Cost-Effectiveness of Total Hip Arthroplasty Versus Nonoperative Management in Normal, Overweight, Obese, Severely Obese, Morbidly Obese, and Super Obese Patients: A Markov Model

Published:August 24, 2018DOI:



      We estimated the cost-effectiveness of performing total hip arthroplasty (THA) vs nonoperative management (NM) among 6 body mass index (BMI) cohorts.


      We constructed a state-transition Markov model to compare the cost utility of THA and NM in the 6 BMI groups over a 15-year period. Model parameters for transition probability (risk of revision, re-revision, and death), utility, and costs (inflation adjusted to 2017 US dollars) were estimated from the literature. Direct medical costs of managing hip arthritis were accounted in the model. Indirect societal costs were not included. A 3% annual discount rate was used for costs and utilities. The primary outcome was the incremental cost-effectiveness ratio (ICER) of THA vs NM. One-way and Monte Carlo probabilistic sensitivity analyses of the model parameters were performed to determine the robustness of the model.


      Over the 15-year time period, the ICERs for THA vs NM were the following: normal weight ($6043/QALYs [quality-adjusted life years]), overweight ($5770/QALYs), obese ($5425/QALYs), severely obese ($7382/QALYs), morbidly obese ($8338/QALYs), and super obese ($16,651/QALYs). The 2 highest BMI groups had higher incremental QALYs and incremental costs. The probabilistic sensitivity analysis suggests that THA would be cost-effective in 100% of the normal, overweight, obese, severely obese, and morbidly obese simulations, and 99.95% of super obese simulations at an ICER threshold of $50,000/QALYs.


      Even at a willingness-to-pay threshold of $50,000/QALYs, which is considered low for the United States, our model showed that THA would be cost-effective for all obesity levels. BMI cut-offs for THA may lead to unnecessary loss of healthcare access.


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        • Kurtz S.
        • Ong K.
        • Lau E.
        • Mowat F.
        • Halpern M.
        Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
        J Bone Joint Surg Am. 2007; 89: 780-785
        • Derman P.B.
        • Fabricant P.D.
        • David G.
        The role of overweight and obesity in relation to the more rapid growth of total knee arthroplasty volume compared with total hip arthroplasty volume.
        J Bone Joint Surg Am. 2014; 96: 922-928
        • WHO
        Global database on body mass index.
        ([accessed 12.02.17])
        • Lash H.
        • Hooper G.
        • Hooper N.
        • Frampton C.
        Should a patients BMI status be used to restrict access to total hip and knee arthroplasty? Functional outcomes of arthroplasty relative to BMI - single centre retrospective review.
        Open Orthop J. 2013; 7: 594-599
        • Schwarzkopf R.
        • Thompson S.L.
        • Adwar S.J.
        • Liublinska V.
        • Slover J.D.
        Postoperative complication rates in the “super-obese” hip and knee arthroplasty population.
        J Arthroplasty. 2012; 27: 397-401
        • Lübbeke A.
        • Duc S.
        • Garavaglia G.
        • Finckh A.
        • Hoffmeyer P.
        BMI and severity of clinical and radiographic signs of hip osteoarthritis.
        Obesity (Silver Spring). 2009; 17: 1414-1419
        • Maradit Kremers H.
        • Visscher S.L.
        • Kremers W.K.
        • Naessens J.M.
        • Lewallen D.G.
        Obesity increases length of stay and direct medical costs in total hip arthroplasty.
        Clin Orthop. 2014; 472: 1232-1239
      1. Online scorecard shows surgeons’ complication rates.
        ([accessed 21.06.17])
      2. U.S. news & world report to rate knee, hip surgeons by fall 2017.
        ([accessed 21.06.17])
        • McLawhorn A.S.
        • Steinhaus M.E.
        • Southren D.L.
        • Lee Y.-Y.
        • Dodwell E.R.
        • Figgie M.P.
        Body mass index class is independently associated with health-related quality of life after primary total hip arthroplasty: an institutional registry-based study.
        J Arthroplasty. 2017; 32: 143-149
        • McCalden R.W.
        • Charron K.D.
        • MacDonald S.J.
        • Bourne R.B.
        • Naudie D.D.
        Does morbid obesity affect the outcome of total hip replacement? An analysis of 3290 THRs.
        J Bone Joint Surg Br. 2011; 93: 321-325
        • Rajgopal R.
        • Martin R.
        • Howard J.L.
        • Somerville L.
        • MacDonald S.J.
        • Bourne R.
        Outcomes and complications of total hip replacement in super-obese patients.
        Bone Joint J. 2013; 95-B: 758-763
        • Wood A.M.
        • Brock T.M.
        • Heil K.
        • Holmes R.
        • Weusten A.
        A review on the management of hip and knee osteoarthritis.
        Int J Chronic Obstr Pulm Dis. 2013; 2013: e845015
      3. 2016 Annual Reports: AOANJRR - AOANJRR.
        ([accessed 30.05.17])
        • Wagner E.R.
        • Kamath A.F.
        • Fruth K.M.
        • Harmsen W.S.
        • Berry D.J.
        Effect of body mass index on complications and reoperations after total hip arthroplasty.
        J Bone Joint Surg Am. 2016; 98: 169-179
      4. 2007: AOANJRR - AOANJRR.
        ([accessed 30.05.17])
        • Vulcano E.
        • Lee Y.-Y.
        • Yamany T.
        • Lyman S.
        • Valle A.G.D.
        Obese patients undergoing total knee arthroplasty have distinct preoperative characteristics: an institutional study of 4718 patients.
        J Arthroplasty. 2013; 28: 1125-1129
        • Gandhi R.
        • Wasserstein D.
        • Razak F.
        • Davey J.R.
        • Mahomed N.N.
        BMI independently predicts younger age at hip and knee replacement.
        Obesity (Silver Spring). 2010; 18: 2362-2366
        • Postler A.E.
        • Beyer F.
        • Wegner T.
        • Lützner J.
        • Hartmann A.
        • Ojodu I.
        • et al.
        Patient-reported outcomes after revision surgery compared to primary total hip arthroplasty.
        Hip Int. 2017; 27: 180-186
        • McLawhorn A.S.
        • Southren D.
        • Wang Y.C.
        • Marx R.G.
        • Dodwell E.R.
        Cost-effectiveness of bariatric surgery prior to total knee arthroplasty in the morbidly obese: a computer model-based evaluation.
        J Bone Joint Surg Am. 2016; 98: e6
        • Bedair H.
        • Cha T.D.
        • Hansen V.J.
        Economic benefit to society at large of total knee arthroplasty in younger patients: a Markov analysis.
        J Bone Joint Surg Am. 2014; 96: 119-126
        • Berger A.
        • Bozic K.
        • Stacey B.
        • Edelsberg J.
        • Sadosky A.
        • Oster G.
        Patterns of pharmacotherapy and health care utilization and costs prior to total hip or total knee replacement in patients with osteoarthritis.
        Arthritis Rheum. 2011; 63: 2268-2275
        • Gupta S.
        • Hawker G.A.
        • Laporte A.
        • Croxford R.
        • Coyte P.C.
        The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition.
        Rheumatology (Oxford). 2005; 44: 1531-1537
      5. EQ-5D instruments – EQ-5D.
        ([accessed 19.04.18])
        • Changulani M.
        • Kalairajah Y.
        • Peel T.
        • Field R.E.
        The relationship between obesity and the age at which hip and knee replacement is undertaken.
        J Bone Joint Surg Br. 2008; 90: 360-363
        • Chang R.W.
        • Pellisier J.M.
        • Hazen G.B.
        A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip.
        J Am Med Assoc. 1996; 275: 858-865
        • Mota R.E.
        Cost-effectiveness analysis of early versus late total hip replacement in Italy.
        Value Health. 2013; 16: 267-279
        • Briggs A.
        • Claxton K.
        • Sculpher M.
        Chapter 4: Making decision models probabilistic. Decis. Model. Health Econ. Eval.
        Oxford University Press, Oxford2006: 77-120
        • Neumann P.J.
        • Cohen J.T.
        • Weinstein M.C.
        Updating cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold.
        N Engl J Med. 2014; 371: 796-797
      6. CABG costs more than PCI but is a “reasonable value.” Medscape.
        ([accessed 11.09.17])
        • Lee C.P.
        • Chertow G.M.
        • Zenios S.A.
        An empiric estimate of the value of life: updating the renal dialysis cost-effectiveness standard.
        Value Health. 2009; 12: 80-87
      7. Comprehensive Care for Joint Replacement Model Center for Medicare & Medicaid Innovation.
        ([accessed 12.02.17])
      8. Smoking cessation programs benefit patients prior to joint replacements.
        ([accessed 30.05.17])
        • Nearing E.E.
        • Santos T.M.
        • Topolski M.S.
        • Borgert A.J.
        • Kallies K.J.
        • Kothari S.N.
        Benefits of bariatric surgery before elective total joint arthroplasty: is there a role for weight loss optimization?.
        Surg Obes Relat Dis. 2017; 13: 457-462
        • Smith T.O.
        • Aboelmagd T.
        • Hing C.B.
        • MacGregor A.
        Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis.
        Bone Joint J. 2016; 98-B: 1160-1166
        • Inacio M.C.S.
        • Kritz-Silverstein D.
        • Raman R.
        • Macera C.A.
        • Nichols J.F.
        • Shaffer R.A.
        • et al.
        The impact of pre-operative weight loss on incidence of surgical site infection and readmission rates after total joint arthroplasty.
        J Arthroplasty. 2014; 29 (e1): 458-464
        • Watts C.
        • Martin J.R.
        • Houdek M.
        • Abdel M.
        • Lewallen D.
        • Taunton M.
        Prior bariatric surgery may decrease the rate of re-operation and revision following total hip arthroplasty.
        Bone Joint J. 2016; 98-B: 1180-1184
        • Werner B.C.
        • Higgins M.D.
        • Pehlivan H.C.
        • Carothers J.T.
        • Browne J.A.
        Super obesity is an independent risk factor for complications after primary total hip arthroplasty.
        J Arthroplasty. 2017; 32: 402-406
        • Nickel B.T.
        • Klement M.R.
        • Penrose C.T.
        • Green C.L.
        • Seyler T.M.
        • Bolognesi M.P.
        Lingering risk: bariatric surgery before total knee arthroplasty.
        J Arthroplasty. 2016; 31: 207-211
        • Martin J.R.
        • Watts C.D.
        • Taunton M.J.
        Bariatric surgery does not improve outcomes in patients undergoing primary total knee arthroplasty.
        Bone Joint J. 2015; 97-B: 1501-1505
        • Huffaker S.
        • Giori N.
        Can we expect morbidly obese patients with osteoarthritis to lose weight in a weight loss program?.
        AAOS 2017 Annual Meeting, Paper Presentation, 2017 (
        • Lui M.
        • Jones C.A.
        • Westby M.D.
        Effect of non-surgical, non-pharmacological weight loss interventions in patients who are obese prior to hip and knee arthroplasty surgery: a rapid review.
        Syst Rev. 2015; 4: 121
        • Martin J.R.
        • Jennings J.M.
        • Dennis D.A.
        Morbid obesity and total knee arthroplasty: a growing problem.
        J Am Acad Orthop Surg. 2017; 25: 188-194
        • Meller M.M.
        • Toossi N.
        • Gonzalez M.H.
        • Son M.-S.
        • Lau E.C.
        • Johanson N.
        Surgical risks and costs of care are greater in patients who are super obese and undergoing THA.
        Clin Orthop. 2016; 474: 2472-2481