Dossier n. 208/2011 [Abstract] Physicians’ role in acquiring medical technologies: the case of hip prosthesis

The decision-making in the acquisition of medical devices requires a broad involvement of physicians who play a crucial role on their adoption. The choice among technological advanced products has large consequences in terms of health outcomes and their related costs.

Therefore the study attempts, by focusing on the case of hip prosthesis, at defining the appropriateness criteria of the implant use through the network of physicians and at estimating its economic impact.

Primary total hip replacement (THR) is a common intervention which has become increasingly frequent. The extensively documented success of the procedure in reducing pain and functional limitations in addition to the availability of a plethora of prosthesis has enlarged the indications for THR during the last decades. As a result costs of THR have incessantly increased and they require to be managed in order not to put the financial viability of healthcare systems at risk.

A large number of hip prosthesis are used, widely differing in design, material and fixation technique. Moreover, newer implants are designed in order to reduce the failure of THR (i.e. to diminish the revision rate) frequently due to aseptic loosening and fragmentation. However, the evidence of long-term clinical effectiveness of most of devices is still under scrutiny since their use is referred to 10 years or less. Therefore the clinician selects the implant on its properties and according to the characteristics and expectations of the patient.

Through the regional register of orthopaedics implant (Registro di implantologia protesica ortopedica, RIPO) it is possible to retrieve and analyse data on the interventions performed in 57 orthopaedics centres located in Emilia-Romagna. Data extracted from the register confirm the raise of hip surgery and also the wide variety of the prosthesis used.

Therefore the Regional Health Service acknowledges THR as a relevant issue and in order to improve the quality of care it tries to deal with it through the support of clinicians.

The present study aims at developing explicit criteria to assess the appropriateness of the prosthesis in patients with a diagnosis of osteoarthritis treated with THR. Since the literature review highlights the absence of clear indications about the choice of implant, the need to develop those criteria through a consensus among experts emerged and, consequently, the RAND Appropriateness Methodology (RAM) is adopted. First, 10 clinicians, who accepted to participate to the panel, identify those clinical factors which are most likely to steer the choice of the prosthesis; second, they provide a detailed list of clinical scenarios; third, they rate each scenario, through a 9-score scale (from 1 for “inappropriate” to 9 for “appropriate”), based on the appropriateness of any prosthesis previously identified in terms of design, material and fixation technique. In order to reduce the level of disagreement, three rounds of assessment are performed and the discussion between the rounds is encouraged. Nevertheless, after the third round, the agreement on the criteria has been achieved only in half of the scenarios. Findings are presented as clinical recommendations.

The expert panel favours the use of highly-performing prosthesis in younger patients coherently with previous findings whereas disagreement on the best material to use in older patients has emerged.

The criteria of appropriateness are then applied to the whole population of patients which underwent THR in 2006-2007. Regional data, by means of the regional integrated database and the RIPO, populate a comparative analysis among the orthopaedic centres. As to the fixation methods the clinical practice seems consistent with the recommendations. As to the materials, in order to deal with the broad disagreement the panel decides to discuss the criteria of appropriateness referred to each scenario during a plenary session.

By applying those criteria it is also possible to estimate the economic impact of the recommendations.

Last, the critical issues of the study are deeply discussed. The methodology adopted seems rather useful in consolidating the network among clinicians, and in developing explicit criteria of appropriateness. Moreover, despite its weaknesses, it serves as an helpful tool both in building recommendations and in estimating their impact on costs. Some policy implications aiming at combining continuous quality improvement efforts and healthcare systems’ financial constraints might be drawn from those findings: firstly reinforcing the relation between physicians and hospital management in dealing with the choice of implant, secondly focusing on the best way to organise the purchasing process.