Please use this identifier to cite or link to this item: https://doi.org/10.3310/hta25660
Title: Unicompartmental compared with total knee replacement for patients with multimorbidities: a cohort study using propensity score stratification and inverse probability weighting
Authors: Prats-Uribe, Albert
Kolovos, Spyros
Berencsi, Klara
Carr, Andrew
Judge, Andrew
Silman, Alan
Arden, Nigel
Petersen, Irene
Douglas, Ian J
Wilkinson, J Mark
Murray, David
Valderas, Jose M 
Beard, David J
Lamb, Sarah E
Ali, M Sanni
Pinedo-Villanueva, Rafael
Strauss, Victoria Y
Prieto-Alhambra, Daniel
Keywords: Science & Technology
Life Sciences & Biomedicine
Health Care Sciences & Services
NATIONAL JOINT REGISTRY
INSTRUMENTAL VARIABLE METHODS
RHEUMATOID-ARTHRITIS
MULTIPLE IMPUTATION
COST-EFFECTIVENESS
MATCHED PATIENTS
MISSING-DATA
OXFORD HIP
EUROQOL
ENGLAND
Issue Date: 1-Nov-2021
Publisher: NIHR JOURNALS LIBRARY
Citation: Prats-Uribe, Albert, Kolovos, Spyros, Berencsi, Klara, Carr, Andrew, Judge, Andrew, Silman, Alan, Arden, Nigel, Petersen, Irene, Douglas, Ian J, Wilkinson, J Mark, Murray, David, Valderas, Jose M, Beard, David J, Lamb, Sarah E, Ali, M Sanni, Pinedo-Villanueva, Rafael, Strauss, Victoria Y, Prieto-Alhambra, Daniel (2021-11-01). Unicompartmental compared with total knee replacement for patients with multimorbidities: a cohort study using propensity score stratification and inverse probability weighting. HEALTH TECHNOLOGY ASSESSMENT 25 (66) : 1-125. ScholarBank@NUS Repository. https://doi.org/10.3310/hta25660
Abstract: Background: Although routine NHS data potentially include all patients, confounding limits their use for causal inference. Methods to minimise confounding in observational studies of implantable devices are required to enable the evaluation of patients with severe systemic morbidity who are excluded from many randomised controlled trials. Objectives: Stage 1 – replicate the Total or Partial Knee Arthroplasty Trial (TOPKAT), a surgical randomised controlled trial comparing unicompartmental knee replacement with total knee replacement using propensity score and instrumental variable methods. Stage 2 – compare the risk benefits and cost-effectiveness of unicompartmental knee replacement with total knee replacement surgery in patients with severe systemic morbidity who would have been ineligible for TOPKAT using the validated methods from stage 1. Design: This was a cohort study.Setting: Data were obtained from the National Joint Registry database and linked to hospital inpatient (Hospital Episode Statistics) and patient-reported outcome data. Participants: Stage 1 – people undergoing unicompartmental knee replacement surgery or total knee replacement surgery who met the TOPKAT eligibility criteria. Stage 2 – participants with an American Society of Anesthesiologists grade of ≥ 3. Intervention: The patients were exposed to either unicompartmental knee replacement surgery or total knee replacement surgery. Main outcome measures: The primary outcome measure was the postoperative Oxford Knee Score. The secondary outcome measures were 90-day postoperative complications (venous thromboembolism, myocardial infarction and prosthetic joint infection) and 5-year revision risk and mortality. The main outcome measures for the health economic analysis were health-related quality of life (EuroQol-5 Dimensions) and NHS hospital costs. Results: In stage 1, propensity score stratification and inverse probability weighting replicated the results of TOPKAT. Propensity score adjustment, propensity score matching and instrumental variables did not. Stage 2 included 2256 unicompartmental knee replacement patients and 57,682 total knee replacement patients who had severe comorbidities, of whom 145 and 23,344 had linked Oxford Knee Scores, respectively. A statistically significant but clinically irrelevant difference favouring unicompartmental knee replacement was observed, with a mean postoperative Oxford Knee Score difference of < 2 points using propensity score stratification; no significant difference was observed using inverse probability weighting. Unicompartmental knee replacement more than halved the risk of venous thromboembolism [relative risk 0.33 (95% confidence interval 0.15 to 0.74) using propensity score stratification; relative risk 0.39 (95% confidence interval 0.16 to 0.96) using inverse probability weighting]. Unicompartmental knee replacement was not associated with myocardial infarction or prosthetic joint infection using either method. In the long term, unicompartmental knee replacement had double the revision risk of total knee replacement [hazard ratio 2.70 (95% confidence interval 2.15 to 3.38) using propensity score stratification; hazard ratio 2.60 (95% confidence interval 1.94 to 3.47) using inverse probability weighting], but half of the mortality [hazard ratio 0.52 (95% confidence interval 0.36 to 0.74) using propensity score stratification; insignificant effect using inverse probability weighting]. Unicompartmental knee replacement had lower costs and higher quality-adjusted life-year gains than total knee replacement for stage 2 participants. Limitations: Although some propensity score methods successfully replicated TOPKAT, unresolved confounding may have affected stage 2. Missing Oxford Knee Scores may have led to information bias. Conclusions: Propensity score stratification and inverse probability weighting successfully replicated TOPKAT, implying that some (but not all) propensity score methods can be used to evaluate surgical innovations and implantable medical devices using routine NHS data. Unicompartmental knee replacement was safer and more cost-effective than total knee replacement for patients with severe comorbidity and should be considered the first option for suitable patients.
Source Title: HEALTH TECHNOLOGY ASSESSMENT
URI: https://scholarbank.nus.edu.sg/handle/10635/236309
ISSN: 1366-5278
2046-4924
DOI: 10.3310/hta25660
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