surgery. Litigation in healthcare has also dramatically increased over the last 10 years. The outstanding liability of clinical negligence claims, according to data from the National Health Service Litigation Authority (NHSLA), exceeded £1.3 billion by 2011. The NHSLA also reported a year-on-year increase in such claims. A review of NHSLA database was performed as part of this thesis. All cases involving adverse events occurring as a result from surgery to the knee were examined, to determine the costs of these adverse events, to analyse trends and predict future costs. A significant number of events involving technical errors were identified as part of this review. In addition to the cost implications, this represents potentially preventable events, and may represent an issue with training and/or patient safety. A study analysing the clinical relevance and costs of repeating x-rays for knee osteoarthritis was also undertaken. Only a small proportion of patients referred for knee radiographs have weight-bearing films, with a significant number of hospitals in London do not routinely perform weight-bearing radiographs to investigate suspected knee osteoarthritis. The potential delay in diagnosis, referral or treatment of these patients, in addition cost burden to the NHS was examined. The principles of Time Driven Activity based costing was successfully applied to a small cohort of Total Knee Replacement patients in our study. There remains the potential for larger studies with more heterogeneous patient groups to better inform policy makers attempting to benchmark treatment costs more accurately.