This is the author’s version of a work that was submitted/accepted for pub-lication in the following source:

Frossard, Laurent A., Merlo, Gregory, Quincey, Tanya, Berg, Debra, &Burkett, Brendan(2015)Cost-effectiveness of bone-anchored prosthesis: the Queensland experi-ence. InAustralian Orthotic Prosthetic Association (AOPA) Congress, 25 Septem-ber 2015, Adelaide, S.A.

This file was downloaded from: https://eprints.qut.edu.au/87958/

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Cost-effectiveness of bone-anchored prosthesis: the Queensland experience

2015. Australian Orthotic Prosthetic Association (AOPA) Congress Page 1 of 4

Cost-effectiveness of bone-anchored prosthesis: the Queensland experience

Laurent Frossard(1,2)

, Gregory Merlo(1,3)

, Tanya Quincey(4)

, Debra Berg(4)

, Brendan Burkett(2)

(1)

Queensland University of Technology, Brisbane, QLD, Australia (2)

University of the Sunshine Coast, Maroochydore, QLD, Australia (3)

Australian Centre for Health Services and Innovation, QLD, Australia (4)

Queensland Health, Queensland Artificial Limb Service, QLD, Australia

Frossard L, Merlo G, Quincey T, Berg D, Burkett B. Cost-effectiveness of bone-anchored

prosthesis: the Queensland experience. Australian Orthotic Prosthetic Association (AOPA)

Congress. 2015. Adelaide, Australia. p 13

Biography

Dr Laurent Frossard is currently an

adjunct Professor of Biomechanics at the

Queensland University of Technology

(QUT) and University of Sunshine Coast

(USC) as well as the Chief Scientist Officer

at YourResearchProject. As project leader

and active researcher, his expertise in

Biomechanics relates to the development of

biomechanical tools and improvement of

basic knowledge of the locomotion and

rehabilitation of individuals with lower limb

loss fitted with osseointegrated implant and

socket. He is one of the very few

independent experts in the clinical benefits

of bone-anchorage prostheses. His academic

track record includes over 120 publications,

multiple grants, several supervisions of

postgraduate students and international

collaborations (More information:

www.LaurentFrossard.com)

Summary

Individuals with limb amputation

fitted with conventional socket-suspended

prostheses often experience socket-related

discomfort leading to a significant decrease

in quality of life. Bone-anchored prostheses

are increasingly acknowledged as viable

alternative method of attachment of artificial

limb. In this case, the prosthesis is attached

directly to the residual skeleton through a

percutaneous fixation.

To date, a few osseointegration

fixations are commercially available.

Several devices are at different stages of

development particularly in Europe and the

US. [1-15]

Clearly, surgical procedures are

currently blooming worldwide. Indeed,

Australia and Queensland, in particular,

have one of the fastest growing populations.

Previous studies involving either

screw-type implants or press-fit fixations for

bone-anchorage have focused on

biomechanics aspects as well as the clinical

benefits and safety of the procedure. [16-25]

In principle, bone-anchored

prostheses should eliminate lifetime

expenses associated with sockets and,

consequently, potentially alleviate the

financial burden of amputation for

governmental organizations.

Unfortunately, publications focusing

on cost-effectiveness are sparse. In fact,

only one study published by Haggstrom et al

(2012), reported that “despite significantly

fewer visits for prosthetic service the annual

mean costs for osseointegrated prostheses

were comparable with socket-suspended

prostheses”.[26]

Consequently, governmental

organizations such as Queensland Artificial

Limb Services (QALS) are facing a number

of challenges while adjusting financial

assistance schemes that should be fair and

Cost-effectiveness of bone-anchored prosthesis: the Queensland experience

2015. Australian Orthotic Prosthetic Association (AOPA) Congress Page 2 of 4

equitable to their clients fitted with bone-

anchored prostheses.

Clearly, more scientific evidence

extracted from governmental databases is

needed to further consolidate the analyses of

financial burden associated with both

methods of attachment (i.e., conventional

sockets prostheses, bone-anchored

prostheses).

The purpose of the presentation will be

to share the current outcomes of a cost-

analysis study lead by QALS. The specific

objectives will be:

To outline methodological avenues

to assess the cost-effectiveness of

bone-anchored prostheses compared

to conventional sockets prostheses,

To highlight the potential obstacles

and limitations in cost-effectiveness

analyses of bone-anchored

prostheses,

To present cohort results of a cost-

effectiveness (QALY vs cost)

including the determination of fair

Incremental cost-effectiveness

Ratios (ICER) as well as cost-

benefit analysis focusing on the

comparing costs and key outcome

indicators (e.g., QTFA, TUG,

6MWT, activities of daily living)

over QALS funding cycles for both

methods of attachment.

References

1. Kang, N.V., D. Morritt, C.

Pendegrass, and G. Blunn, Use of

ITAP implants for prosthetic

reconstruction of extra-oral

craniofacial defects. J Plast Reconstr

Aesthet Surg, 2013. 66(4): p. 497-

505.

2. Kang, N.V., C. Pendegrass, L.

Marks, and G. Blunn,

Osseocutaneous integration of an

intraosseous transcutaneous

amputation prosthesis implant used

for reconstruction of a transhumeral

amputee: Case report. The Journal of

Hand Surgery, 2010. 35(7): p. 1130-

1134.

3. Pendegrass, C., C. Fontaine, and G.

Blunn, Intraosseous transcutaneous

amputation prostheses vs dental

implants: a comparison between

keratinocyte and gingival epithelial

cell adhesion in vitro. Journal of

Bone & Joint Surgery, British

Volume, 2012. 94-B(SUPP

XXXVI): p. 10.

4. Aschoff, H.H., R.E. Kennon, J.M.

Keggi, and L.E. Rubin,

Transcutaneous, distal femoral,

intramedullary attachment for above-

the-knee prostheses: an endo-exo

device. J Bone Joint Surg Am, 2010.

92 Suppl 2(Supplement 2): p. 180-6.

5. Aschoff, H.-H. and R. McGough,

The Endo-Exo Femoral Prosthesis: a

new rehabilitation concept following

above knee amputation. Journal of

Bone & Joint Surgery, British

Volume, 2012. 94-B(SUPP

XXXIX): p. 77.

6. Hillock, R., J. Keggi, R. Kennon, E.

McPherson, T. Clyburn, D. Brazil,

and T. McTighe, A Global

Collaboration - Osteointegration

Implant (OI) for Transfemoral

Amputation - Case Report.

Reconstructive review - Joint

Implant Surgery & Research

Foundation, 2013. 3(2): p. 50-54.

7. Rubin, L., L. Kennon, J. Keggi, and

H. Aschoff, Surgical management

of trans-femoral amputation with a

transcutaneous, press-fit distal

femoral intra-medullary device:

analysis with minimum 2 year

follow-up. Journal of Bone & Joint

Surgery, British Volume, 2012. 94-

B(SUPP XXI): p. 95.

8. Van de Meent, H., M.T. Hopman,

and J.P. Frolke, Walking ability and

Cost-effectiveness of bone-anchored prosthesis: the Queensland experience

2015. Australian Orthotic Prosthetic Association (AOPA) Congress Page 3 of 4

quality of life in subjects with

transfemoral amputation: a

comparison of osseointegration with

socket prostheses. Arch Phys Med

Rehabil, 2013. 94(11): p. 2174-2178.

9. Tomaszewski, P.K., B. Lasnier, G.

Hannink, G.J. Verkerke, and N.

Verdonschot, Experimental

assessment of a new direct fixation

implant for artificial limbs. J Mech

Behav Biomed Mater, 2013. 21: p.

77-85.

10. Tomaszewski, P.K., M. van Diest,

S.K. Bulstra, N. Verdonschot, and

G.J. Verkerke, Numerical analysis of

an osseointegrated prosthesis

fixation with reduced bone failure

risk and periprosthetic bone loss. J

Biomech, 2012. 45(11): p. 1875-80.

11. Tomaszewski, P.K., N. Verdonschot,

S.K. Bulstra, J.S. Rietman, and G.J.

Verkerke, Simulated bone

remodeling around two types of

osseointegrated implants for direct

fixation of upper-leg prostheses. J

Mech Behav Biomed Mater, 2012.

15(0): p. 167-75.

12. Tomaszewski, P.K., N. Verdonschot,

S.K. Bulstra, and G.J. Verkerke, A

New Osseointegrated Fixation

Implant for Amputated Patients.

Journal of Biomechanics, 2012.

45(0): p. S322.

13. Jeyapalina, S., J.P. Beck, K.N.

Bachus, O. Chalayon, and R.D.

Bloebaum, Radiographic Evaluation

of Bone Adaptation Adjacent to

Percutaneous Osseointegrated

Prostheses in a Sheep Model. Clin

Orthop Relat Res, 2014: p. 1-12.

14. Shelton, T.J., J.P. Beck, R.D.

Bloebaum, and K.N. Bachus,

Percutaneous osseointegrated

prostheses for amputees: Limb

compensation in a 12-month ovine

model. J Biomech, 2011. 44(15): p.

2601-6.

15. Shevtsov, M.A., O.V. Galibin, N.M.

Yudintceva, M.I. Blinova, G.P.

Pinaev, A.A. Ivanova, O.N.

Savchenko, D.N. Suslov, I.L.

Potokin, E. Pitkin, G. Raykhtsaum,

and M.R. Pitkin, Two-stage

implantation of the skin- and bone-

integrated pylon seeded with

autologous fibroblasts induced into

osteoblast differentiation for direct

skeletal attachment of limb

prostheses. J Biomed Mater Res A,

2014. 102(9): p. 3033-48.

16. Frossard, L., D.L. Gow, K. Hagberg,

N. Cairns, B. Contoyannis, S. Gray,

R. Branemark, and M. Pearcy,

Apparatus for monitoring load

bearing rehabilitation exercises of a

transfemoral amputee fitted with an

osseointegrated fixation: a proof-of-

concept study. Gait Posture, 2010.

31(2): p. 223-8.

17. Frossard, L., K. Hagberg, E.

Haggstrom, and R. Branemark,

Load-relief of walking aids on

osseointegrated fixation: instrument

for evidence-based practice. IEEE

Trans Neural Syst Rehabil Eng,

2009. 17(1): p. 9-14.

18. Frossard, L., K. Hagberg, E.

Häggström, D.L. Gow, R.

Brånemark, and M. Pearcy,

Functional Outcome of Transfemoral

Amputees Fitted With an

Osseointegrated Fixation: Temporal

Gait Characteristics. JPO Journal of

Prosthetics and Orthotics, 2010.

22(1): p. 11-20.

19. Frossard, L., N. Stevenson, J.

Smeathers, E. Haggstrom, K.

Hagberg, J. Sullivan, D. Ewins, D.L.

Gow, S. Gray, and R. Branemark,

Monitoring of the load regime

applied on the osseointegrated

fixation of a trans-femoral amputee:

a tool for evidence-based practice.

Cost-effectiveness of bone-anchored prosthesis: the Queensland experience

2015. Australian Orthotic Prosthetic Association (AOPA) Congress Page 4 of 4

Prosthet Orthot Int, 2008. 32(1): p.

68-78.

20. Frossard, L., N. Stevenson, J.

Smeathers, D. Lee Gow, S. Gray, J.

Sullivan, C. Daniel, E. Häggström,

K. Hagberg, and R. Brånemark,

Daily activities of a transfemoral

amputee fitted with osseointegrated

fixation: continuous recording of the

loading for an evidence-based

practice. Kinesitherapie Revue,

2006. 6(56-57): p. 53-62.

21. Frossard, L., R. Tranberg, E.

Haggstrom, M. Pearcy, and R.

Branemark, Fall of a transfemoral

amputee fitted with osseointegrated

fixation: loading impact on

residuum. Gait & Posture, 2009.

30(Supplement 2): p. S151-S152.

22. Frossard, L.A., R. Tranberg, E.

Haggstrom, M. Pearcy, and R.

Branemark, Load on osseointegrated

fixation of a transfemoral amputee

during a fall: loading, descent,

impact and recovery analysis.

Prosthet Orthot Int, 2010. 34(1): p.

85-97.

23. Lee, W., L. Frossard, K. Hagberg, E.

Haggstrom, and R. Brånemark,

Kinetics analysis of transfemoral

amputees fitted with osseointegrated

fixation performing common

activities of daily living. Clinical

Biomechanics, 2007. 22(6): p. 665-

673.

24. Lee, W.C., L.A. Frossard, K.

Hagberg, E. Haggstrom, D.L. Gow,

S. Gray, and R. Branemark,

Magnitude and variability of loading

on the osseointegrated implant of

transfemoral amputees during

walking. Med Eng Phys, 2008.

30(7): p. 825-833.

25. Vertriest, S., P. Coorevits, K.

Hagberg, R. Branemark, E.

Haggstrom, G. Vanderstraeten, and

L. Frossard, Static load bearing

exercises of individuals with

transfemoral amputation fitted with

an osseointegrated implant:

reliability of kinetic data. IEEE

Trans Neural Syst Rehabil Eng,

2015. 23(3): p. 423-30.

26. Haggstrom, E.E., E. Hansson, and K.

Hagberg, Comparison of prosthetic

costs and service between

osseointegrated and conventional

suspended transfemoral prostheses.

Prosthet Orthot Int, 2013. 37(2): p.

152-60.

Laurent Frossard (1,2), Gregory Merlo (1,3), Tanya Quincey (4), Debra Berg (4), Brendan Burkett (2)

Adelaide, Australia – 25/09/2015

(1) Queensland University of Technology, Brisbane, QLD, Australia

(2) University of the Sunshine Coast, Maroochydore, QLD, Australia

(3) Australian Centre for Health Services and Innovation

(4) Queensland Artificial Limb Service, QLD, Australia

Cost-effectiveness of bone-anchored prosthesis: the Queensland experience

www.LaurentFrossard.com

The Australian Orthotic Prosthetic Association (AOPA) Congress 2015

Background

[1] http://opraosseointegration.com/[2] Al Muderis et Al, ISPO-2012, Al Muderis et Al, Personal communication, 2015[3] Hillock et Al, Joint Implant Surgery & Research Foundation. 2013;3:50-54

Nearly ¼ of the population

worldwide live in Australia

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Background

[1] Al Muderis et Al, ISPO-2012, Al Muderis et Al, Personal communication, 2015

Background

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Background

Background

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Background

Background

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Funding organizations are facing a number of challenges while adjusting financial assistance

schemes that should be fair and equitable to their clients fitted with bone-anchored prostheses

Challenge

Government Insurance Etc…

State

Federal National Disability Insurance Scheme (NDIS) & DVA

Queensland Artificial Limb Services (QALS)QLD

WorkCover

Challenge

Queensland Artificial Limb Services (QALS)State QLD

Funding organizations are facing a number of challenges while adjusting financial assistance

schemes that should be fair and equitable to their clients fitted with bone-anchored prostheseseP

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Queensland Artificial Limb Services (QALS)

Challenge

Funding organizations are facing a number of challenges while adjusting financial assistance

schemes that should be fair and equitable to their clients fitted with bone-anchored prostheses

Queensland Artificial Limb Services (QALS)QLD2013

Research project

will

Cost-effectiveness analysis

Literature review

Haggstrom, E.E., E. Hansson, and K. Hagberg, Comparison of prosthetic costs and service between osseointegrated and conventional suspended transfemoral prostheses. Prosthet Orthot Int, 2013. 37(2): p. 152-60.

Cost-effectiveness analysis

2013

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Literature review

Cost-effectiveness analysis

Fewer QALYs

More QALYs

Higher cost

Lower cost

ICER2013

Literature review

Cost-effectiveness analysis

2013

Fewer QALYs

More QALYs

Higher cost

Lower cost

ICER

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Purpose

Cost-effectiveness analysis

2014

Fewer QALYs

More QALYs

Higher cost

Lower cost

ICER

Purpose

Cost-effectiveness analysis

2015

Fewer QALYs

More QALYs

Higher cost

Lower cost

ICER

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Purpose

Cost-effectiveness analysis

2015

Purpose

Cost-effectiveness analysis

2015

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Methods – Participants - Selection

QALS clients N=2,700 between 1998 and 2015

TFA N=540 (20%)

TTA N=1,520 (57%)

OtherN=620 (23%)

Methods – Participants - Selection

QALS clients N=2,700 between 1998 and 2015

TFA N=540 (20%)

TTA N=1,520 (57%)

OtherN=620 (23%)

SocketN=522 (20%)

BAPN=12 (1%)

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Methods – Participants - Selection

QALS DVAN=4

QALS MixtN=2

QALS onlyN=6

QALS clients N=2,700 between 1998 and 2015

TFA N=540 (20%)

TTA N=1,520 (57%)

OtherN=620 (23%)

SocketN=522 (20%)

BAPN=12 (1%)

Methods – Participants - Selection

QALS DVAN=4

QALS MixtN=2

QALS onlyN=6

QALS clients N=2,700 between 1998 and 2015

TFA N=540 (20%)

TTA N=1,520 (57%)

OtherN=620 (23%)

SocketN=522 (20%)

BAPN=12 (1%)

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Methods – Participants - Selection

Clients with socket Clients with fixationQALS only

Secondary attachmentSocket before

Methods – Participants - Selection

�c

N = 12

Clients with socket Clients with fixation

N = 12

N = 16N = 16

N = 6 N = 6

N = 6

N = 0

N = 6

N = 0

QALS only

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Methods – Data collection

Clients with socket Clients with fixation

Y1 Date of last voucher

Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6Y1 Y2 Y3 Y4 Y5 Y6 S1

Y1 Y2 Y3 Y4 Y5 Y6S1

6 years 6 years

QALS only

11 12 13 14 15 16

11 12 13 14 15 16Y1 Y2 Y3 Y4 Y5 Y6

Methods – Data collection

Y1

Clients with socket Clients with fixation

Date of last voucher

Y2 Y3 Y4 Y5 Y6

S1

S1

6 years 2-3 years

QALS only

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Methods – Calculation ICER

Cost-utility analysis

Fewer QALYs

More QALYs

Higher cost

Lower cost

ICER

Methods – Calculation ICER - QALYs

Cost-utility analysis

Fewer QALYs

More QALYs

Higher cost

Lower cost

ICER

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Methods – Calculation ICER - QALYs

SF36

Mapping algorithm

EQ 5D

QALYs

Methods – Calculation ICER - Costs

Cost-utility analysis

Fewer QALYs

More QALYs

Higher cost

Lower cost

ICER

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Methods – Calculation ICER - Costs

Case 0

Methods – Calculation ICER - Costs

Case 0

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Methods – Calculation ICER - Costs

Methods – Calculation ICER - Costs

Cost with socket Cost with fixation

Y1 Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6Y1 Y2 Y3 Y4 Y5 Y6 S1

Y1 Y2 Y3 Y4 Y5 Y6S1

6 years 6 years

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Methods – Calculation ICER - Costs

Cost with socket Cost with fixation

Y1 Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6Y1 Y2 Y3 Y4 Y5 Y6 S1

Y1 Y2 Y3 Y4 Y5 Y6S1

6 years 6 years

Real

Methods – Calculation ICER - Costs

Cost with socket Cost with fixation

Y1 Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6Y1 Y2 Y3 Y4 Y5 Y6 S1

Y1 Y2 Y3 Y4 Y5 Y6S1

6 years 6 years

Real

Projected

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Methods – Calculation ICER - Costs

Cost with socket Cost with fixation

Y1 Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6Y1 Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6

6 years 6 years

Real

Projected

Accuracy

÷

=

Methods – Calculation ICER - Costs

Cost with socket Cost with fixation

Y1 Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6Y1 Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6

6 years 6 years

Real

Projected

+

=

1 Cycle

Total cost

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Methods – Calculation ICER - Costs

Cost with socket Cost with fixation

Y1 Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6Y1 Y2 Y3 Y4 Y5 Y6

Y1 Y2 Y3 Y4 Y5 Y6

12 years 12 years

Real

Projected

+

=

2 Cycles

Total cost

X

2

Results

$15K / cycle

1.71 years

ICER

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Results

Results

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Results

Results

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Results

Results

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Discussion - Outcomes

$14,340

$8,587

$30,000

$0

$625

Discussion - Outcomes

$14,340

$8,587

$30,000

$0

$625

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Discussion - Limitation

• Small sample size

• Matched (N=6)More case series

than study!

Discussion - Limitation

• Small sample size

o Matched (N=6)• Moderate to low accuracy in cost estimation

o Timelineo Short history of surgery

• Sensibility of SF36 data o Immediate historyo Adverse eventseP

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Discussion – Future directions• For TFAs and TTAs

o Increase sample size o Monitoring up coming years (�accuracy)o Look at cost-benefits:

� Functional outcomes (TUG, 6MWT)� Activity of daily living (SenseWear)� Return to work

o Study ICER for OI as primary intervention

Most unlikely

Conclusion

Fewer QALYs

More QALYs

Higher cost

Lower cost

Likely

ICER

Very unlikely Likely

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AcknowledgmentsLaurent and Brendan would like to express their gratitude to :

• Debra Berg• Tanya Quincey

• Danielle Formosa• Barry Leech• Michele Mahoney• Luke Lorenzin• Munjed Al Muderis

Laurent Frossard (1,2), Gregory Merlo (1,3), Tanya Quincey (4), Debra Berg (4), Brendan Burkett (2)

Adelaide, Australia – 25/09/2015

(1) Queensland University of Technology, Brisbane, QLD, Australia

(2) University of the Sunshine Coast, Maroochydore, QLD, Australia

(3) Australian Centre for Health Services and Innovation

(4) Queensland Artificial Limb Service, QLD, Australia

Cost-effectiveness of bone-anchored prosthesis: the Queensland experience

www.LaurentFrossard.com

The Australian Orthotic Prosthetic Association (AOPA) Congress 2015eP

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Websitewww.laurentfrossard.com

www.YourResearchProject.com

LinkedInwww.ca.linkedin.com/pub/laurent-frossard/5/4b4/b59/

Google+www.plus.google.com/#113083134851353167716/about

Facebookwww.facebook.com/YourResearchProject

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