Professional Documents
Culture Documents
the effectiveness
of health service
interventions for
decision makers
Nuffield Institute for Health,
University of Leeds,
NHS Centre for Reviews
and Dissemination,
University of York
OCTOBER 1996 VOLUME 2 NUMBER 7 ISSN: 0965-0288
Total hip
replacement
Effective
HealthCare
I The rate of elective total
hip replacement is
increasing. Around 40,000
were carried out by the
NHS in 1994/95 and a
substantial number by the
private sector.
I Total hip replacement is a
highly cost-effective
procedure, however
outcomes vary across the
country.
I Decision aids to identify
patients suitable for referal
for total hip replacement
have been developed.
I A large number of hip
prostheses are used in
Britain widely differing in
price. Very few of these
have had proper long-term
evaluation.
I The cheaper, standard
cemented, implants such as
the Charnley and the
Stanmore have been the
most thoroughly evaluated
and have been shown to
have the lowest long-term
failure rates over 1020
years follow-up.
I Purchasers and providers
should promote the use of
those prostheses which
have been shown to
perform best in long-term
follow-up.
I New prostheses should
only be used after they
have been thoroughly
evaluated or as part of a
national coordinated study.
I There is some evidence
that patients operated on
by trainees and surgeons
with low volume of activity
have poorer outcomes.
I Purchasing lifetime hip
care rather than individual
procedures may provide an
incentive to promote
quality.
2 EFFECTIVE HEALTH CARE Total hip replacement OCTOBER 1996
A. Background
Elective total hip replacement
(THR) surgery is performed
primarily to relieve pain, stiffness
and deformity caused by disease of
the hip joint.
There has been an increase in the
overall rate of THRs performed
over the last decade (Fig. 1) with
over 38,000 elective THRs
performed by the NHS in England
in 1994/5. Over three-quarters of
these were performed as a primary
procedure.
1
The demand for
primary THR may increase further
because disease of the hip is age-
related and people are living
longer (Table 1).
Some hip replacements fail after a
period of time by breaking,
loosening, wearing or becoming
infected. Hip replacements to
replace a failed one (revision
procedure) form about 11% of all
elective THRs and are likely to
increase as the length of life of
those receiving hip replacements
increases.
In a study of three English health
districts in 1991, 20% of THRs had
been performed privately.
2
This is
confirmed by a recent estimate
that around 11,000 operations are
undertaken in the private sector
each year. (Houghton, personal
communication, 1995)
This bulletin considers the
research evidence on whether
health care needs are being met,
the effectiveness and cost-
effectiveness of different types of
THR surgery and suggests how
this evidence can be used by
purchasers, providers and policy
makers to improve the quality of
care. Relevant literature was
identified by electronic and
manual searches, as detailed in
Appendix 2.
There are important aspects of this
subject that are not dealt with in
this bulletin:
Validation of pro-active
methods of predicting the long-
term success of hip surgery
which can be carried out using
feasible measures within a few
years of the operation. This will
facilitate more rigorous testing
of new equipment.
Evaluation of approaches to
promoting quality such as
purchasing lifetime hip care
Appendix 1: Routine hospital data
Data on the number of procedures
came from the Hospital Episode
Statistics for the relevant years.
Total Hip Replacement procedures
and prosthetic replacement of the
head of femur (OPCS codes W37,
W38, W39, W46, W47, and W48
and all subsidiary codes).
Emergency cases and those where
the primary diagnosis was
fractured neck of femur (ICD
codes 820 and 821) were excluded.
Appendix 2: Search strategy
The following databases were
searched: Medline (1966-1995);
EM-base (1981-1995); Science
Citation Index (1975-1995).
A manual search was made of
Index Medicus and of references
listed in other publications.
For the general search the key
words used were: hip replacement,
hip arthroplasty, hip prosthesis.
The searches were limited to
human subjects and English
language articles. Foreign articles
were reviewed if there was an
abstract in English.
Studies using experimental and
observational data which followed
up patients and measured patient
outcomes, including radiographic
changes, were identified.
References
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Donovan J. DHA Project: Research Programme
Epidemiologically Based Needs Assessment.
Total Hip Replacement. Health Care
Evaluation Unit/NHS Management Executive,
Dept Epidemiology & Public Health Medicine,
University of Bristol,Bristol 1992;1.
3. National Institutes of Health. National
Institutes of Health Consensus Developement
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September 12-14, 1994.
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10 EFFECTIVE HEALTH CARE Total hip replacement OCTOBER 1996
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Total hip replacement EFFECTIVE HEALTH CARE 11 OCTOBER 1996
12 EFFECTIVE HEALTH CARE Total hip replacement OCTOBER 1996
The Research Team:
This bulletin is based on a review
commissioned from the
Department of Social Medicine,
University of Bristol.
Writing of the bulletin and additional
research by the Effective Health Care
research team:
NHS Centre for Reviews and
Dissemination, University of York
I Professor Trevor Sheldon, Joint
Manager of Effective Health Care
I Alison Eastwood
I Dr Amanda Sowden
I Frances Sharp
Members of the Steering Group:
I Dr Peter Bourdillon, Head of Specialist
Clinical Services Division, NHS
Executive
I Dr Jenny Carpenter, Health Care
Directorate Public Health, NHS
Executive
I Ian Donnachie, Chief Executive,
Bradford Health Authority
I Professor Mike Drummond, Centre for
Health Economics, University of York
I Jane Emminson, Chief Executive,
Wolverhampton Health Executive
I Mr Philip Hewitson, Leeds FHSA/NHS
Executive
I Dr Anthony Hopkins, Director of
Research Unit, RCP
I Dr Liz Kernohan, Deputy Director of
Public Health, Bradford Health
Authority
I Andrew Long, Joint Manager of
Effective Health Care, Nuffield
Institute for Health, University of
Leeds
I Dr Diana McInnes, Principal Medical
Officer, DoH
I Dr Tom Mann, Head of Division,
Health Care Directorate Public Health,
NHS Executive
Acknowledgements:
Effective Health Care would like to
acknowledge the helpful assistance of the
following, who commented on earlier
drafts of the bulletin:
I Annie Britton, London School of
Hygiene and Tropical Medicine,
London
I Mr Christopher Bulstrode, Nuffield
Orthopaedic Centre, Oxford
I Professor Peter Croft, North
Staffordshire Medical Institute
I Dr Ray Fitzpatrick, Nuffield College,
Oxford
I Mr Michael Freeman, Harley Street,
London
I Professor P.J. Gregg, Glenfield Hospital,
Leicester
I Dr Rajan Madhok, Gateshead and
South Tyneside Health Authority
I Mr David Murray, Nuffield
Orthopaedic Centre, Oxford
We gratefully acknowledge the
contribution of staff in the Statistics
Division (SD2A) of the Department of
Health who provided data for this
bulletin.
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