Diagnosis of Periprosthetic Joint Infection in Medicare Patients: The Role of Multicriteria Decision Analysis

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Authors: Diaz-Ledezma C,  Lichstein PM, Dolan J, Parvizi J.

Title: Diagnosis of Periprosthetic Joint Infection in Medicare Patients: The Role of Multicriteria Decision Analysis

The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA

Background: In the setting of finite healthcare resources, developing cost-efficient strategies for diagnosis of periprosthetic joint infection (PJI) is paramount.

Hypothesis/Purpose: The aim of this study is to determine the best diagnostic strategy for knee and hip PJI among Medicare patients, considering benefits, opportunities, costs and risks (BOCR) through multicriteria decision analysis (MCDA).

Methods: The Musculoskeletal Infection Society (MSIS) definition of PJI was employed for our study. Four diagnostic strategies comprising eight different tests were evaluated. MCDA was conducted in two stages: creation of a balance sheet followed by an analytic hierarchy process (AHP) that involved only the efficient diagnostic strategies. They were compared in terms of BOCR utilizing a preclinical model that involved a Medicare patient seen in the ambulatory setting.

Results: The efficient strategies for the diagnosis of PJI in both hip and knee models were: 1) Screening with serum markers (ESR/CRP) followed by arthrocentesis in those positive cases, 2) immediate arthrocentesis, and 3) serum markers requested simultaneously with arthrocentesis. The AHP model showed that screening strategy with serum markers followed by arthrocentesis in those positive cases is the best diagnostic strategy in hip (normalized priority value: 0.487) and knee (normalized priority value: 0.490).

Discussion: Sensitivity analysis revealed that regardless of the importance allocated to the criterion benefits, opportunities or risks, the order in which the diagnostic strategies were ranked is not affected. However, if the priority allocated to costs is > 55% in knees or >54% in hips, the ranking is modified.

Conclusion: The categorical PJI diagnostic criteria issued by the MSIS allow the use of MCDA to prioritize different diagnostic strategies. After considering the BOCR of the efficient strategies, our preclinical model supports the AAOS recommendations regarding the use of serum ESR/CRP before arthrocentesis as the best diagnostic strategy for PJI among Medicare patients.