Cost-Utility Analyses in US Orthopaedic Foot and Ankle Surgery: A Systematic Review

2018 ◽  
Vol 11 (6) ◽  
pp. 548-552 ◽  
Author(s):  
Aditya V. Karhade ◽  
John Y. Kwon
Keyword(s):  
Systematic Review ◽  
Health Economic ◽  
Cost Effective ◽  
The United States ◽  
Cost Utility ◽  
Ankle Fractures ◽  
Foot And Ankle ◽  
End Stage ◽  
Economic Studies

Background. While investigations have been performed examining the quality of US-based cost-utility analyses for other orthopaedic subspecialties and have provided important insights, a similar analysis has not been performed examining the foot and ankle literature. Methods. A systematic review of foot and ankle studies was conducted to identify cost-utility analyses published between 2000 and 2017. Of 687 studies screened by abstract, 4 cost-utility studies were identified and scored by the Quality of Health Economic Studies instrument. Results. Of these 4 studies, 3 examined end-stage arthritis and 1 examined unstable ankle fractures. Cost-effective interventions identified by these studies included the performance of total ankle arthroplasty over ankle arthrodesis or nonoperative treatment for end-stage arthritis and suture button fixation over syndesmotic screws for unstable supination–external rotation ankle fractures. The mean Quality of Health Economic Studies scores for these studies was 87.5. Conclusion. Despite the increasing focus on value-based care delivery in the United States, there are few foot and ankle cost-utility analyses. Nonetheless, the quality of existing analyses is high. Certain interventions have been identified as cost-effective as highlighted above and the findings of this review can be used to help design future analyses in order to best demonstrate the cost-effectiveness of foot and ankle interventions. Levels of Evidence: Level III: Systematic Review of level III studies

scholarly journals Cost-Utility Analyses in Foot & Ankle Surgery

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0028
Author(s):  
Aditya Karhade ◽  
John Kwon
Keyword(s):  
Health Economic ◽  
Cost Effective ◽  
Cost Utility ◽  
Ankle Sprains ◽  
Foot And Ankle ◽  
Percentile Score ◽  
Ankle Surgery ◽  
Value Based Care ◽  
Economic Studies

Category: Other Introduction/Purpose: Orthopedic surgery lies at the forefront of the initiative to deliver value-based care. As a result, cost utility analyses have gained increased importance in the orthopedic literature. While other authors have previously reviewed the quality of US-based cost-utility analyses in orthopedic trauma, spine, sports, and arthroplasty, a similar analysis specific to foot and ankle surgery has not been performed. As such, the practicing foot and ankle surgeon does not yet have a comprehensive analysis of the available cost-utility analyses or the quality of the available evidence. The purpose of this study was to perform a systematic review of cost-utility analyses in foot and ankle surgery. Methods: A systematic review of foot and ankle studies was conducted to identify cost-utility based analyses published between 2000 and 2017. Of 687 studies screened by abstract, eight cost-utility foot and ankle studies were identified that met inclusion criteria and were scored by the Quality of Health Economic Studies instrument for overall quality. Results: Of the eight studies that met inclusion criteria, four were published in the U.S. Regarding topic, three examined end-stage arthritis, two examined diabetic foot ulcers, two examined ankle fractures and one examined ankle sprains. Cost-effective interventions identified by these studies included total ankle arthroplasty over ankle fusion or nonoperative treatment, adjunctive hyperbaric oxygen therapy for diabetic foot ulcers, suture button fixation over syndesmotic screws for unstable supination-external rotation type IV ankle fractures, and below knee cast and fracture boot immobilization over tubular bandages for acute severe ankle sprains respectively. The mean Quality of Health Economic Studies scores for these studies was 81.9 with interquartile range, 25th percentile score of 74.8 to 75th percentile score of 86. Conclusion: Despite the increasing focus on value-based care delivery, there are few foot and ankle cost-utility analyses in the current literature. Nonetheless, the quality of existing analyses is high as rated by the Quality of Health Economic Studies and certain interventions have been identified as cost-effective as highlighted above. The findings of this review can be used to help design future analyses in order to best demonstrate the cost-effectiveness of foot and ankle interventions.

scholarly journals Can polygenic risk scores contribute to cost-effective cancer screening? A systematic review

2021 ◽  
Author(s):  
Padraig Dixon ◽  
Edna Keeney ◽  
Jenny C Taylor ◽  
Sarah Wordsworth ◽  
Richard Martin
Keyword(s):  
Systematic Review ◽  
Health Economic ◽  
Cost Effectiveness ◽  
Cancer Screening ◽  
Cost Effective ◽  
Risk Scores ◽  
Polygenic Risk ◽  
The Cost ◽  
Economic Studies

Polygenic risk is known to influence susceptibility to cancer. The use of data on polygenic risk, in conjunction with other predictors of future disease status, may offer significant potential for preventative care through risk-stratified screening programmes. An important element in the evaluation of screening programmes is their cost-effectiveness. We undertook a systematic review of papers evaluating the cost-effectiveness of screening interventions informed by polygenic risk scores compared to more conventional screening modalities. We included papers reporting cost-effectiveness outcomes in the English language published as articles or uploaded onto preprint servers with no restriction on date, type of cancer or form of polygenic risk modelled. We excluded papers evaluating screening interventions that did not report cost-effectiveness outcomes or which had a focus on monogenic risk. We evaluated studies using the Quality of Health Economic Studies checklist. Ten studies were included in the review, which investigated three cancers: prostate (n=5), colorectal (n=3) and breast (n=2). All study designs were cost-utility papers implemented as Markov models (n=6) or microsimulations (n=4). Nine of ten papers scored highly (score >75 on a 0-100) scale) when assessed using the Quality of Health Economic Studies checklist. Eight of ten studies concluded that polygenic risk informed cancer screening was likely to be more cost-effective than alternatives. However, the included studies lacked robust external data on the cost of polygenic risk stratification, did not account for how very large volumes of polygenic risk data on individuals would be collected and used, did not consider ancestry-related differences in polygenic risk, and did not fully account for downstream economic sequalae stemming from the use of polygenic risk data in these ways. These topics merit attention in future research on how polygenic risk data might contribute to cost-effective cancer screening.

A Systematic Review of the Cost-Effectiveness of Recombinant Factor VIIa (rFVIIa) and Activated Prothrombin Complex Concentrate (aPCC) in the Treatment of Mild to Moderate Bleeding Episodes for Haemophilia Patients with Inhibitors

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 4678-4678
Author(s):  
Chris Knight ◽  
Anne Møller Danø ◽  
Tessa Kennedy-Martin
Keyword(s):  
Systematic Review ◽  
Cost Effectiveness ◽  
Factor Viia ◽  
Cost Effective ◽  
Primary Treatment ◽  
Cost Utility ◽  
Economic Consequences ◽  
Modelling Framework ◽  
The Cost

Abstract Objectives: Although haemophilia patients with inhibitors are rare, the clinical, humanistic and economic consequences associated with this disorder are considerable. The primary treatment for such patients is either rFVIIa or aPCC. The aim of this study was to identify, review and evaluate the quality of the published literature on the relative cost-effectiveness of rFVIIa and aPCC in treating haemophilia patients with inhibitors. Methods: The review concentrates on the model type, the model design, model assumptions, and results. Results: The results of this study suggest that rFVIIa may be the cost-effective alternative to treatment with aPCC due to the superior efficacy of rFVIIa and hence the avoidance of subsequent lines of treatment. In 7 of the 9 studies, rFVIIa had the lower average treatment cost. The adapted modelling framework is similar in all the economic models reviewed, suggesting clinical acceptability of the approach used. The estimates of efficacy varied between the models, especially for aPCC. The efficacy for aPCC derived from retrospective studies was lower than reported in the literature. Sensitivity analysis had been undertaken in the majority of the economic analyses and the results were found to be robust to realistic parameter variations. Only one of the studies was a cost-utility study, showing the lack of measuring health status within this area. The results showed the large impact appropriate treatment can have on the quality of life for haemophilia patients with inhibitors. Conclusions: Ideally, there should be a systematic approach to identifying the relevant data and the lack of data from relevant randomized head-to-head trials is a contributing factor to the variation in efficacy rates and average dosages assumed. However, this systematic review has shown that despite differences in the estimates of efficacy, average dosage required, and unit costs the overall results are robust and appear to favour rFVIIa as the cost-effectiveness treatment for haemophilia patients with inhibitors.

scholarly journals Systematic Review of Healthcare Economic Evaluation on Malaysia: An Overview on Cancer-Related Economic Studies

2018 ◽  
Vol 4 (Supplement 2) ◽  
pp. 76s-76s
Author(s):  
K.N. Ku Abdul Rahim ◽  
K. Hanin Farhana
Keyword(s):  
Systematic Review ◽  
Cervical Cancer ◽  
Health Economic ◽  
Economic Evaluation ◽  
Full Text ◽  
Evaluation Studies ◽  
Hpv Vaccination ◽  
Data Retrieval ◽  
Economic Studies

Background: In Malaysia, the inclusion of health economic evidence in health technology assessment improves the efficiency of the healthcare spending as it is used to promote the use of value for money in policy making. However, despite the potential of its use in ensuring the value of health technologies, its adoption is constrained by several factors. Limited number of researchers to produce economic evaluation, challenges in local data retrieval and lack of awareness and understanding of value-based concept among decision makers are among the most common limiting factors in Malaysia. Aim: To conduct a systematic review of economic evaluation studies in Malaysia and to explore and describe cancer-related economic evaluation studies in Malaysia. Methods: A comprehensive scientific electronic databases was conducted and the last search was done on 20 March 2017. Additional articles were identified from reviewing the references of retrieved articles and personal communication with the local higher institution representatives. Only full text of full and partial economic evaluations conducted in Malaysia were considered to be eligible for the review. Data extraction was performed by first author and verified by second author. Critical Appraisal Skills Program (CASP) checklist and Quality of Health Economic Studies (QHES) instrument was used as the quality appraisal tools in view of variability of the quality of conduct and reporting of economic evaluation. Results: Based on the evidence search, 1014 titles were retrieved from the scientific electronic databases. After articles selection, 39 full text articles were finally selected to be included in this review. Of these, eight studies (20.5%) are cancer-related economic evaluation. Five cost-utility analyses, two cost-effectiveness analyses and one cost-minimization analysis were conducted in Malaysia up to March 20, 2017. The studies are on HPV vaccination in preventing cervical cancer, early screening of cervical cancer, treatment using monoclonal antibody for colorectal cancer, targeted therapy in HER2+ breast cancer and antiemetic in chemotherapy induced nausea and vomiting. Among the interventions that were highly cost effective were screening strategies and HPV vaccination in prevention of cervical cancer as well as additional of granisetron as antiemetic regimens for chemotherapy-induced emesis. Conclusion: This review provides useful information on the overall scenario of economic evaluation in Malaysia, particularly on cancer which incur high financial impact to the healthcare system. Various type of analysis has been conducted in recent years which provide different findings and information such as the incremental value, local costs data, patient preference and economic burden. These information may be adopted by other researchers in conducting future economic evaluation by facilitating and accelerating the process of producing the evaluation.

scholarly journals Cost-Effectiveness of Therapist-Guided Internet-Based Cognitive Behavioral Therapy for Stress-Related Disorders: Secondary Analysis of a Randomized Controlled Trial (Preprint)

2019 ◽  
Author(s):  
Elin Lindsäter ◽  
Erland Axelsson ◽  
Sigrid Salomonsson ◽  
Fredrik Santoft ◽  
Brjánn Ljótsson ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Health Economic ◽  
Cost Effectiveness ◽  
Behavioral Therapy ◽  
Controlled Trial ◽  
Cost Effective ◽  
Cost Utility ◽  
Randomized Controlled ◽  
Remission Rates

BACKGROUND Stress-related disorders are associated with significant suffering, functional impairment, and high societal costs. Internet-based cognitive behavioral therapy (ICBT) is a promising treatment for stress-related disorders but has so far not been subjected to health economic evaluation. OBJECTIVE The objective of this study was to evaluate the cost-effectiveness and cost-utility of ICBT for patients with stress-related disorders in the form of adjustment disorder (AD) or exhaustion disorder (ED). We hypothesized that ICBT, compared with a waitlist control (WLC) group, would generate improvements at low net costs, thereby making it cost-effective. METHODS Health economic data were obtained in tandem with a randomized controlled trial of a 12-week ICBT in which patients (N=100) were randomized to an ICBT (n=50) or a WLC (n=50) group. Health outcomes and costs were surveyed pre- and posttreatment. We calculated incremental cost-effectiveness ratios (ICERs) based on remission rates and incremental cost-utility ratios (ICURs) based on health-related quality of life. Bootstrap sampling was used to assess the uncertainty of our results. RESULTS The ICER indicated that the most likely scenario was that ICBT led to higher remission rates compared with the WLC and was associated with slightly larger reductions in costs from pre- to posttreatment. ICBT had a 60% probability of being cost-effective at a willingness to pay (WTP) of US $0 and a 96% probability of being cost-effective at a WTP of US $1000. The ICUR indicated that ICBT also led to improvements in quality of life at no net societal cost. Sensitivity analyses supported the robustness of our results. CONCLUSIONS The results suggest that ICBT is a cost-effective treatment for patients suffering from AD or ED. Compared with no treatment, ICBT for these patients yields large effects at no or minimal societal net costs. CLINICALTRIAL ClinicalTrials.gov NCT02540317; https://clinicaltrials.gov/ct2/show/NCT02540317

scholarly journals Cost-Effectiveness of Therapist-Guided Internet-Based Cognitive Behavioral Therapy for Stress-Related Disorders: Secondary Analysis of a Randomized Controlled Trial

10.2196/14675 ◽  
2019 ◽  
Vol 21 (9) ◽  
pp. e14675
Author(s):  
Elin Lindsäter ◽  
Erland Axelsson ◽  
Sigrid Salomonsson ◽  
Fredrik Santoft ◽  
Brjánn Ljótsson ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Health Economic ◽  
Cost Effectiveness ◽  
Behavioral Therapy ◽  
Controlled Trial ◽  
Cost Effective ◽  
Cost Utility ◽  
Randomized Controlled ◽  
Remission Rates

Background Stress-related disorders are associated with significant suffering, functional impairment, and high societal costs. Internet-based cognitive behavioral therapy (ICBT) is a promising treatment for stress-related disorders but has so far not been subjected to health economic evaluation. Objective The objective of this study was to evaluate the cost-effectiveness and cost-utility of ICBT for patients with stress-related disorders in the form of adjustment disorder (AD) or exhaustion disorder (ED). We hypothesized that ICBT, compared with a waitlist control (WLC) group, would generate improvements at low net costs, thereby making it cost-effective. Methods Health economic data were obtained in tandem with a randomized controlled trial of a 12-week ICBT in which patients (N=100) were randomized to an ICBT (n=50) or a WLC (n=50) group. Health outcomes and costs were surveyed pre- and posttreatment. We calculated incremental cost-effectiveness ratios (ICERs) based on remission rates and incremental cost-utility ratios (ICURs) based on health-related quality of life. Bootstrap sampling was used to assess the uncertainty of our results. Results The ICER indicated that the most likely scenario was that ICBT led to higher remission rates compared with the WLC and was associated with slightly larger reductions in costs from pre- to posttreatment. ICBT had a 60% probability of being cost-effective at a willingness to pay (WTP) of US $0 and a 96% probability of being cost-effective at a WTP of US $1000. The ICUR indicated that ICBT also led to improvements in quality of life at no net societal cost. Sensitivity analyses supported the robustness of our results. Conclusions The results suggest that ICBT is a cost-effective treatment for patients suffering from AD or ED. Compared with no treatment, ICBT for these patients yields large effects at no or minimal societal net costs. Trial Registration ClinicalTrials.gov NCT02540317; https://clinicaltrials.gov/ct2/show/NCT02540317

scholarly journals Immunoglobulin Replacement Therapy is critical and cost-effective in increasing life expectancy and quality of life in patients suffering from Common Variable Immunodeficiency Disorders (CVID): A health-economic assessment

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0247941
Author(s):  
Philippe van Wilder ◽  
Irina Odnoletkova ◽  
Mehdi Mouline ◽  
Esther de Vries
Keyword(s):  
Health Economic ◽  
Cost Effectiveness ◽  
Diagnostic Delay ◽  
Cost Effective ◽  
Cost Utility ◽  
Life Years ◽  
Health Economic Model ◽  
Simulated Cohort ◽  
Common Variable

Background Common variable immunodeficiency disorders (CVID), the most common form of primary antibody deficiency, are rare conditions associated with considerable morbidity and mortality. The clinical benefit of immunoglobulin replacement therapy (IgGRT) is substantial: timely treatment with appropriate doses significantly reduces mortality and the incidence of CVID-complications such as major infections and bronchiectasis. Unfortunately, CVID-patients still face a median diagnostic delay of 4 years. Their disease burden, expressed in annual loss of disability-adjusted life years, is 3-fold higher than in the general population. Hurdles to treatment access and reimbursement by healthcare payers may exist because the value of IgGRT is poorly documented. This paper aims to demonstrate cost-effectiveness and cost-utility (on life expectancy and quality) of IgGRT in CVID. Methods and findings With input from a literature search, we built a health-economic model for cost-effectiveness and cost-utility assessment of IgGRT in CVID. We compared a mean literature-based dose (≥450mg/kg/4wks) to a zero-or-low dose (0 to ≤100 mg/kg/4wks) in a simulated cohort of adult patients from time of diagnosis until death; we also estimated the economic impact of diagnostic delay in this simulated cohort. Compared to no or minimal treatment, IgGRT showed an incremental benefit of 17 life-years (LYs) and 11 quality-adjusted life-years (QALYs), resulting in an incremental cost-effectiveness ratio (ICER) of €29,296/LY and €46,717/QALY. These results were robust in a sensitivity analysis. Reducing diagnostic delay by 4 years provided an incremental benefit of six LYs and four QALYs compared to simulated patients with delayed IgGRT initiation, resulting in an ICER of €30,374/LY and €47,495/QALY. Conclusions The health-economic model suggests that early initiation of IgGRT compared to no or delayed IgGRT is highly cost-effective. CVID-patients’ access to IgGRT should be facilitated, not only because of proven clinical efficacy, but also due to the now demonstrated cost-effectiveness.

A systematic review of economic evaluation in fecal microbiota transplantation

2020 ◽  
Vol 41 (4) ◽  
pp. 458-466 ◽  
Author(s):  
Thomas Stalder ◽  
Nathalie Kapel ◽  
Sophie Diaz ◽  
Frédéric Grenouillet ◽  
Stéphane Koch ◽  
...  
Keyword(s):  
Systematic Review ◽  
Fecal Microbiota Transplantation ◽  
Cost Effective ◽  
Fecal Microbiota ◽  
Cost Utility ◽  
Economic Evaluations ◽  
Measurement Tool ◽  
Eligibility Criteria ◽  
Cost Effective Treatment

AbstractBackground:Fecal microbiota transplantation (FMT) is an effective therapy in recurrent Clostridium difficile infection (rCDI). It is only recommended for this indication by European and American guidelines. Other indications of FMT are being studied, such as inflammatory bowel disease (IBD), and they have shown promising results.Objectives:To identify and review published FMT-related economic evaluations (EEs) to assess their quality and the economic impact of FMT in the treatment of these diseases.Data sources:The systematic literature research was conducted in both PubMed and Cochrane to identify EEs published before July 1, 2019.Study eligibility criteria:Articles were included if they concerned FMT (whatever the disease and its line of treatment), if they reported full or partial EEs, and if they were written in English. Articles were excluded if they did not concern FMT; if they did not report an EE; or if they were a systematic review, editorial, comment, letter to the editor, practice point, or poster.Methods:A measurement tool, AMSTAR, was used to optimize the quality of this systematic review. Based on the CHEERS checklist, data were identified and extracted from articles. The quality of each EE was assessed using the Drummond checklist.Results:Overall, 9 EEs were included: all EEs were full evaluations and 8 were cost-utility analyses (CUAs). All EEs had a Drummond score ≥ 7, which indicated high quality. All CUAs related to rCDI and IBD concluded that FMT was cost-effective compared with other reference treatments, at a threshold ≤$50,000/QALY. One EE about initial CDI showed that FMT was dominated by metronidazole.Conclusions:Despite a limited number of EEs, FMT seems to be a promising and cost-effective treatment for rCDI. More EE studies on other diseases like IBD are necessary to address FMT efficiency for new indications. Therefore, our systematic review provides a framework for healthcare decision making.

scholarly journals Cost Analysis in Shoulder Surgery: A Systematic Review

2020 ◽  
Vol 8 (5) ◽  
pp. 232596712091712
Author(s):  
Thomas Tischer ◽  
Robert Lenz ◽  
Jochen Breinlinger-O’Reilly ◽  
Christoph Lutter
Keyword(s):  
Systematic Review ◽  
Health Economic ◽  
Cost Effectiveness ◽  
Rotator Cuff ◽  
Cost Analysis ◽  
Total Shoulder Arthroplasty ◽  
Cost Effective ◽  
Shoulder Surgery ◽  
Rotator Cuff Tears

Background: Cost analysis studies in medicine were uncommon in the past, but with the rising importance of financial considerations, it has become increasingly important to use available resources most efficiently. Purpose: To analyze the current state of cost-effectiveness analyses in shoulder surgery. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the current literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All full economic analyses published since January 1, 2010 and including the terms “cost analysis” and “shoulder” were checked for usability. The methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence and established health economic criteria (Quality of Health Economic Studies [QHES] instrument). Results: A total of 34 studies fulfilled the inclusion criteria. Compared with older studies, recent studies were of better quality: one level 1 study and eight level 2 studies were included. The mean QHES score was 87 of 100. The thematic focus of most studies (n = 13) was rotator cuff tears, with the main findings as follows: (1) magnetic resonance imaging is a cost-effective imaging strategy, (2) primary (arthroscopic) rotator cuff repair (RCR) with conversion to reverse total shoulder arthroplasty in case of failure is the most cost-effective strategy, (3) the platelet-rich plasma augmentation of RCR seems not to be cost-effective, and (4) the cost-effectiveness of double-row RCR remains unclear. Other studies included shoulder instability (n = 3), glenohumeral osteoarthritis (n = 3), proximal humeral fractures (n = 4), subacromial impingement (n = 4), and other shoulder conditions (n = 7). Conclusion: Compared with prior studies, the quality of recently available studies has improved significantly. Current studies could help decision makers to appropriately and adequately allocate resources. The optimal use of financial resources will be of increasing importance to improve medical care for patients. However, further studies are still necessary.

scholarly journals Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence

BMJ Open ◽  
2020 ◽  
Vol 10 (1) ◽  
pp. e032204 ◽  
Author(s):  
Mark G Pritchard ◽  
Jacqueline Murphy ◽  
Lok Cheng ◽  
Roshni Janarthanan ◽  
Andrew Judge ◽  
...  
Keyword(s):  
Systematic Review ◽  
Health Economic ◽  
Cost Effectiveness ◽  
Usual Care ◽  
Enhanced Recovery ◽  
Cost Effective ◽  
Cost Utility ◽  
Risk Of Bias ◽  
Enhanced Recovery Pathways ◽  
Recovery Pathways

AbstractObjectivesTo assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work.DesignSystematic review of cost–utility analyses.Data sourcesOvid MEDLINE, Embase, the National Health Service Economic Evaluations Database and EconLit, January 2000 to August 2019.Eligibility criteriaEnglish-language peer-reviewed cost–utility analyses of enhanced recovery pathways, or components of one, compared with usual care, in patients having total hip or knee arthroplasties for osteoarthritis.Data extraction and synthesisData extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria list, the International Society for Pharmacoeconomics and Outcomes Research and Assessment of the Validation Status of Health-Economic decision models tools; for trial-based studies the Cochrane Collaboration’s tool to assess risk of bias. No quantitative synthesis was undertaken.ResultsWe identified 17 studies: five trial-based and 12 model-based studies. Two analyses evaluated entire enhanced recovery pathways and reported them to be cost-effective compared with usual care. Ten pathway components were more effective and cost-saving compared with usual care, three were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation.ConclusionsConsistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies.PROSPERO registration numberCRD42017059473.

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