Contingent Valuation Studies in Orthopaedic Surgery: A Health Economic Review



A greater emphasis on providing high-value orthopaedic interventions has resulted in increased health economic reporting. The contingent-valuation method (CVM) is used to determine consumer valuation of the benefits provided by healthcare interventions. CVM is an important value-based health economic tool that is underutilized in orthopaedic surgery.


The purpose of this study was to (1) identify previously published CVM studies in the orthopaedic literature, (2) assess the methodologies used for CVM research, and (3) understand how CVM has been used in the orthopaedic cost–benefit analysis framework.


A systematic review of the literature using the MEDLINE database was performed to compile CVM studies. Search terms incorporated the phrase willingness to pay (WTP) or willingness to accept (WTA) in combination with orthopaedic clinical key terms. Study methodology was appraised using previously defined empirical and conceptual criteria for CVM studies.


Of the 160 studies retrieved, 22 (13.8%) met our inclusion criteria. The economics of joint arthroplasty (n = 6, 27.3%) and non-operative osteoarthritis care (n = 4, 18.2%) were the most common topics. Most studies used CVM for pricing and/or demand forecasting (n = 16, 72.7%); very few studies used CVM for program evaluation (n = 6). WTP was used in all included studies, and one study used both WTP and WTA. Otherwise, there was little consistency among included studies in terms of CVM methodology. Open-ended questioning was used by only ten studies (45.5%), a significant number of studies did not perform a sensitivity analysis (n = 9, 40.9%), and none of the studies accounted for the risk preference of subjects. Only two of the included studies applied CVM within a cost–benefit analysis framework.


CVM is not commonly reported in orthopaedic surgery and is seldom used in the context of cost–benefit analysis. There is wide variability in the methods used to perform CVM. We propose that CVM is an appropriate and underappreciated method for understanding the value of orthopaedic interventions. Increased attention should be paid to consumer valuations for orthopaedic interventions.

This is a preview of subscription content, log in to check access.

Fig. 1


  1. 1.

    Cost-benefit and other analysis requirements in the rulemaking process 2014. Congressional Research Service. Available at Accessed July 4, 2017.

  2. 2.

    Alolabi B, Bajammal S, Shirali J, Karanicolas PJ, Gafni A, Bhandari M. Treatment of displaced femoral neck fractures in the elderly: a cost-benefit analysis. J Orthop Trauma. 2009;23:442–446.

    Article  Google Scholar 

  3. 3.

    Arrow K, Solow R, Portney PR, Leamer EE, Radner R, Schuman H. Report of the NOAA Panel on Contingent Valuation. 1993. Available at: Accessed July 4, 2017.

  4. 4.

    Birch S, Donaldson C. Valuing the benefits and costs of health care programmes: where’s the “extra” in extra-welfarism? Soc Sci Med. 2003;56:1121–1133.

    Article  Google Scholar 

  5. 5.

    Bozic KJ, Chiu V, Slover JD, Immerman I, Kahn JG. Patient preferences and willingness to pay for arthroplasty surgery in patients with osteoarthritis of the hip. J Arthroplasty. 2012;27:503–506.e502.

  6. 6.

    Byrne MM, O’Malley KJ, Suarez-Almazor ME. Ethnic differences in health preferences: analysis using willingness-to-pay. J Rheumatol. 2004;31:1811–1818.

    PubMed  Google Scholar 

  7. 7.

    Chang K. Comorbidities, quality of life and patients’ willingness to pay for a cure for type 2 diabetes in Taiwan. Public Health. 2010;124:284–294.

    CAS  Article  Google Scholar 

  8. 8.

    Cross MJ, March LM, Lapsley HM, Tribe KL, Brnabic AJ, Courtenay BG, Brooks PM. Determinants of willingness to pay for hip and knee joint replacement surgery for osteoarthritis. Rheumatology (Oxford). 2000;39:1242–1248.

    CAS  Article  Google Scholar 

  9. 9.

    de Bekker-Grob EW, Essink-Bot ML, Meerding WJ, Pols HA, Koes BW, Steyerberg EW. Patients’ preferences for osteoporosis drug treatment: a discrete choice experiment. Osteoporos Int. 2008;19:1029–1037.

  10. 10.

    Deogaonkar R, Hutubessy R, van der Putten I, Evers S, Jit M. Systematic review of studies evaluating the broader economic impact of vaccination in low and middle income countries. BMC Public Health. 2012;12:878.

    Article  Google Scholar 

  11. 11.

    Diener A, O’Brien B, Gafni A. Health care contingent valuation studies: a review and classification of the literature. Health Economics. 1998;7:313–326.

    CAS  Article  Google Scholar 

  12. 12.

    Ethgen O, Tancredi A, Lejeune E, Kvasz A, Zegels B, Reginster JY. Do utility values and willingness to pay suitably reflect health outcome in hip and knee osteoarthritis? A comparative analysis with the WOMAC Index. J Rheumatol. 2003;30:2452–2459.

    PubMed  Google Scholar 

  13. 13.

    Gyldmark M, Morrison GC. Demand for health care in Denmark: results of a national sample survey using contingent valuation. Soc Sci Med. 2001;53:1023–1036.

    CAS  Article  Google Scholar 

  14. 14.

    Haefeli M, Elfering A, McIntosh E, Gray A, Sukthankar A, Boos N. A cost-benefit analysis using contingent valuation techniques: a feasibility study in spinal surgery. Value Health. 2008;11:575–588.

    Article  Google Scholar 

  15. 15.

    Haines TP, McPhail S. Patient preference for falls prevention in hospitals revealed through willingness-to-pay, contingent valuation survey. J Eval Clin Pract. 2011;17:304–310.

    Article  Google Scholar 

  16. 16.

    Hall MP, Chiang-Colvin AS, Bosco JA, 3rd. Willingness to pay for anterior cruciate ligament reconstruction. Bulletin of the Hospital for Joint Disease. 2013;71:218–221.

    Google Scholar 

  17. 17.

    Hamid KS, Nwachukwu BU, Bozic KJ. Decisions and Incisions: A Value-Driven Practice Framework for Academic Surgeons. J Bone Joint Surg Am. 2017;99:e50.

    Article  Google Scholar 

  18. 18.

    Harris AH, Youd J, Buchbinder R. A comparison of directly elicited and pre-scored preference-based measures of quality of life: the case of adhesive capsulitis. Qual Life Res. 2013;22:2963–2971.

    Article  Google Scholar 

  19. 19.

    Hendry GJ, Turner DE, Gardner-Medwin J, Lorgelly PK, Woodburn J. An exploration of parents' preferences for foot care in juvenile idiopathic arthritis: a possible role for the discrete choice experiment. J Foot Ankle Res. 2014;7:10.

    Article  Google Scholar 

  20. 20.

    Johannesson M. Economic evaluation of hypertension treatment. Int J Technol Assess Health Care. 1992;8:506–523.

    CAS  Article  Google Scholar 

  21. 21.

    Jones-Lee MW, Hammerton M, Philips PR. The value of safety: results of a national sample survey. Econ J. 1985;95:49–72.

    Article  Google Scholar 

  22. 22.

    Joy SM, Little E, Maruthur NM, Purnell TS, Bridges JF. Patient preferences for the treatment of type 2 diabetes: a scoping review. PharmacoEconomics. 2013;31:877–892.

    Article  Google Scholar 

  23. 23.

    Jutkowitz E, Gitlin LN, Pizzi LT. Evaluating willingness-to-pay thresholds for dementia caregiving interventions: application to the tailored activity program. Value Health. 2010;13:720–725.

    Article  Google Scholar 

  24. 24.

    King JT, Jr., Moossy JJ, Tsevat J, Roberts MS. Multimodal assessment after surgery for cervical spondylotic myelopathy. J Neurosurg Spine. 2005;2:526–534.

    Article  Google Scholar 

  25. 25.

    King JT, Jr., Tsevat J, Roberts MS. Positive association between current health and health values for hypothetical disease states. Med Decis Making. 2004;24:367–378.

    Article  Google Scholar 

  26. 26.

    Lansky D, Nwachukwu BU, Bozic KJ. Using financial incentives to improve value in orthopaedics. Clin Orthop Relat Res.2012;470:1027–1037.

    Article  Google Scholar 

  27. 27.

    Lavernia CJ, Contreras JS, Parvizi J, Sharkey PF, Barrack R, Rossi MD. Do patient expectations about arthroplasty at initial presentation for hip or knee pain differ by sex and ethnicity? Clin Orthop Relat Res.2012;470:2843–2853.

    Article  Google Scholar 

  28. 28.

    Maitra C, Hodge A, Jimenez Soto E. A scoping review of cost benefit analysis in reproductive, maternal, newborn and child health: What we know and what are the gaps? Health Policy Plan. 2016;31:1530–1547.

    Article  Google Scholar 

  29. 29.

    Mitchell RC, Carson RT. Using surveys to value public goods: the contingent valuation method. Washington, DC: Resources for the Future; 1989.

    Google Scholar 

  30. 30.

    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:1006–1012.

    Article  Google Scholar 

  31. 31.

    Nwachukwu BU, Bozic KJ, Schairer WW, Bernstein JL, Jevsevar DS, Marx RG, Padgett DE. Current status of cost utility analyses in total joint arthroplasty: a systematic review. Clin Orthop Relat Res. 2015;473:1815–1827.

    Article  Google Scholar 

  32. 32.

    Nwachukwu BU, Hamid KS, Bozic KJ. Measuring value in orthopaedic surgery. JBJS Reviews. 2013;1.

  33. 33.

    Nwachukwu BU, Schairer WW, Bernstein JL, Dodwell ER, Marx RG, Allen AA. Cost-effectiveness analyses in orthopaedic sports medicine: a systematic review. Am J Sports Med. 2015;43:1530–1537.

    Article  Google Scholar 

  34. 34.

    Nwachukwu BU, Schairer WW, O’Dea E, McCormick F, Lane JM. The quality of cost-utility analyses in orthopedic trauma. Orthopedics. 2015;38:e673–680.

    Article  Google Scholar 

  35. 35.

    Nwachukwu BU, Schairer WW, Shifflett GD, Kellner DB, Sama AA. Cost-utility analyses in spine care: a qualitative and systematic review. Spine. 2015;40:31–40.

    Article  Google Scholar 

  36. 36.

    O'Brien B, Viramontes JL. Willingness to pay: a valid and reliable measure of health state preference? Med Decis Making. 1994;14:289–297.

    CAS  Article  Google Scholar 

  37. 37.

    Ofman JJ, Sullivan SD, Neumann PJ, Chiou CF, Henning JM, Wade SW, Hay JW. Examining the value and quality of health economic analyses: implications of utilizing the QHES. J Manag Care Pharm. 2003;9:53–61.

    PubMed  Google Scholar 

  38. 38.

    Olsen JA, Donaldson C. Helicopters, hearts and hips: using willingness to pay to set priorities for public sector health care programmes. Soc Sci Med. 1998;46:1–12.

    CAS  Article  Google Scholar 

  39. 39.

    Pereira MJ, Coombes BK, Bisset LM, Vicenzino B, Connelly L. Estimating the monetary value of relief of tennis elbow: a contingent valuation study of willingness-to-pay. Value Health. 2015;18:A654.

    CAS  Article  Google Scholar 

  40. 40.

    Poder TG, He J. Willingness to pay and the sensitivity of willingness to pay for interdisciplinary musculoskeletal clinics: a contingent valuation study in Quebec, Canada. Int J Health Econ Manag. 2016;16:337–361.

    Article  Google Scholar 

  41. 41.

    Posnett J, Dixit S, Oppenheimer B, Kili S, Mehin N. Patient preference and willingness to pay for knee osteoarthritis treatments. Patient Prefer Adherence. 2015;9:733–744.

    PubMed  PubMed Central  Google Scholar 

  42. 42.

    Saltzman BM, Cvetanovich GL, Nwachukwu BU, Mall NA, Bush-Joseph CA, Bach BR, Jr. Economic Analyses in Anterior Cruciate Ligament Reconstruction: A Qualitative and Systematic Review. Am J Sports Med. 2016;44:1329–1335.

    Article  Google Scholar 

  43. 43.

    Sanders GD, Neumann PJ, Basu A, Brock DW, Feeny D, Krahn M, Kuntz KM, Meltzer DO, Owens DK, Prosser LA, Salomon JA, Sculpher MJ, Trikalinos TA, Russell LB, Siegel JE, Ganiats TG. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA. 2016;316:1093–1103.

    Article  Google Scholar 

  44. 44.

    Schiffner R, Schiffner-Rohe J, Gerstenhauer M, Hofstadter F, Landthaler M, Stolz W. Willingness to pay and time trade-off: sensitive to changes of quality of life in psoriasis patients? Br J Dermatol. 2003;148:1153–1160.

    CAS  Article  Google Scholar 

  45. 45.

    Schwartz AJ, Fraser JF, Shannon AM, Jackson NT, Raghu TS. Patient perception of value in bundled payments for total joint arthroplasty. J Arthroplasty. 2016;31:2696–2699.

    Article  Google Scholar 

  46. 46.

    von Arx LB, Kjeer T. The patient perspective of diabetes care: a systematic review of stated preference research. Patient. 2014;7:283–300.

    Article  Google Scholar 

  47. 47.

    Werner P, Vered I. Women’s willingness to pay out-of-pocket for drug treatment for osteoporosis before and after the enactment of regulations providing public funding: evidence from a natural experiment in Israel. Osteoporos Int. 2002;13:228–234.

    CAS  Article  Google Scholar 

  48. 48.

    Xie F, Thumboo J, Fong KY, Lo NN, Yeo SJ, Yang KY, Li SC. A study on indirect and intangible costs for patients with knee osteoarthritis in Singapore. Value Health. 2008;11 Suppl 1:S84–90.

    Article  Google Scholar 

  49. 49.

    Yasunaga H, Ide H, Imamura T, Ohe K. Analysis of factors affecting willingness to pay for cardiovascular disease-related medical services. Int Heart J. 2006;47:273–286.

    Article  Google Scholar 

  50. 50.

    Yeung RY, Smith RD. Can we use contingent valuation to assess the demand for childhood immunisation in developing countries?: a systematic review of the literature. Appl Health Econ Health Policy. 2005;4:165–173.

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Benedict U. Nwachukwu MD, MBA.

Ethics declarations

Conflict of Interest

Benedict U. Nwachukwu, MD, MBA, Claire D. Eliasberg, MD, Kamran S. Hamid, MD, MPH, Michael C. Fu, MD, MHS, Bernard R. Bach, MD, and Answorth A. Allen, MD, declare that they have no conflicts of interest. Todd J. Albert, MD, reports royalties from DePuy Synthes and Facet Link; investment interest in Biomerix, Crosstrees Medical, Gentis, International Orthopaedic Alliance, InVivo Therapeutics, Invuity, Paradigm Spine, Pulse Equity, and Spinicity; stock options in Vital 5; personal fees from Zimmer Biomet and Lineum Cervical System and Polaris Spinal System; and medical advisory board membership at United Healthcare, outside the submitted work.

Human/Animal Rights


Informed Consent


Required Author Forms:

Disclosure forms provided by the authors are available with the online version of this article.

Additional information

This investigation was performed at the Hospital for Special Surgery.

Electronic Supplementary Material


(PDF 1224 kb).


(PDF 1224 kb).


(PDF 1224 kb).


(PDF 1224 kb).


(PDF 1224 kb).


(PDF 1224 kb).


(PDF 1225 kb).

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Nwachukwu, B.U., Eliasberg, C.D., Hamid, K.S. et al. Contingent Valuation Studies in Orthopaedic Surgery: A Health Economic Review. HSS Jrnl 14, 314–321 (2018).

Download citation


  • contingent valuation method
  • cost–benefit analysis
  • cost-effectiveness analysis
  • willingness to pay