theuseof6axis external$fixaon$ …llrs.org/pdfs/annual meeting presentations...ilizarov$ •...

The  Use  Of  6-­‐Axis  External  Fixa5on  Is  More  Cost-­‐Effec5ve  Than  Ilizarov  For  Canadian  Health  Care  Centres  

Khalid  Alkhelaifi  MD,    Elisabeth  Leblanc,  MSc  MD  FRCSC  

 Mohammad  Alzahrani  MD;  Karine  Perreault  MSc,    Marie  Gdalevitch  MD  FRCSC  

DISCLOSURES  

•  Senior  author  is  an  educa5onal  consultant  for  Smith  and  Nephew  

Post-Traumatic

Dysplastic

Congenital

Deformity correction Limb lengthening

Developmental

Pathologic

INTRODUCTION  

And  Or  

CIRCULAR EXTERNAL FIXATION

6-Axis EF (TSF) Ilizarov

ILIZAROV  

•  Important  innova5on  in  limb  reconstruc5on    

•  Rings,  threaded  rods  and  hinges    

•  Difficulty  in    mul5-­‐planar  and  rota5onal  correc5ons    

•  Increase  need  to  return  to  OR  for  adjustments  

TAYLOR  SPATIAL  FRAME  

•  Computer  assisted  6-­‐axis  deformity  correc5on  EF    

•  Mul5-­‐planar  and  rota5onal  deformity  correc5on    

•  More  accurate  correc5ons    

•  Decreases  return  to  OR  

ILIZAROV  RING  FIXATOR    

• Difficulty with multi-planar corrections

• Increase need to return to OR for frame adjustments

• Gold  standard  in  Canada  due  to  lower  cost  of  equipment  

• Mean unit cost : 1600$

TSF  (6  axis  EF)  • Mul6-­‐planar  correc6ons    

• Improved  accuracy    

• Decreased  complica6ons  

• Limited use in Canada due to cost

• Standard in US

• Mean  unit  cost:  8000$  

ILIZAROV  VS.  TSF  

•  Publicly-­‐funded  •  Elevated  implant  costs  =  limit  their  poten5al  use    •  Difficult  to  get  hospitals  to  approve  budgets  for  6  axis  EF  

secondary  to  its  cost  

CANADIAN  HEALTH  CARE  SYSTEM  

Determine  if  the  use  of  the  TSF  (or  6-­‐axis  EF)  is  cost-­‐effecEve  given  the  iniEal  implant  cost?  

OBJECTIVE  

GAIN  IN  HEALTH  

COST  ASSOCIATED  

COST-­‐EFFECTIVENESS  Is  an  economic  evalua5on  that  determines  both  the  cost  and  health  outcomes  of  alterna5ve  interven5on  strategies:    Ilizarov  vs.  TSF  

Choose  the  most  cost-­‐effec5ve  fixator  from  the  perspec5ve  of  a  Hospital  in  the  Canadian  

Health  Care  System    

Included Excluded •  Initial admission and OR time •  Implants •  Readmission •  Reoperation (for complications or

readjustments)

•  Surgeon / anesthetist fees (not paid by hospital)

•  Complications not requiring OR

Deformity and LLD

cases from 2006-2013:

70 cases 11 excluded (clubfeet)

59 included

29 Ilizarov

30 TSF

METHODS  

Total  treatment  cost  per  paEent  

Shriners  Hospital  Montreal  

Cost  differenEal  (TSF  –  Ilizarov)  

Health  benefits  (TSF  –  Ilizarov)  

IniEal  procedure  

Implant  

Admission  

Opera5ng  room  

Added  procedures  

Re-­‐Admission  

Return  to  OR  

TOTAL  TREATMENT  

Favorable  to  TSF  

Unfavorable  to  TSF  

Neutral  

Per patient

RESULTS  

Cost  differenEal  (TSF  –  Ilizarov)  

Health  benefits  (TSF  –  Ilizarov)  

IniEal  procedure  

Implant   +  $6,400   Increased  accuracy  

Admission  

Opera5ng  room  

Added  procedures  

Re-­‐Admission  

Return  to  OR  

TOTAL  TREATMENT  

Favorable  to  TSF  

Unfavorable  to  TSF  

Neutral  

Per patient

RESULTS  

Cost  differenEal  (TSF  –  Ilizarov)  

Health  benefits  (TSF  –  Ilizarov)  

IniEal  procedure  

Implant   +  $6,400   Increased  accuracy  

Admission   No  difference   No  difference  

Opera5ng  room   No  difference   No  difference  

Added  procedures  

Re-­‐Admission  

Return  to  OR  

TOTAL  TREATMENT  

Favorable  to  TSF  

Unfavorable  to  TSF  

Neutral  

Per patient

RESULTS  

Cost  differenEal  (TSF  –  Ilizarov)  

Health  benefits  (TSF  –  Ilizarov)  

IniEal  procedure  

Implant   +  $6,400   Increased  accuracy  

Admission   No  difference   No  difference  

Opera5ng  room   No  difference   No  difference  

Added  procedures  

Re-­‐Admission   -­‐    $566,08   -­‐    1,4  days  saved  per  pa5ent  

Return  to  OR  

TOTAL  TREATMENT  

Favorable  to  TSF  

Unfavorable  to  TSF  

Neutral  

Per patient

RESULTS  

TSF   Ilizarov  

CAD  

Cost  of  readmission    

Cost  differenEal  (TSF  –  Ilizarov)  

Health  benefits  (TSF  –  Ilizarov)  

IniEal  procedure  

Implant   +  $6,400   Increased  accuracy  

Admission   No  difference   No  difference  

Opera5ng  room   No  difference   No  difference  

Added  procedures  

Re-­‐Admission   -­‐    $566,08   -­‐    1,4  days  saved  per  pa5ent  

Return  to  OR   -­‐    $581,29   -­‐    1.5  hrs  saved  per  pa5ent  

TOTAL  TREATMENT  

Favorable  to  TSF  

Unfavorable  to  TSF  

Neutral  

Per patient

RESULTS  Cost  OR  returns  

TSF   Ilizarov  

CAD  

Favorable  to  TSF  

Unfavorable  to  TSF  

Neutral  

Per patient

RESULTS  Cost  differenEal  (TSF  –  Ilizarov)  

Health  benefits  (TSF  –  Ilizarov)  

IniEal  procedure  

Implant   +  $6,400   Increased  accuracy  

Admission   No  difference   No  difference  

Opera5ng  room   No  difference   No  difference  

Added  procedures  

Re-­‐Admission   -­‐    $566   -­‐    1,4  days  saved  per  pa5ent  

Return  to  OR   -­‐    $581   -­‐    1.5  hrs  saved  per  pa5ent  

TOTAL  TREATMENT  +  $3,763  (single  use)  

No  difference  (used  twice)  

Total  cost  and  implant  re-­‐use  

Implant  reuse  

Total  cost  (CA

D)  

TSF  

Ilizarov  

Favorable  to  TSF  

Unfavorable  to  TSF  

Neutral  

Per patient

RESULTS  Cost  differenEal  (TSF  –  Ilizarov)  

Health  benefits  (TSF  –  Ilizarov)  

IniEal  procedure  

Implant   +  $6,400   é  accuracy  

Admission   No  difference   No  difference  

Opera5ng  room   No  difference   No  difference  

Added  procedures  

Re-­‐Admission   -­‐    $566   -­‐    1,4  days  

Return  to  OR   -­‐    $581   -­‐    1.5  hrs  

TOTAL  TREATMENT  +  $3,763  (single  use)  

ê  complica5ons  No  difference  (used  twice)  

Complica5on  rate  

TSF   Ilizarov  

Num

ber  o

f  com

plica5

ons  

CONCLUSION  •  Re-­‐admission,  return  to  OR  and  complica5on  rates  were  all  significantly  lower  in  the  TSF  

•  TSF  Cost-­‐effec5ve?  =    YES!  •  Clear  added  health  benefits  with  no  significant  difference  in  cost  if  implants  are  used  twice  –  In  Canada  re-­‐use  frames  

For  Canadian  Hospitals  6-­‐axis  EF  is  a  cost-­‐effecEve  soluEon  for  limb  reconstrucEon  

DISCUSSION  

•  Is  6-­‐axis  EF  cost-­‐effec5ve  for  single  use?  •  Single  use  is  $3  763  more  expensive  but…  Does  not  account  for:  •  Surgeon  and  anaesthe5st  fees  for  each  OR  return  •  Opportunity  cost  of  the  OR  •  Socio-­‐economic  cost  to  the  pa5ent  •  Hard  to  determine  $$  of  health  benefits  

Probable  that  single  use  of  6-­‐axis  EF  is    cost-­‐effecEve  (cost  vs.  health  benefits)  

ACKNOWLEDGMENTS  

Special  thanks  to  Mrs  Myriam  Denault  for  the  financial  analysis  of  the  data  

REFERENCES    1.  Y,  E.  and  F.  M,  Deformity  Correc5on  with  an  external  Fixator:  ease  of  use  and  accuracy?  Orthopedics,  2009.  32(2).  2.  Blondel,  B.,  et  al.,  Limb  lengthening  and  deformity  correc5on  in  children  using  hexapodal  external  fixa5on:  preliminary  results  for  36  cases.  Orthop  Traumatol  Surg  Res,  2009.  95(6):  p.  425-­‐30.      3.  Sluga,  M.,  et  al.,  Lower  limb  deformi5es  in  children:  two-­‐stage  correc5on  using  the  Taylor  spa5al  frame.  J  Pediatr  Orthop  B,  2003.  12(2):  p.  123-­‐8.  4.  Fadel,  M.  and  G.  Hosny,  The  Taylor  spa5al  frame  for  deformity  correc5on  in  the  lower  limbs.  Int  Orthop,  2005.  29(2):  p.  125-­‐9.  5.  Dammerer,  D.,  et  al.,  Clinical  value  of  the  Taylor  Spa5al  Frame:  a  comparison  with  the  Ilizarov  and  Orthofix  fixators.  J  Child  Orthop,  2011.  5:  p.  343-­‐9.  6.  Rozbruch,  S.R.,  et  al.,  Does  the  Taylor  Spa5al  Frame  accurately  correct  5bial  deformi5es?  Clin  Orthop  Relat  Res,  2010.  468(5):  p.  1352-­‐61.  7.  Kris5ansen,  L.P.,  H.  Steen,  and  O.  Reikeras,  No  difference  in  5bial  lengthening  index  by  use  of  Taylor  spa5al  frame  or  Ilizarov  external  fixator.  Acta  Orthop,  2006.  77(5):  p.  772-­‐7.  8.  Manner,  H.M.,  et  al.,  Accuracy  of  complex  lower-­‐limb  deformity  correc5on  with  external  fixa5on:  a  comparison  of  the  Taylor  Spa5al  Frame  with  the  Ilizarov  Ringfixator.  J  Child  Orthop,  2007.  1:  p.  55-­‐61.  9.  Bleichrodt  H,  Quiggin  J  (December  1999).  "Life-­‐cycle  preferences  over  consump5on  and  health:  when  is  cost-­‐effec5veness  analysis  equivalent  to  cost-­‐benefit  analysis?".  J  Health  Econ  18  (6):  681–708.      10.  Black,  William  (1990).  "A  Graphical  Representa5on  of  Cost-­‐Effec5veness.".  Med  Decis  Making  10  (3):  212–214.    

Thank  you  

STATISTICS  

•  IBM  SPSS  sta5s5cs  version  21.0.0.0  for  mac  •  Means  and  standard  devia5ons  •  Sta5s5cal  significance  p  ≤  0,05  •  Student  t-­‐test  for  normally  distributed    •  Mann  Whitney  U  Test  for  non-­‐normally  •  Frequency  difference  in  primary  diagnosis  Pearson  chi-­‐squared  test.    

UNEVEN  DIAGNOSIS  DISTRIBUTION  

Ilizarov  

Dysplas5c  

Congenital  

Trauma5c  

Developmental  

Pathologic  

6-­‐Axis  EF  

Dysplas5c  

Congenital  

Trauma5c  

Developmental  

Pathologic