Abstract
BACKGROUND: Ceramic-on-ceramic (CoCs) implants offer potential durability benefits in total hip arthroplasty (THA) but require notably high out-of-pocket copayments in Taiwan. This study assessed the cost-effectiveness of third- (3rd-CoCs) and fourth-generation CoC implants (4th-CoCs) compared with fully covered metal-on-polyethylene (MoPs) from a payer's perspective. METHODS: Using Taiwan's National Health Insurance (NHI) claims data (2009-2019), we identified osteoarthritis patients aged ≥ 50 years undergoing their first primary THA. We applied both exact matching and propensity score matching between patients who received 3rd- and 4th-CoCs and those who received MoPs. Cox regression and generalized linear models were used to assess clinical outcomes and total healthcare costs, including NHI payments and implant copayments. Incremental cost‒effectiveness ratios (ICERs) were calculated via 1,000 bootstrap iterations. RESULTS: This 10-year retrospective cohort included 15,233 patients (10,158 MoPs; 1,565 3rd-CoCs; 3,504 4th-CoCs), with median follow-up durations of 6.2 years for 3rd-CoCs and 3.3 years for 4th-CoCs. Compared with MoPs, 3rd-CoCs had lower adjusted hazard ratios (HR) for revision (HR 0.53, 95% CI 0.34-0.85) and postoperative complications (HR 0.69, 95% CI 0.49-0.99), with ICERs of US$704 per 1% gain in revision-free survival and US$794 per 1% gain in postoperative complication-free survival, respectively. 4th-CoCs reduced 90-day medical complications (HR 0.29, 95% CI 0.15-0.54) but had higher ICERs of US$2,947 per 1% gain in medical complication-free survival. CONCLUSIONS: Nationwide data suggests that 3rd-CoCs appear to be more cost-effective than MoPs. In contrast, 4th-CoCs demonstrated limited short-term value and uncertain cost-effectiveness, warranting future long-term evaluation.