Value-based Healthcare: Increasing Value by Reducing Implant-related Health Care Costs.

Value in healthcare can be defined as health outcomes that matter to patients divided by the cost incurred to achieve those outcomes [8]. Value is increased by improving health outcomes, reducing costs, or both. One way to increase value is to reduce implant-related costs, provided that doing so does not compromise pain reduction, functional gains, or other improvements in endpoints that matter to patients. In a 2014 paper, Egol and colleagues [3] outlined six strategies for reducing trauma implant-related healthcare costs. Of those strategies, the use of generic fracture implants stands out for its relative simplicity, provided that generic implants are functionally equivalent to conventional implants. Indeed, if researched and implemented correctly, the use of generic implants has the potential to improve value and have wide application across orthopaedic subspecialties. Surprisingly, clinical research comparing conventional and generic orthopaedic implants is relatively limited. One study [1] found that generic sacroiliac screws could result in cost savings of USD 327 per procedure over conventional screws in patients who were otherwise similar in terms of age, sex, fracture pattern complication rate, and radiographic outcomes. The authors reported similarfindings for screws used for the internal fixation of femoral neck fractures. Another study [7] reported savings of USD 1197 per procedure (a 56% reduction) when generic locking plates were compared to conventional ones for fractures of the proximal humerus, distal radius, proximal tibia, tibial pilon, and ankle, with no increase in complications or surgical time. Findings in arthroplasty are a bitmore complicated, if still quite preliminary. WhileWaddell and colleagues [9] found that generic total hip implants were comparable to more-expensive prostheses at 2-year followup with respect to clinical endpoints, Hothi and colleagues [5] identified potentially important design differences between branded and generic stems in terms of trunnion surface roughness and mass, but not volume. Greater trunnion roughness (as was found in the generic stem) has been associated with greater corrosion at the head-stem junction [5, 11]. The mass and volume findings suggest different material densities, manufacturing processes, and possibly mechanical properties between the two stem designs of uncertain clinical significance. These findings led Haddad [4] to caution against rushing to adopt generic implants and to urge clinicians instead to conduct a “full and thorough stepwise evaluation” before considering them for routine care. We agree that for joint replacements, the adoption of generic implants should be more cautious. Yet this caution should be tempered by the need to provide value-based care, which incorporates consideration of cost. The use of generic implants remains limited despite the evidence that simple generic implants such as plates and screws are functionally equivalent to (and less expensive than) conventional implants. A 2016 survey of A note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the latest Value-based Healthcare column (formerly Orthopaedic Healthcare Worldwide). Valuebased Healthcare explores strategies to enhance the value of musculoskeletal care by improving health outcomes and reducing the overall cost of care delivery. We welcome reader feedback on all of our columns and articles; please send your comments to eic@ clinorthop.org. One author (KJB) is Chair of the American Joint Replacement Registry Steering Committee. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. K. J. Bozic MD, MBA (✉), Dell Medical School at the University of Texas at Austin 1701 Trinity Street, Austin, TX 78712. Email: kevin.bozic@austin.utexas.edu V. H. Waldrop, Medical Student, Dell Medical School at The University of Texas at Austin, Austin, TX. D. Laverty, Clinical Assistant Professor, Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, TX. K. Bozic, Chair, Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, TX.