0
March 20, 1996, Vol 275, No. 11 >
ARTICLE | March 20, 1996

A Cost-effectiveness Analysis of Total Hip Arthroplasty for Osteoarthritis of the Hip FREE

Rowland W. Chang, MD, MPH; James M. Pellissier, PhD; Gordon B. Hazen, PhD
[+] Author Affiliations

Reprint requests to the Northwestern University Multipurpose Arthritis and Musculoskeletal Diseases Center, 303 E Chicago Ave, Mail Stop W121, Chicago, IL 60611 (Dr Chang).


JAMA. 1996;275(11):858-865. doi:10.1001/jama.1996.03530350040032
Text Size: A A A
Published online
Article
References

Objective.  —To quantify the trade-off between the expected increased short- and long-term costs and the expected increase in quality-adjusted life expectancy (QALE) associated with total hip arthroplasty (THA) for persons with functionally significant hip osteoarthritis.

Design.  —A cost-effectiveness study was performed from the societal perspective by constructing stochastic tree, decision analytic models designed to estimate lifetime functional outcomes and costs of THA and nonoperative managements.

Main Outcome Measures.  —A modified four-state American College of Rheumatology functional status classification was used to measure effectiveness. These functional classes were assigned utility values to allow the relative effectiveness of THA to be expressed in quality-adjusted life years (QALYs). Lifetime costs included costs associated with primary and potential revision surgeries and long-term care costs associated with the functionally dependent class.

Data Used in the Cost-effectiveness Model.  —Probability and incidence rate data were summarized from the literature. The THA hospital cost data were obtained from local teaching hospitals' cost accounting systems. Estimates of recurring medical costs for functionally significant hip osteoarthritis and for custodial care were derived from the literature.

Results.  —The THA cost-effectiveness ratio increases with age and is higher for men than for women. In the base-case scenario for 60-year-old white women who have functionally significant but not dependent hip osteoarthritis, the model predicts that THA is cost saving because of the high costs of custodial care associated with dependency due to worsening hip osteoarthritis and that the procedure increases QALE by about 6.9 years. In the base-case scenario for men aged 85 years and older, the average lifetime cost associated with THA is $9100 more than nonoperative management, with an average increase in QALE of about 2 years. Thus, the THA cost-effectiveness ratio for men aged 85 years and older is $4600 per QALY gained, less than that of procedures intended to extend life such as coronary artery bypass surgery or renal dialysis. Worst-case analysis suggests that THA remains minimally cost-effective for this oldest age category ($80 000/QALY) even if probabilities, rates, utilities, costs, and the discount rate are simultaneously varied to extreme values that bias the analysis against surgery.

Conclusions.  —For persons with hip osteoarthritis associated with significant functional limitation, THA can be cost saving or, at worst, cost-effective in improving QALE when both short- and long-term outcomes are considered. Further research is needed to determine whether this procedure is actually being used in this cost-effective manner, especially in older age categories.(JAMA. 1996;275:858-865)

REFERENCES

1 +
Harris WH, Sledge CB.  Total hip and total knee replacement. N Engl J Med. 1990;;323:725-731.
2 +
NIH Consensus Development Panel on Total Hip Replacement.  Total hip replacement. JAMA . 1995;;273:1950-1956.
3 +
Friedman B, Elixhauser A.  Increased use of an expensive, elective procedure: total hip replacements in the 1980s. Med Care . 1993;;31:581-596.
4 +
Liang MH, Cullen KE, Larson MG, et al.  Cost-effectiveness of total joint.arthroplasty in osteoarthritis. Arthritis Rheum . 1986;;29:937-943.
5 +
Laupacis A, Bourne R, Rorabeck C, et al.  Costs of elective total hip arthroplasty during the first year. J Arthroplasty . 1994;;9:481-487.
6 +
Steinbrocker 0, Traeger CH, Batterman RC.  Therapeutic criteria in rheumatoid arthritis. JAMA . 1949;;140:659-662.
7 +
Hazen GB.  Stochastic trees: a new technique for temporal medical decision modeling. Med Decis Making . 1992;;12:163-178.
8 +
Hazen GB.  Factored stochastic trees: a tool for solving complex temporal medical decision making problems. Med Decis Making . 1993;;13:227-236.
9 +
Cox DR.  A use of complex probabilities in the theory of stochastic processes. Proc Camb Phil Soc . 1955;;51:313-319.
10 +
Pellissier JM, Hazen GB.  Coxian mortality factors for stochastic tree modelling. Med Decis Making . 1994;;14:439. Abstract.
11 +
 Mortality, part A.  In: Vital Statistics of the United States . Hyattsville, Md: US Dept of Health and Human Services; 1993;;2:12.
12 +
Harris WH.  Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment and end-result stage using a new method of result evaluation. J Bone Joint Surg Am . 1969;;51A:737-755.
13 +
Kavanagh BF, Fitzgerald RH Jr.  Clinical and roentgenographic assessment of total hip arthroplasty: a new hip score. Clin Orthop . 1985;;193:133-140.
14 +
Kavanagh BF, Dewitz MA, Ilstrup DM, Stauffer RN, Coventry MB.  Charnley total hip arthroplasty with cement: fifteen-year results. J Bone Joint Surg Am . 1989;;71A:1496-1503.
15 +
Kavanagh BF, Fitzgerald RH Jr.  Multiple revisions for failed total hip arthroplasty not associated with infection. J Bone Joint Surg Am . 1987;; 69A:1144-1149.
16 +
Sanzen L, Carlsson AS, Josefsson G, Lindberg LT.  Revision operations on infected total hip arthroplasties. Clin Orthop Rel Res . 1988;;229:165-172.
17 +
White RH, McCurdy SA, Marder RA.  Early morbidity after total hip replacement: rheumatoid arthritis versus osteoarthritis. J Gen Intern Med . 1990;;5:304-309.
18 +
Coventry MB, Beckenbaugh RD, Nolan DR, Ilstrup DM.  2012 total hip arthroplasties: a study of postoperative causes and early complications. J Bone Joint Surg Am . 1974;;56A:273-284.
19 +
Orthopedic Knowledge Update, Volume IV . Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1993;.
20 +
Booth RE, Balderston RA, Rothman RH. Total Hip Arthroplasty . Philadelphia, Pa: WB Saunders Co; 1988;.
21 +
Beckenbaugh R, Ilstrup DM.  Total hip arthroplasty: a review of three hundred thirty-three cases with long follow-up. J Bone Joint Surg Am . 1978;; 60A:306-313.
22 +
Eftekhar NS, Tzitzikalakis GI.  Failures and reoperations following low-friction arthroplasty of the hip. Clin Orthop . 1986;;211:65-78.
23 +
Herberts P, Ahnfelt L, Malchau M, Strömberg C, Andersson GBJ.  Multicenter clinical trials and their value in assessing total joint arthroplasty. Clin Orthop . 1989;;249:48-55.
24 +
Schulte KR, Callaghan JJ, Kelley SS, Johnston RC.  The outcome of Charnley total hip arthroplasty with cement after a minimum twenty-year follow-up. J Bone Joint Surg Am . 1993;;75A:961-975.
25 +
Schutzer SF, Harris WH.  Deep-wound infection after total hip replacement under contemporary aseptic conditions. J Bone Joint Surg Am . 1988;;70A:724-727.
26 +
Hunter GA, Welsh RP, Cameron HU, Bailey WH.  The results of revision total hip arthroplasty. J Bone Joint Surg Br . 1979;;61B:419-421.
27 +
Jones JM.  Revisional total hip replacement for failed Ring arthroplasty. J Bone Joint Surg Am . 1979;;61A:1029-1034.
28 +
Hoogland T, Razzano CD, Marks KE, Wilde AH.  Revision of Mueller total hip arthroplasties. Clin Orthop . 1981;;161:180-185.
29 +
Anderson MA, Murray WR.  Revision surgery for failed total hip arthroplasty. Orthop Trans . 1981;; 5:75.
30 +
Cameron HU, Fedorkow DM.  The early results of the Bateman single assemble total hip used as a revision prosthesis. Acta Orthop Belg . 1981;;47:49-53.
31 +
Pellici PM, Wilson PD Jr, Sledge CB, Salvati EA, Ranawat CS, Poss R.  Revision total hip arthroplasty. Clin Orthop . 1982;;170:34-41.
32 +
Gustilo RB, Pasternak HS.  Revision total hip arthroplasty with titanium ingrowth prosthesis and bone grafting for failed cemented femoral component loosening. Clin Orthop . 1988;;235:111-119.
33 +
Retpen JB, Varmarken J, Steen Jensen J.  Survivorship analysis of failure pattern after revision total hip arthroplasty. J Arthroplasty . 1989;;4:311-317.
34 +
Marti RK, Schüller HM, Besselaar PP, Vanfrank Haasnoot EL.  Results of revision of hip arthroplasty with cement: a five to fourteen-year follow-up. J Bone Joint Surg Am . 1990;;72A:346-354.
35 +
Estok DM, Harris WH.  Long-term results of cemented femoral revision surgery using second-generation techniques: an average 11.7-year follow-up evaluation. Clin Orthop . 1994;;299:190-202.
36 +
Wroblewski BM.  Results of the Charnley low-friction arthroplasty. Clin Orthop . 1986;;211:30-35.
37 +
Older J.  Low-friction arthroplasty of the hip: a ten to twelve year follow-up study. Clin Orthop . 1986;;211:36-42.
38 +
Dall DM, Grobbelaar CJ, Learmonth ID, et al.  Charnley low-friction arthroplasty of the hip: long-term results in South Africa. Clin Orthop . 1986;; 211:85-90.
39 +
Jinnah RH, Chir B, Amstutz HC, Tooke SM, Dorey F, Dalseth T.  The UCLA Charnley experience: a long-term follow-up using survival analysis. Clin Orthop . 1986;;211:164-172.
40 +
McCoy TH, Salvati EA, Ranawat CS, Wilson PD.  A fifteen-year follow-up study of one hundred Charnley low-friction arthroplasties. Orthop Clin North Am . 1988;;19:467-476.
41 +
Fowler JL, Gie GA, Lee AJ, et al.  Experience with the Exeter total hip replacement since 1970. Orthop Clin North Am . 1988;;19:477-489.
42 +
Russotti GM, Coventry MB, Stauffer RN.  Cemented total hip arthroplasty with contemporary techniques. Clin Orthop . 1988;;235:141-147.
43 +
Collis DK.  Long term results of an individual surgeon. Orthop Clin North Am . 1988;;19:541-550.
44 +
Schurman DJ, Bloch DA, Segal MR, Tanner CM.  Conventional cemented total hip arthroplasty: assessment of clinical factors associated with revision for mechanical failure. Clin Orthop . 1989;;240: 172-180.
45 +
Mulroy RD, Harris WH.  The effect of improved cementing techniques on component loosening in total hip replacement: an eleven year radiographic review. J Bone Joint Surg Br . 1990;;72B:757-760.
46 +
Gustilo RB, Kyle RF.  Revision of femoral component loosening with titanium ingrowth prosthesis and bone grafting.  In: Welch RB, ed. Proceedings of the 12th Annual Meeting of the Hip Society . St Louis, Mo: CV Mosby; 1984;:342-346.
47 +
Amstutz HC, Ma SM, Jinnah RH, Mai L.  Revision of aseptic loose total hip arthroplasties. Clin Orthop . 1982;;170:21-33.
48 +
Broughton NS, Rushton H.  Revision hip arthroplasty. Acta Orthop Scand . 1982;;53:923-928.
49 +
Esses S, Hastings D, Schatzker J.  Revision of total hip arthroplasty. Can J Surg . 1983;;26:345-347.
50 +
Reigstad A, Hetland KR.  Rearthroplasty after conventional total hip prosthesis and double cup prosthesis. Arch Orthop Traumatic Surg . 1984;;103: 152-155.
51 +
Pellici PM, Wilson PD Jr, Sledge CB, et al.  Long-term results of revision total hip replacement: a follow-up report. J Bone Joint Surg Am . 1985;; 67A:513-516.
52 +
Kavanagh BF, Ilstrup DM, Fitzgerald RH Jr.  Revision total hip arthroplasty. J Bone Joint Surg Am . 1985;;67A:517-526.
53 +
James ETR, Hunter GA, Cameron HU.  Total hip revision arthroplasty: does sepsis influence the results? Clin Orthop . 1982;;170:88-94.
54 +
Danielsson LG.  Incidence and prognosis of coxarthrosis. Acta Orthop Scand . 1964;;66:9-87.
55 +
Pellissier JM, Hazen GB.  Implementation of continuous risk utility assessment: the total hip replacement decision. Socio-Economic Plann Sci . 1994;;28:251-276.
56 +
Laupacis A, Bourne R, Rorabeck C, et al.  The effect of elective total hip replacement on health-related quality of life. J Bone Joint Surg Am . 1993;; 75A:1619-1626.
57 +
Katz JN, Phillips CB, Fossel AH, Liang MH.  Stability and responsiveness of utility measures. Med Care . 1994;;32:183-188.
58 +
Barber TC, Healy WL.  The hospital cost of total hip arthroplasty. J Bone Joint Surg Am . 1993;; 75A:321-325.
59 +
Economic Indicators . Washington, DC: US Government Printing Office; December 1994;:23.
60 +
Background Facts on Aging Services . American Association of Homes and Services for the Aging; April 1994;.
61 +
Weinstein MC, Stason WB.  Cost-effectiveness of coronary artery bypass surgery. Circulation . 1982;;66( (suppl III) ):56-65.
62 +
Garner TI, Dardis R.  Cost-effectiveness analysis of end stage renal disease treatments. Med Care . 1987;;25:25-34.
63 +
Edelson JT, Weinstein MC, Tosteson AN, Williams L, Lee TH, Goldman L.  Long-term cost-effectiveness of various initial monotherapies for mild to moderate hypertension. JAMA . 1990;;263:407-413.
64 +
Mushlin AI, Fintor L.  Is screening for breast cancer cost-effective? Cancer . 1992;;69:1957-1962.
65 +
Kinosian BP, Eisenberg JM.  Cutting into cholesterol: cost-effective alternatives for treating hypercholesterolema. JAMA . 1988;;259:2249-2254.
66 +
Eddy DM, Hasselblad V, McGivney W, Hendee W.  The value of mammography screening in women under age 50 years. JAMA . 1988;;259:1512-1519.
67 +
Etchason J, Petz L, Keeler E, et al.  The cost effectiveness of preoperative autologous blood donations. N Engl J Med . 1995;;332:719-724.
68 +
Schulman KA, Lynn LA, Glick HA, Eisenberg JM.  Cost effectiveness of low-dose zidovudine therapy for asymptomatic patients with human immunodeficiency virus (HIV) infection. Ann Intern Med . 1991;;114:798-802.
69 +
Kaplan RM, Bush JV, Berry CC.  Health status: types of validity and the index of well-being. Health Serv Res . 1976;;4:478-507.
70 +
Whittle J, Steinberg EP, Anderson GF, Herbert R, Hochberg MC.  Mortality after elective total hip arthroplasty in elderly Americans: age, gender, and indication for surgery predict survival. Clin Orthop . 1993;;205:119-126.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Harris WH, Sledge CB.  Total hip and total knee replacement. N Engl J Med. 1990;;323:725-731.
2 +
NIH Consensus Development Panel on Total Hip Replacement.  Total hip replacement. JAMA . 1995;;273:1950-1956.
3 +
Friedman B, Elixhauser A.  Increased use of an expensive, elective procedure: total hip replacements in the 1980s. Med Care . 1993;;31:581-596.
4 +
Liang MH, Cullen KE, Larson MG, et al.  Cost-effectiveness of total joint.arthroplasty in osteoarthritis. Arthritis Rheum . 1986;;29:937-943.
5 +
Laupacis A, Bourne R, Rorabeck C, et al.  Costs of elective total hip arthroplasty during the first year. J Arthroplasty . 1994;;9:481-487.
6 +
Steinbrocker 0, Traeger CH, Batterman RC.  Therapeutic criteria in rheumatoid arthritis. JAMA . 1949;;140:659-662.
7 +
Hazen GB.  Stochastic trees: a new technique for temporal medical decision modeling. Med Decis Making . 1992;;12:163-178.
8 +
Hazen GB.  Factored stochastic trees: a tool for solving complex temporal medical decision making problems. Med Decis Making . 1993;;13:227-236.
9 +
Cox DR.  A use of complex probabilities in the theory of stochastic processes. Proc Camb Phil Soc . 1955;;51:313-319.
10 +
Pellissier JM, Hazen GB.  Coxian mortality factors for stochastic tree modelling. Med Decis Making . 1994;;14:439. Abstract.
11 +
 Mortality, part A.  In: Vital Statistics of the United States . Hyattsville, Md: US Dept of Health and Human Services; 1993;;2:12.
12 +
Harris WH.  Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment and end-result stage using a new method of result evaluation. J Bone Joint Surg Am . 1969;;51A:737-755.
13 +
Kavanagh BF, Fitzgerald RH Jr.  Clinical and roentgenographic assessment of total hip arthroplasty: a new hip score. Clin Orthop . 1985;;193:133-140.
14 +
Kavanagh BF, Dewitz MA, Ilstrup DM, Stauffer RN, Coventry MB.  Charnley total hip arthroplasty with cement: fifteen-year results. J Bone Joint Surg Am . 1989;;71A:1496-1503.
15 +
Kavanagh BF, Fitzgerald RH Jr.  Multiple revisions for failed total hip arthroplasty not associated with infection. J Bone Joint Surg Am . 1987;; 69A:1144-1149.
16 +
Sanzen L, Carlsson AS, Josefsson G, Lindberg LT.  Revision operations on infected total hip arthroplasties. Clin Orthop Rel Res . 1988;;229:165-172.
17 +
White RH, McCurdy SA, Marder RA.  Early morbidity after total hip replacement: rheumatoid arthritis versus osteoarthritis. J Gen Intern Med . 1990;;5:304-309.
18 +
Coventry MB, Beckenbaugh RD, Nolan DR, Ilstrup DM.  2012 total hip arthroplasties: a study of postoperative causes and early complications. J Bone Joint Surg Am . 1974;;56A:273-284.
19 +
Orthopedic Knowledge Update, Volume IV . Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1993;.
20 +
Booth RE, Balderston RA, Rothman RH. Total Hip Arthroplasty . Philadelphia, Pa: WB Saunders Co; 1988;.
21 +
Beckenbaugh R, Ilstrup DM.  Total hip arthroplasty: a review of three hundred thirty-three cases with long follow-up. J Bone Joint Surg Am . 1978;; 60A:306-313.
22 +
Eftekhar NS, Tzitzikalakis GI.  Failures and reoperations following low-friction arthroplasty of the hip. Clin Orthop . 1986;;211:65-78.
23 +
Herberts P, Ahnfelt L, Malchau M, Strömberg C, Andersson GBJ.  Multicenter clinical trials and their value in assessing total joint arthroplasty. Clin Orthop . 1989;;249:48-55.
24 +
Schulte KR, Callaghan JJ, Kelley SS, Johnston RC.  The outcome of Charnley total hip arthroplasty with cement after a minimum twenty-year follow-up. J Bone Joint Surg Am . 1993;;75A:961-975.
25 +
Schutzer SF, Harris WH.  Deep-wound infection after total hip replacement under contemporary aseptic conditions. J Bone Joint Surg Am . 1988;;70A:724-727.
26 +
Hunter GA, Welsh RP, Cameron HU, Bailey WH.  The results of revision total hip arthroplasty. J Bone Joint Surg Br . 1979;;61B:419-421.
27 +
Jones JM.  Revisional total hip replacement for failed Ring arthroplasty. J Bone Joint Surg Am . 1979;;61A:1029-1034.
28 +
Hoogland T, Razzano CD, Marks KE, Wilde AH.  Revision of Mueller total hip arthroplasties. Clin Orthop . 1981;;161:180-185.
29 +
Anderson MA, Murray WR.  Revision surgery for failed total hip arthroplasty. Orthop Trans . 1981;; 5:75.
30 +
Cameron HU, Fedorkow DM.  The early results of the Bateman single assemble total hip used as a revision prosthesis. Acta Orthop Belg . 1981;;47:49-53.
31 +
Pellici PM, Wilson PD Jr, Sledge CB, Salvati EA, Ranawat CS, Poss R.  Revision total hip arthroplasty. Clin Orthop . 1982;;170:34-41.
32 +
Gustilo RB, Pasternak HS.  Revision total hip arthroplasty with titanium ingrowth prosthesis and bone grafting for failed cemented femoral component loosening. Clin Orthop . 1988;;235:111-119.
33 +
Retpen JB, Varmarken J, Steen Jensen J.  Survivorship analysis of failure pattern after revision total hip arthroplasty. J Arthroplasty . 1989;;4:311-317.
34 +
Marti RK, Schüller HM, Besselaar PP, Vanfrank Haasnoot EL.  Results of revision of hip arthroplasty with cement: a five to fourteen-year follow-up. J Bone Joint Surg Am . 1990;;72A:346-354.
35 +
Estok DM, Harris WH.  Long-term results of cemented femoral revision surgery using second-generation techniques: an average 11.7-year follow-up evaluation. Clin Orthop . 1994;;299:190-202.
36 +
Wroblewski BM.  Results of the Charnley low-friction arthroplasty. Clin Orthop . 1986;;211:30-35.
37 +
Older J.  Low-friction arthroplasty of the hip: a ten to twelve year follow-up study. Clin Orthop . 1986;;211:36-42.
38 +
Dall DM, Grobbelaar CJ, Learmonth ID, et al.  Charnley low-friction arthroplasty of the hip: long-term results in South Africa. Clin Orthop . 1986;; 211:85-90.
39 +
Jinnah RH, Chir B, Amstutz HC, Tooke SM, Dorey F, Dalseth T.  The UCLA Charnley experience: a long-term follow-up using survival analysis. Clin Orthop . 1986;;211:164-172.
40 +
McCoy TH, Salvati EA, Ranawat CS, Wilson PD.  A fifteen-year follow-up study of one hundred Charnley low-friction arthroplasties. Orthop Clin North Am . 1988;;19:467-476.
41 +
Fowler JL, Gie GA, Lee AJ, et al.  Experience with the Exeter total hip replacement since 1970. Orthop Clin North Am . 1988;;19:477-489.
42 +
Russotti GM, Coventry MB, Stauffer RN.  Cemented total hip arthroplasty with contemporary techniques. Clin Orthop . 1988;;235:141-147.
43 +
Collis DK.  Long term results of an individual surgeon. Orthop Clin North Am . 1988;;19:541-550.
44 +
Schurman DJ, Bloch DA, Segal MR, Tanner CM.  Conventional cemented total hip arthroplasty: assessment of clinical factors associated with revision for mechanical failure. Clin Orthop . 1989;;240: 172-180.
45 +
Mulroy RD, Harris WH.  The effect of improved cementing techniques on component loosening in total hip replacement: an eleven year radiographic review. J Bone Joint Surg Br . 1990;;72B:757-760.
46 +
Gustilo RB, Kyle RF.  Revision of femoral component loosening with titanium ingrowth prosthesis and bone grafting.  In: Welch RB, ed. Proceedings of the 12th Annual Meeting of the Hip Society . St Louis, Mo: CV Mosby; 1984;:342-346.
47 +
Amstutz HC, Ma SM, Jinnah RH, Mai L.  Revision of aseptic loose total hip arthroplasties. Clin Orthop . 1982;;170:21-33.
48 +
Broughton NS, Rushton H.  Revision hip arthroplasty. Acta Orthop Scand . 1982;;53:923-928.
49 +
Esses S, Hastings D, Schatzker J.  Revision of total hip arthroplasty. Can J Surg . 1983;;26:345-347.
50 +
Reigstad A, Hetland KR.  Rearthroplasty after conventional total hip prosthesis and double cup prosthesis. Arch Orthop Traumatic Surg . 1984;;103: 152-155.
51 +
Pellici PM, Wilson PD Jr, Sledge CB, et al.  Long-term results of revision total hip replacement: a follow-up report. J Bone Joint Surg Am . 1985;; 67A:513-516.
52 +
Kavanagh BF, Ilstrup DM, Fitzgerald RH Jr.  Revision total hip arthroplasty. J Bone Joint Surg Am . 1985;;67A:517-526.
53 +
James ETR, Hunter GA, Cameron HU.  Total hip revision arthroplasty: does sepsis influence the results? Clin Orthop . 1982;;170:88-94.
54 +
Danielsson LG.  Incidence and prognosis of coxarthrosis. Acta Orthop Scand . 1964;;66:9-87.
55 +
Pellissier JM, Hazen GB.  Implementation of continuous risk utility assessment: the total hip replacement decision. Socio-Economic Plann Sci . 1994;;28:251-276.
56 +
Laupacis A, Bourne R, Rorabeck C, et al.  The effect of elective total hip replacement on health-related quality of life. J Bone Joint Surg Am . 1993;; 75A:1619-1626.
57 +
Katz JN, Phillips CB, Fossel AH, Liang MH.  Stability and responsiveness of utility measures. Med Care . 1994;;32:183-188.
58 +
Barber TC, Healy WL.  The hospital cost of total hip arthroplasty. J Bone Joint Surg Am . 1993;; 75A:321-325.
59 +
Economic Indicators . Washington, DC: US Government Printing Office; December 1994;:23.
60 +
Background Facts on Aging Services . American Association of Homes and Services for the Aging; April 1994;.
61 +
Weinstein MC, Stason WB.  Cost-effectiveness of coronary artery bypass surgery. Circulation . 1982;;66( (suppl III) ):56-65.
62 +
Garner TI, Dardis R.  Cost-effectiveness analysis of end stage renal disease treatments. Med Care . 1987;;25:25-34.
63 +
Edelson JT, Weinstein MC, Tosteson AN, Williams L, Lee TH, Goldman L.  Long-term cost-effectiveness of various initial monotherapies for mild to moderate hypertension. JAMA . 1990;;263:407-413.
64 +
Mushlin AI, Fintor L.  Is screening for breast cancer cost-effective? Cancer . 1992;;69:1957-1962.
65 +
Kinosian BP, Eisenberg JM.  Cutting into cholesterol: cost-effective alternatives for treating hypercholesterolema. JAMA . 1988;;259:2249-2254.
66 +
Eddy DM, Hasselblad V, McGivney W, Hendee W.  The value of mammography screening in women under age 50 years. JAMA . 1988;;259:1512-1519.
67 +
Etchason J, Petz L, Keeler E, et al.  The cost effectiveness of preoperative autologous blood donations. N Engl J Med . 1995;;332:719-724.
68 +
Schulman KA, Lynn LA, Glick HA, Eisenberg JM.  Cost effectiveness of low-dose zidovudine therapy for asymptomatic patients with human immunodeficiency virus (HIV) infection. Ann Intern Med . 1991;;114:798-802.
69 +
Kaplan RM, Bush JV, Berry CC.  Health status: types of validity and the index of well-being. Health Serv Res . 1976;;4:478-507.
70 +
Whittle J, Steinberg EP, Anderson GF, Herbert R, Hochberg MC.  Mortality after elective total hip arthroplasty in elderly Americans: age, gender, and indication for surgery predict survival. Clin Orthop . 1993;;205:119-126.

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