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VOLUME 4, ISSUE 2  
 2021 

 

STAKEHOLDER  PERSPECTIVES 

Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb 

service’s experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

This article has been invited and reviewed by Co-Editor-In-Chief, Dr. Silvia Ursula Raschke. 
English proofread by: Karin Ryan, M.A., B.Sc., P.T. 
Managing Editor: Dr. Hossein Gholizadeh 
 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

 

 

 
STAKEHOLDER  PERSPECTIVES 

 

HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF LIMB LOWER BONE-

ANCHORED PROSTHESES: A SUMMARY OF THE QUEENSLAND ARTIFICIAL LIMB SERVICE’S 

EXPERIENCE 

Berg D1, Frossard L2-5 * 
 

 

1 Queensland Artificial Limb Service, Brisbane, Australia.  
2 YourResearchProject Pty Ltd, Brisbane, Australia. 
3 Griffith University, Gold Coast, Australia. 
4 University of the Sunshine Coast, Maroochydore, Australia. 
5 Queensland University of Technology, Brisbane, Australia. 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

INTRODUCTION 

My name is Debra Berg. For over 20 years, I have been the 

manager of Queensland Artificial Limb Service (QALS), a 

Queensland Health organization delivering artificial limbs to 

individuals suffering from limb loss. My principal mandate 

as manager of state service is to support the best possible 

prosthetic care while ensuring accountability for the use of 

taxpayer dollars. 

 

 

 

 

 

Initial awareness 

I became aware that osseointegration could provide 

opportunities for direct skeletal prosthetic attachment in the 

early 1990s, when the first cases were presented at various 

international conferences by Dr. Rickard Branemark, a 

leading surgeon from the Sahlgrenska University Hospital, 

Gothenburg, Sweden.1-3 Similar to the rest of the prosthetic 

care community, I recognized the potential capacity of this 

surgical procedure to alleviate caveats of socket-suspended 

prostheses (SSPs).4 However, it was unclear how 

contraindications for consumers experiencing vascular 

problems and the inevitable adverse events (e.g., 

infections) that could lead to removal of the implant and 

reamputation should be dealt with.5  

 
OPEN  ACCESS Volume 4, Issue 2, Article No.12. 2021 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

The emergence of skeletal prosthetic attachments leaves governmental organizations facing the 

challenge of implementing equitable policies that support the provision of bone-anchored 

prostheses (BAPs). In 2013, the Queensland Artificial Limb Service (QALS) started a five-year 

research project focusing on health service delivery and economic evaluation of BAPs. This paper 

reflects on the QALS experience, particularly the lessons learned. QALS’ jurisdiction and drivers 

are presented first, followed by the impact of outcomes, barriers, and facilitators, as well as future 

developments of this work. The 21 publications produced during this project (e.g., reimbursement 

policy, role of prosthetists, continuous improvement procedure, quality of life, preliminary cost-

utilities) were summarized. Literature on past, current, and upcoming developments of BAP was 

reviewed to discuss the practical implications of this work. A primary outcome of this project was a 

policy developed by QALS supporting up to 22 h of labor for the provision of BAP care. The indicative 

incremental cost-utility ratio for transfemoral and transtibial BAPs was approximately AUD$17,000 

and AUD$12,000, respectively, per quality-adjusted life-year compared to socket prostheses. This 

project was challenged by 17 barriers (e.g., limited resources, inconsistency of care pathways, 

design of preliminary cost-utility analyses) but eased by 18 facilitators (e.g., action research plan, 

customized database, use of free repositories). In conclusion, we concluded that lower limb BAP 

might be an acceptable alternative to socket prostheses from an Australian government prosthetic 

care perspective. Hopefully, this work will inform promoters of prosthetic innovations committed to 

making bionic solutions widely accessible to a growing population of individuals suffering from limb 

loss worldwide.  

CITATION 

Berg D, Frossard L. Health service 

delivery and economic evaluation of limb 

lower bone-anchored prostheses: A 

summary of the Queensland artificial 

limb service’s experience. Canadian 

Prosthetics & Orthotics Journal. 2021; 

Volume 4, Issue 2, No.12. 

https://doi.org/10.33137/cpoj.v4i2.36210 

KEYWORDS 

Artificial Limbs, Bionics, Bone-Anchored 

Prosthesis, Cost-Effectiveness, Cost-

Utility, Health Economic Evaluation, 

Health Service Delivery, 

Osseointegration 

 

* CORRESPONDING AUTHOR 

Laurent Frossard (PhD), Professor of Bionics, 
YourResearchProject Pty Ltd, Brisbane, Australia. 

E-mail: laurentfrossard@outlook.com 

ORCID number: https://orcid.org/0000-0002-0248-9589 

Special Issue: Health Economics in Prosthetics & Orthotics 

https://doi.org/10.33137/cpoj.v4i2.36210
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v4i2.36210
mailto:laurentfrossard@outlook.com
https://orcid.org/0000-0002-0248-9589


 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

Berg D. & Frossard L., 2021 CPOJ 

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Regardless, it was clear that the progress of this new 

treatment was remarkable and truly worth monitoring. 

Osseointegration was systematically included in QALS’ 

regular horizon scans of prosthetic care innovations having 

potential to alleviate the clinical and financial burdens of 

prosthetic attachment for Queenslanders (e.g., review of 

literature about efficacy and safety). 

A handful of patients were first fitted with a screw-type 

implant in 2000 by a team in Melbourne, Victoria, in 

collaboration with the pioneering group in Sweden.6 Curious 

to know more, I invited Dr. Kerstin Hagberg, an acclaimed 

Rehabilitation Specialist from Sahlgrenska University 

Hospital, to give a talk on her Osseointegrated Prostheses 

for the Rehabilitation of Amputees (OPRA) study for 

consumers, clinicians, and healthcare administrators in 

Brisbane, Queensland, in 2005.2,7,8 This presentation gave 

us a better understanding of the rehabilitation program as 

well as the benefits (e.g., improvement in health-related 

quality of life, prosthetic use, embodiment, prosthetic knee 

and hip range of motion, sitting comfort, donning and 

doffing, osseoperception, walking ability) and harms of 

osseointegration (e.g., skin irritation around the stoma, 

loosening, periprosthetic fractures, mechanical failure of 

implant parts, deep and superficial infections, removal).1,7,9 

It also highlighted that bone-anchored prostheses (BAPs) 

could lessen expenditure from socket fittings and residuum-

related skin treatments.4 This was the first time I wondered 

how the emergence of new treatments relying on direct 

skeletal attachment and the subsequent provision of BAP 

could impact the day-to-day work of a governmental 

organization such as QALS. 

Challenges 

Answering this question became critical when the first 

Queenslanders with unilateral transfemoral amputation 

were treated interstate in late 2012. Initially, we dealt with 

these consumers on a case-by-case basis. This approach 

was required to understand and address immediate needs. 

However, it created too much uncertainty and 

unpredictability to be sustainable. Furthermore, we 

anticipated a significant influx of consumers in the short 

term. Soon after, QALS faced the challenge of putting in 

place a procedure to warrant a fair and equitable delivery of 

lower limb BAP to its consumers. 

Needs 

As an administrator, and often gatekeeper of taxpayers’ 

money, I considered it essential to make decisions about a 

new treatment based on the best clinical and 

socioeconomic evidence available. Prosthetic care must be 

supported but  resources are limited. Like many other 

managers of government healthcare organizations, every 

dollar spent by QALS must be spent according to “financial 

marching orders” (e.g., schedule of allowable expenses).  

 

Literature searches conducted during horizon scans and 

discussions with colleagues revealed that there was limited 

information about the alleged socioeconomic advantages of 

BAP.10,11 Clearly, there was a knowledge gap: What could 

the provision of BAP mean for government healthcare 

organizations in terms of service delivery and expenditures? 

In 2013, I initiated what turned out to be a five-year project 

of research gathering evidence to support the provision of 

BAP from the QALS perspective (Figure 1). We assessed 

the areas of disruptions while trying to find ways to 

accommodate new expectations. 

This project examined changes related to the service 

delivery of BAP, including the development of a policy 

supporting the provision of BAP, the role of prosthetists, 

adjustments of continuous improvement procedures, and 

consumers’ quality of life. This project also involved a health 

economic evaluation of transfemoral and transtibial BAPs, 

including cost comparison and preliminary cost-utility 

analyses (CUAs), compared to SSP. 

Purposes 

This paper reflects on the QALS experience gained during 

this research project. The main purpose was to summarize 

the outcomes from a bird’s-eye view. We have shared the 

lessons learned during our journey through hands-on 

information that might be helpful for all BAP promoters, 

including end users and carers, providers of prosthetic 

solutions, and administrators of healthcare organizations, 

amongst others. 

The specific objectives were to: 

• Introduce some background information about 

QALS’ jurisdiction to facilitate cross-comparison and 

transferability of our experience 

• Outline the drivers that motivated this work 

LIST OF ABBREVIATIONS 

BAP: Bone-anchored prostheses 

CQI: continuous quality improvement 

CUA: Cost-utility analysis 

ESAR: Energy storing and return feet 

HEE: Health economic evaluation  

ICUR: Incremental cost-utility ratio 

K: Medicare Functional Classification Level 

MPK: Microprocessor-controlled knee 

QALY: Quality-adjusted life-year 

SF36: 36-Item Short Form Survey 

SSP: Sockets-suspended prostheses 

WTP: Willingness-to-pay threshold 

https://doi.org/10.33137/cpoj.v4i2.36210


 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

Berg D. & Frossard L., 2021 CPOJ 

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• Present an overview of the impacts and outcomes 

• Share the selected barriers and facilitators met 

during this project separately, although they were 

intertwined and 

• Suggest briefly future developments of this work 

alongside some calls to action to further promote 

innovations in the service delivery and economic 

evaluation of BAP 

Drivers, barriers, and facilitators we deemed within and 

beyond QALS’ influence were highlighted so that other 

organizations could identify their internal strengths and 

possible external threats during the strategic planning of 

similar research projects (e.g., strengths, weaknesses, 

opportunities, and threats analysis). 

Supplementary materials to be published in a Data In Brief 

paper provided additional information about the QALS’ 

jurisdiction, publications (e.g., distribution, breakdown of 

impacts, downloads worldwide), allowable hours for 

prosthetist’s labor (e.g., phases of treatment, tasks), study 

cohorts (e.g., sample size, representativeness), and 

datasets considered to estimate costs (e.g., number of 

claims, prediction), as well as detailed descriptions of all 

barriers and facilitators. 

 

JURISDICTION 

QALS is in the jurisdiction of the Queensland State 

Government Minister of Health, one of the six states and 

three territories of Australia. The role of QALS is to ensure 

equitable provision and funding of external prosthetic 

components to eligible residents of Queensland. Eligible 

consumers must be registered with the QALS and (1) be 

eligible for definitive prosthetic funding support under the 

Queensland Government’s “Artificial Limb Scheme” or (2) 

be eligible under the Rehabilitation Appliance Program of 

the Department of Veteran Affairs. QALS has a yearly 

budget of AUD$5.4 million to provide prosthetic services to 

3,600 active consumers annually through a network of up to 

10 individual prosthetists (e.g., CPO). Although Queensland 

has predominantly an urban population, QALS services 

consumers across the whole state. 

Queensland has hot and humid weather for the most part of 

the year. These conditions make the typical SSP difficult to 

tolerate and increase the need for frequent socket fittings. 

Access to the closest point of care can be particularly critical 

for some consumers who might have to travel hundreds of 

kilometers to visit their prosthetist for socket and component 

fittings. Altogether, the prospect of socket-free prosthetic 

solutions could be particularly appealing for QALS 

consumers. 

Continuous 

quality 

improvement  

Role of 

prosthetists 

Policy for 

provision  

Health 

service 

delivery  

TTA 

Preliminary  

cost-utility 

Cost-

comparison 

Health 

economic 

evaluation  

QALS’ project of 

research about 

provision of BAP 

TF

Preliminary  

Cost-utility 

Cost-

comparis

TFA 

Preliminary  

cost-utility 

Cost-

comparison 

Consumer’s 

quality of life  

Figure 1: Overview of the research project focusing health service delivery and health economic evaluations of transfemoral (TFA) and 

transtibial (TTA) bone-anchored prostheses (BAPs) led by the Queensland Artificial Limb Service (QALS). 

https://doi.org/10.33137/cpoj.v4i2.36210


 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

Berg D. & Frossard L., 2021 CPOJ 

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Currently, QALS is looking after a case-mix of nearly 100 

consumers using unilateral, bilateral, and quadrilateral 

BAPs, representing approximately 11% and 6% of the 

existing population using BAP which is estimated at 950 in 

Australia and 1,600 worldwide, respectively. The number of 

QALS consumers has increased steadily by up to 10 per 

year over the last three years, generating one of the largest 

growing populations worldwide. 

DRIVERS 

Beyond our initial genuine interest in the economic impacts 

of the provision of BAP, this research project was 

pragmatically motivated by a series of external and internal 

drivers to the organization. 

External drivers 

As hinted at in the historical introduction, this project 

emerged because of external drivers, including, but not 

limited to, the following: 

•  A growing number of consumers. In 2012, QALS 

started to experience a significant influx of existing and 

new consumers choosing direct skeletal attachments. 

Projections estimated that the number of consumers 

choosing BAP will continue to increase noticeably, 

possibly reaching between 150 and 200 consumers by 

2025. 

• Prosthetists’ concerns. This project was also required to 

adequately recognize the hours spent by prosthetic care 

providers looking after consumers with BAP that should 

be supported by QALS. In 2012, there were no items 

within the existing QALS’ schedules of allowable hours 

that prosthetists could claim after they provided 

standard care to fit BAP (e.g., no set hours for a specific 

service). The pathways for the compensation of their 

services were unclear. Providers could potentially 

experience improper compensation for fitting the BAP 

and loss of revenues from socket fittings. 

Internal drivers 

This research project was also needed from several QALS 

organizational standpoints, including, but not limited to, the 

need to: 

• Apply evidence-based practice. Like other government 

organizations, QALS was required to provide evidence 

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Citations 

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Figure 2: Key indicators of the overall scientific impact of the research project (e.g., publication output, scientific recognition, international 

acknowledgments) focusing on the health service delivery and health economic evaluation of limb lower bone-anchored prostheses lead by 

the Queensland Artificial Limb Service between 2015 and 2020. 

https://doi.org/10.33137/cpoj.v4i2.36210


 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

Berg D. & Frossard L., 2021 CPOJ 

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supporting decisions about reimbursement standards, 

particularly for the provision of new health technology 

innovations that could be costly and obsolete within five 

years.12 

• Manage stakeholders’ expectations. Clarification of the 

processes for service delivery of BAP was required to 

manage expectations from QALS stakeholders, 

including consumers and prosthetic care providers. 

Consideration whether the proposed procedures had 

legal bearings might be irrelevant (e.g., unlikelihood of 

lawsuits). Regardless, QALS believed that outlying 

these processes should help mitigate potential 

misunderstandings and conflicts inherent to the 

implementation of a new and, possibly, risky treatment. 

• Verify cost-saving potential. Economic evaluations were 

required to confirm and, more importantly, to quantify if 

taxpayers’ money could be saved with the provision of 

BAP, reducing the costs of socket fittings. 

Understanding cost-saving was essential to facilitate 

implementation given the budget constraints.  

• Assist strategic planning. One of the most critical drivers 

was to gather sufficient information to complete the 

QALS’ five-year strategic business plan, including yearly 

budgets for the provision of prosthetic care stratified by 

case-mix, including those with BAP. It was anticipated 

that the outcomes of this project would assist QALS with 

predictable workflow, help manage resources, and 

ultimately plan a realistic budget. 

• Take leadership. Perhaps less pragmatic but equally 

important was QALS’ aspiration to take a leadership role 

in the area of health economic research on prosthetic 

osseointegration solutions that was then overlooked. 

IMPACT 

Overview 

The overall impact of the project was summarized by nine 

key indicators which are presented in Figure 2 reflecting the 

publication outputs, scientific recognitions, and international 

acknowledgments. 

Publication outputs 

To date, we have authored a series of 21 publications 

between 2015 and 2020 (e.g., Digital Object Identifier, 

International Standard Book Number), including six (48%) 

original research papers, one (5%) dataset paper, three 

(14%) repository papers, nine (43%) abstracts in national 

and international conferences, and two (10%) scientific 

annual reports.13-33 Only manuscripts published or in press 

were considered here. However, several manuscripts are 

currently in preparation for submission to health economics 

and prosthetic care journals as well as open access 

repositories (e.g., Data In Brief). 

Scientific recognitions 

The recognition of each publication was assessed using 

conventional bibliometrics and altmetrics, including the 

number of views, downloads, and citations extracted from 

research institutions’ repositories, social network sites for 

scientists, publishers’ websites, and citation databases. To 

date, these publications have accumulated approximately 

13,600 views, 6,500 downloads, and 95 citations, as 

detailed in Table 1. Citations of the three papers were in the 

46th, 71st, and 46th percentiles corresponding to average, 

good, and above-average attention scores compared to 

other papers of a similar age in all journals, according to 

PharmacoEconomics-Open, Journal of Prosthetics and 

  Items Views(1) Download(1) Citations(1) 
  (#) (%) (#) (%) (#) (%) (#) (%) 

Total publications 21 100 13,666 100 6,543 100 95 100 

Total papers 10 48 9,859 72 5,298 81 94 99 

Original papers (2) 6 29 9,638 71 5,144 79 91 96 

Dataset papers (3) 1 5 221 2 154 2 3 3 

Repository papers (4) 3 14 0 0 0 0 0 0 

Total abstracts 9 43 2,930 21 841 13 0 0 

International conference (5) 1 5 243 2 62 1 0 0 

National conference (6) 8 38 2,687 20 779 12 0 0 

Total reports 2 10 877 6 404 6 1 1 

(1) Extracted from research institutions’ free-access repositories (i.e., Queensland University of Technology’s ePrint, University of the Sunshine Coast’s Research 
Banks, Griffith University Research Online), social networks sites for scientists (i.e., ResearchGate, Mendeley), publishers’ websites (i.e., Canadian Prosthetics 
& Orthotics Journal, Data In Brief, Journal of Prosthetics and Orthotics, PharmacoEconomics-Open, Prosthetics and Orthotics International) and citation 
databases (i.e., Google Scholar, Elsevier's Scopus); (2) Published in Canadian Prosthetics & Orthotics Journal, Journal of Prosthetics and Orthotics, 
PharmacoEconomics-Open, Prosthetics and Orthotics International, The AOPA Revie; (3) Published in Data In Brief; (4) Published in Mendeley; (5) Presented at 
International Society of Prosthetics and Orthotics; (6) Presented at Australasian Osseointegrated for Amputees Conference 

 

Table 1: Number and percentage of views, downloads, and citations of each type of publication focusing on the health service delivery and 

health economic evaluation of limb lower bone-anchored prostheses produced by the Queensland Artificial Limb Service (QALS) between 

2015 and 2020. 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

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Orthotics, and Prosthetics and Orthotics International, 

respectively.14,16 

International acknowledgments 

Analyses of ePrint records indicated that publications were 

downloaded from approximately 70 countries, with 75% of 

the downloads made from Australia (32%), United States of 

America (30%), Canada (6%), United Kingdom of Great 

Britain and Northern Ireland (4%), and Ireland (3%). More 

importantly, these publications were considered and often 

cited in recent health technology assessments of 

osseointegrated prosthetic solutions produced by several 

government organizations (e.g., Australian states, 

Canadian provinces, United Kingdom, New Zealand, 

Spain).34-40 This work provided guidance when the 

Australian National Disability Insurance Scheme developed 

its funding model. 

CONTRIBUTIONS 

The actual developments of each topic of research 

progressed altogether and often organically, depending on 

opportunities and resources. Therefore, contributions are 

presented by topics rather than historical evolution. 

Health service delivery 

Our primary contribution was the development of a policy 

regulating the provision of BAP-specific prosthetic care. 

Effectively, these procedures organized a workflow 

meshing role for prosthetists, a quality improvement of 

specific procedures, and assessment of overall consumers’ 

experience and quality of life. 

Policy for provision of BAP 

In 2012, information from health technology assessments of 

direct skeletal attachment that could help develop this policy 

was sparse.10,11,41-44 Consequently, we conducted an 

action research study involving the first 18 QALS 

consumers between January 2011 and June 2015 to create 

QALS policy for the provision of transfemoral BAP.14,23,28  

An initial version of this policy was published in 2017 (e.g., 

tasks, documents, costs), including possible obstacles and 

facilitators to implementation.14 An equitable provision of 

transfemoral BAP was based on seven processes involving 

fixed expenses during the treatment and five processes 

regulating ongoing prosthetic care expenses. The 

cornerstone of this policy was the allowance of 22 h toward 

prosthetist’s labor to support delivery of BAP care costing 

up to AUD$3,300 per consumer. A prosthetist could spend 

2.5 h (11%), 2.5 h (11%), 6.5 h (30%), and 10.5 h (48%) 

during the preoperative, surgical, fitting of light and definitive 

limb prostheses, and postoperative phases of the treatment, 

respectively. 

This policy required adjustments related to the prosthetists’ 

scope of practice, funding of prosthetic limbs during 

rehabilitation, and allocation of microprocessor-controlled 

prosthetic knees. 

Role of prosthetists 

Early investigations revealed that the role of prosthetists in 

the provision of BAP has been largely overlooked, although 

they are at the heart of treatment (e.g., primary point of 

contact for consumers, responsible for prosthetic 

loading).10,17,42 In the policy presented earlier, prosthetists 

could claim up to 22 h of labor including 4 h (18%), 2 h (9%), 

14 h (64%), and 2 h (9%) to consult with the clinical team, 

evaluate functional outcomes, fit light and definitive 

prostheses, and report progress to stakeholders before and 

after the surgical implantation of the osseointegrated 

fixation, respectively.14 

As summarized in Figure 3, Frossard et al. (2018) further 

detailed the critical roles prosthetists could play during the 

provision of BAP, including referral of consumers (e.g., 

discussing fitting options, elucidating surgical procedures, 

selecting the surgical team).17 The survey presented by 

Frossard et al. (2019) indicated that 25% of QALS 

consumers found information about the surgical procedure 

from a prosthetist.20 As expected, prosthetists should be 

responsible for usual fitting tasks (e.g., selection of 

components, alignment of prosthesis, prevention of falls). 

However, as reported in Clark (2021), prosthetists also play 

a key role in the prevention of load-related adverse events 

when fitting bone-anchored bionics prostheses.45 Fittings of 

BAP must be made with additional constraints to limit 

unwanted loads, leading to increased risks for the bone-

implant interface (e.g., loosening, breakage of connector 

and safety device, periprosthetic fractures, infection, 

removal).46-50 

Altogether, this study showed that the provision of BAP has 

the potential to be slightly outside the usual scope of 

practice of prosthetists.51 Training opportunities by qualified 

experts, guidelines from suppliers of implants, and formal 

recommendations from governing bodies about prosthetic 

care of consumers fitted with BAP and business 

management that could help reduce risks are sparse, or 

even missing, in some jurisdictions. Prosthetists may 

potentially be exposed to increased risks when treating BAP 

consumers.17 

Quality improvement procedure 

The implementation of the QALS policy for the provision of 

transfemoral BAP has subsequently created a need for a 

continuous quality improvement (CQI) procedure seeking to 

enhance consumers’ experience with the QALS process, 

supporting the provision of BAP. 

 

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7 

Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

Berg D. & Frossard L., 2021 CPOJ 

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Figure 3: Roles, actions and focus of prosthetic care provided by prosthetists to consumers fitted with transfemoral and transtibial bone-

anchored prostheses at various stages of treatment (e.g., pre-op, surgery, post-op, on-going) included tasks supported by Queensland 

Artificial Limb Service (QALS) and tasks of the fringe of usual scope of practice of prosthetists. Adapted from Frossard et al (2018).17 

Pre-op 

Definitive prosthesis 

Manage 
Bone/implant 

coupling 

Select 

consumer R
o
le

 
F

o
c
u
s
 

On-going Surgeries 

Rehabilitation 

prosthesis 

Post-op 

Provide  prosthetic care 

A
c
ti
o
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Action supported by QALS 

Refer 

Fall 

Periprosthetic 

fractures 

Component breakage 

Under loading 

Over loading 

Removal 

Superficial/Deep 

Infection Infections 

Eligibility 
Implant 

placement 

Understand 
residuum 

configuration 

Screen 

Report 

Consult 

Report 

Fit 

Assess 

Report 

Service 

Assess 

Report 

Prevent 

Monitor 

Address 

Loosening 

Action at the fringe of scope of practice Action supported by QALS 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

Berg D. & Frossard L., 2021 CPOJ 

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Frossard et al. (2018) presented a BAP-inclusive CQI 

procedure.17,32 A redesign study led to this procedure to 

collect, analyze, and report the experience of 65 QALS 

consumers who delivered BAP-specific prosthetic care, as 

presented in Figure 4. The proposed CQI procedure 

required 1.3 h of prosthetist labor or 6% of the 22 h allowed 

for the whole procedure presented above, costing AUD$213 

per episode of care. The time spent by a prosthetist, 

consumer, and QALS staff represented 24%, 24%, and 

53% of the CQI procedure, respectively. The costs of labor 

for prosthetist and QALS staff represented 70% and 30% of 

the CQI procedure, respectively. 

This study demonstrated that government organizations 

can redesign a CQI procedure for comprehensive appraisal 

of the provision of prostheses that could be: inclusive of 

BAP, affordable and swift for prosthetists. Achieving a 

minimally disruptive BAP-inclusive CQI procedure can be 

facilitated by adaptation of a procedure already in place 

(e.g., use of routing questions to indicate if the survey is for 

SSP or BAP). 

Consumer’s quality of life 

Another integral part of the CQI procedure was to assess 

consumers’ experience with the overall provision of BAP 

and changes in their quality of life after implantation of an 

osseointegrated fixation. 

Frossard et al. (2019) presented the outcomes of a 25-

question ad hoc survey, including 7 (28%), 5 (20%), and 13 

(52%) questions about “Osseointegration Surgery Details,” 

“Pre-Osseointegration Surgery,” and “Post-Surgery 

Osseointegration”, respectively.20 A total of 12 out of the 65 

eligible QALS consumers completed the survey, giving a 

return rate of 18%. All respondents were “happy” with their 

BAP and indicated that “it works as it should”, including 91% 

of respondents satisfied with the componentry fitted to their 

BAP. Key figures of the respondents’ experience with 

efficacy and safety of the procedure are provided in Table 2. 

More importantly, all respondents reported a level of 

satisfaction and quality of life above eight and seven out of 

10 after surgical implantation of the osseointegrated fixation 

and fitting with BAP, respectively. These outcomes suggest 

that QALS policy about the provision of BAP seemed to 

contribute favorably to overall consumer satisfaction. 

Altogether, this work provided benchmark information that 

can educate the design of patients’ experience surveys and 

clinical trials looking at the effects of bionic solutions on 

consumers’ quality of life (e.g., built-in governmental CQI 

procedure). 

Health economic evaluations 

The QALS policy was validated by economic evaluations. 

Basically, this involved looking at CUA comparing BAP (new 

interventions) and SSP (usual treatment) using the 

incremental cost-utility ratio (ICUR) based on incremental 

costs, expressed in Australian dollars, and utilities, 

expressed in quality-adjusted life-years (QALYs), over time, 

that could be compared to the willingness-to-pay threshold 

(WTP) set at AUD$40,000 per QALY.16,18,52-55 

We purposely chose to perform preliminary CUAs, as 

detailed below, when discussing barriers and facilitators. 

These analyses were conducted following an initial version 

of the 15-step iterative process (e.g., feasibility, constructs, 

analysis, interpretation) presented by Frossard et al. 

(2021).38,39 Both preliminary CUAs of transfemoral and 

transtibial BAPs were performed for a small series of 

plausible scenarios over a six-year time horizon from the 

government perspective.16,18 An overview of our approach 

to collect, extract, and analyze estimates of costs and 

utilities is presented in Figure 5. Total costs combined actual 

and typical costs extracted from financial records and 

allowable expense schedules, respectively. Baseline 

utilities were extracted from the literature, while incremental 

utilities were assumed. 

Table 2: Key figures about the efficacy and safety of surgical 

implantation of the osseointegrated fixation and fitting with bone-

anchored prosthesis (BAP) extracted from self-reported ad hoc 

consumers survey administered by Queensland Artificial Limb 

Service. 

Efficacy Safety 

• Respondents wear their BAP 
on average 17±6 hours per 
day 
 

• 91% of respondents said 
their BAP supported their 
lifestyle needs 

• 58% of respondents 
experienced some 
infections around the exit 
point of their percutaneous 
part post-surgery  
 

• Respondents experience 
an episode of infections 
the exit point of their 
percutaneous part post-
surgery for an average of 
145±170 days 

 

Preliminary cost-utility analysis of transfemoral BAP 

Frossard et al. (2017) cross-compared historical costs for 

the provision of SSP with the simulated costs for 

transfemoral BAP (e.g., labor, parts).14 Costs were 

extracted from QALS regulatory documentation according 

to functional levels (e.g., K-levels) and low-cost, budget, 

and high-cost options for knee and ankle units. The 

provision of a transfemoral BAP was 18% and 79% less 

than SSP for the prosthetist labor and attachment costs, 

respectively. BAP was more economical by AUD$18,200, 

AUD$7,000, and AUD$1,600 when fitted with low-cost, 

budget, and high-cost options, respectively, compared with 

SSP for the highest functional level (i.e., K4). 

Frossard et al. (2018) reported preliminary CUA for a cohort 

of 16 QALS consumers using transfemoral BAP (Table 3).16 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

Berg D. & Frossard L., 2021 CPOJ 

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The average cost for the provision of transfemoral BAPs 

was approximately 40% (AUD$13,562±AUD$16,497) more 

than SSP, which can be partially offset by an increase of 

0.815 QALY. The provision of a transfemoral BAP was cost-

saving and cost-effective for 19% and 88% of the 

consumers, respectively. The indicative ICUR for the 

provision of a transfemoral BAP was approximately 

AUD$17,000 per QALY and significantly below the WTP 

(Figure 6). 

 

Preliminary cost-utility analysis of transtibial BAP 

Frossard et al. (2021) reported a preliminary CUA for six 

QALS consumers using transtibial BAP (Table 3).18 The 

average cost for the provision of transtibial BAPs was 

approximately 20% (AUD$5,604 ± AUD$12,180) more 

costly than SSP, which can be offset by an increase of 0.489 

QALY. The provision of a transtibial BAP was more 

expensive and cost-saving for 67% and 33% of the 

participants, respectively.  

P
ro

s
th

e
ti
c
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a
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p
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v
id

e
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C
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s
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e
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F
o

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A
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Service 

Evaluation  A 

Surgeries Post-op Light limb Pre-op 

Review 

Reimburse 

Enter 

Review 

Enter 

Review 

Enter 

Evaluation C Evaluation B 

PID VOS PSE 

Invoice 

Acknowledge Evaluate Evaluate 

SSP BAP SSP BAP SSP BAP 

Routing question Routing question Routing question 

Definitive limb 

Figure 4: Overview of continuous quality improvement (CQI) procedure seeking to enhance Queensland Artificial Limb Service (QALS) 

consumer’ experience with the provision of socket-suspended (SSP) and bone-anchored (BAP) prostheses that involved collection of data 

with prosthetic care providers and consumers (PID: Prosthetic Issue Document, VOS: Validation of Services, PSE: Prosthetic Service 

Evaluation). Adapted from Frossard et al (2018).17 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

Berg D. & Frossard L., 2021 CPOJ 

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The indicative ICUR for the provision of a transtibial BAP 

was AUD$12,000 per QALY and significantly below the 

WTP (Figure 6). 

Table 3: Outcome of preliminary cost-utility analyses providing 

indicative incremental cost-utility ratio (ICUR) based on incremental 

costs expressed in Australian dollars and utilities expressed in 

quality-adjusted life-years (QALY) for the provision of transfemoral 

(2016-2017 prices: 1 Australian dollar ≈ 0.71 Euro ≈ 0.60 British 

pound ≈ 0.76 US dollar) and transtibial (2018-2019  prices: 1 

Australian dollar ≈ 0.63 Euro ≈ 0.54 British pound ≈ 0.71 US dollar) 

bone-anchored prosthesis (BAP) from Queensland Artificial Limb 

Service (QALS) prosthetic care perspective (N: Number of 

consumers).16,18 

Early evidence of health economic benefits 

These studies revealed that early engagements with 

suppliers of prosthetic components particularly suited for 

transfemoral BAP can strongly impact the overall costs 

(e.g., economical advanced knee and foot/ankle units). 

These studies also highlighted that suppliers of 

osseointegrated fixations can influence the outcomes of 

CUA as the cost of their percutaneous parts (e.g., 

connectors, protective device) could offset the costs of 

socket fittings. In all cases, the provision of both 

transfemoral and transtibial BAPs appeared to be 

acceptable alternatives to SSP from an Australian 

government prosthetic care perspective. 

BARRIERS 

An overview of the 17 main barriers encountered during this 

project is presented in Table 4. A total of 5 barriers (29%) 

were related to service delivery, 11 (65%) to economic 

evaluation, and 5 (29%) to project management. A total of 4 
and 13 barriers were deemed unlikely (e.g., access to 

limited resources, dealing with multiple funding allowances, 

addressing ethics issues, accommodating new national 

Figure 5: Overview of the approach applied to conduct preliminary cost-utility analyses (CUA) of transfemoral and transtibial bone-anchored 

(BAP) compared to socket-suspended (SSP) prostheses providing incremental cost-utility ratios (ICUR) based on incremental costs expressed 

in monetary units and utilities expressed in quality-adjusted life-years (QALY) that were compared to willingness-to-pay threshold (WTP) for 

small series of plausible scenarios (e.g., base-case, worst-case, best-case) over a six-year time horizon from Queensland Artificial Limb 

Service (QALS) prosthetic care perspective.16,18 

Dataset 1 

Actual costs 

Dataset 2 
Typical costs 

Scenario 3 
Base-case 

Scenario 2 
Worst-case 

Scenario 1 
Best-case 

Incremental  
cost 

Incremental  
QALY 

Health related quality of life Educated choices 

Systematic review 
Literature 

review 

Cost 

Legislation 

Finance 
system 

Select 
consumers 

ICUR 

WTP 

BAP BAP BAP BAP 

SSP SSP SSP SSP 

Actual         +         Typical 

  
Increment 

cost 
Increment utility 

Indicative 
ICUR 

   ($/cycle)  (QALY/cycle) ($/QALY) 

Transfemoral BAP (N=16) 
    

Mean $13,562 0.815 $16,632 

Standard deviation $16,497 0.000 $20,231 

Minimum -$20,933 0.815 -$25,671 

Maximum $43,625 0.815 $53,499 

Transtibial BAP (N=12) 
    

Mean $5,604 0.489 $11,453 

Standard deviation $12,180 0.000 $24,895 

Minimum -$12,263 0.489 -$25,065 

Maximum $20,514 0.489 $41,929 

 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

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schemes) and likely (e.g., face inconsistency of care 

pathways, design preliminary CUA, predict timeline of 

publications) to be met by other government organizations 

such as QALS. Here, we have only detailed the core 

barriers that set in motion cause-and-effect reactions onto 

other obstacles. 

Access to limited resources 

As with most prosthetic care departments, resources to 

undertake a research project of developing evidence-based 

policy are sparse. Unfortunately, we were unable to 

collaborate with services specialized in health technology 

assessment within the Minister of Health. In 2016, we 

applied for two unsuccessful grants (e.g., Defense Health 

Foundation Grants for Medical Research, Australian Centre 

for Health Services Innovation – Implementation Grant). 

Supports from other services and funders were curtailed by 

their perception that the provision of BAP was “too niche.” 

Alternatively, the project was to run with QALS and its 

partner resources (e.g., staff time, consultancy). 

 

Face inconsistency of care pathways 

Another root cause barrier was the unpredictability of BAP 

care pathways corresponding to the onset of a series of 

interventions made by specialists during the course of 

treatment. Generic descriptions of the surgical procedures 

and rehabilitation programs specific to either screw-type or 

press-fit implants published by teams overseas were 

available when we started.1,2,,6,7,9,56-62  

Additional ad hoc guidance for specific aspects were 

provided regularly by main teams in Australia as their own 

procedure evolved organically from case to case. 

Sometimes information from various sources agreed, but 

they often contradicted themselves. Consumers in the same 

case-mix rarely followed comparable care plans. Practically, 

it was difficult to grasp “who was doing what and when” 

around the fitting of BAP. Uncertainty about the continuum 

of care across preoperative, surgical, and postoperative 

phases of the treatment created the following barriers: 

• Sort out schedules for allowable expenses. The 

adequate allocation of allowable hours to support the 

provision of BAP-specific prosthetic care was initially 

       

                 $(40,000)

 $(30,000)

 $(20,000)

 $(10,000)

 $-

 $10,000

 $20,000

 $30,000

 $40,000

-1.00 -0.80 -0.60 -0.40 -0.20 0.00 0.20 0.40 0.60 0.80 1.00

C
o
st

 (
A

U
D

$
)

Health gain (QALY)

Transfemoral BAP (N=16) Transtibial BAP (N=12) WTP

Quadrant 2: "Dominated" Quadrant 1: "Consider ICUR"

Quadrant 3: "Consider ICUR" Quadrant 4: "Dominant"

Figure 6: Overview of cost-utility analysis showing indicative incremental cost-utility ratio of AUD$16,632 and AUD$11,453 per quality-

adjusted life-year (QALY) and willingness-to-pay threshold (WTP) of AUD$40,000 per QALY for transfemoral (2016-2017 prices: 1 Australian 

dollar ≈ 0.71 Euro ≈ 0.60 British pound ≈ 0.76 US dollar) and transtibial (2018-2019  prices: 1 Australian dollar ≈ 0.63 Euro ≈ 0.54 British pound 

≈ 0.71 US dollar) bone-anchored prosthesis (BAP) that were more costly and more effective than socket-suspended prosthesis (Quadrant 1) 

and below WTP from Queensland Artificial Limb Service’s (QALS) prosthetic care perspective, respectively (N: Number of consumers).16,18 

$40,000 

 

$30,000 

 

$20,000 

 

$10,000 

 

$ 

 

$10,000 

 

$20,000 

 

$30,000 

 

$40,000 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

Berg D. & Frossard L., 2021 CPOJ 

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complicated by the lack of clarity of overall care 

pathways. Furthermore, providers expressed legitimate 

concerns about the economic viability of delivering BAP, 

reducing revenue from socket fittings. Discussions with 

clinical teams and prosthetists led to a consensus and 

subsequent creation of the QALS schedule, including 22 

allowable h of labor to support BAP care. This was only 

approximately 10 h less compared to the typical 32 h of 

labor allowed for a socket fitting (i.e., 6 h to cast the 

residuum, 20 h to build a socket, 6 h to fit a 

socket).14,17,38,39 However, the loss of income could be 

compensated by fitting BAP with high-end components. 

• Dealing with diversity of outcome measures. Accessing 

clinical outcomes with osseointegrated implants is 

critical for health economic evaluations (e.g., choice of 

utility). However, assessing benefits, let alone harms, of 

surgical treatment was beyond QALS’ prerogatives. 

Alternatively, we had to rely on a limited number of 

outcomes extracted from external sources. Choosing 

relevant outcomes was facilitated by the generic 

evaluation framework presented in Figure 7 which 

mapped out standardized and nonstandardized 

instruments for quantitative or qualitative measures of 

the benefits and harms before and after the fitting of BAP 

used by teams overseas.17,63 Ultimately, we preferred 

health-related quality of life data measured by the 

standardized 36-Item Short Form Survey (SF36) as the 

primary outcomes to reflect benefits and, more 

particularly, utility of the treatment.7,57,64 

• Palliate limited standards of prosthetic care. Inconsistent 

care pathways and diversity in outcome measures, all 

combined, hinder the understanding of the cause-and-

effect relationships between treatment options, benefits, 

and harms (e.g., two-stage for screw-type, single-stage 

for press-fit).65,66 This limited the emergence of 

reasonable standards for BAP-specific prosthetic care, 

let alone the best standards around fitting arrangements 

that could possibly maximize benefits and minimize 

exposure to risks (Figure 7). However, the evaluation 

framework raised our awareness about the links 

between the risks of adverse events and loading 

regimen depending on the fitting of components as well 

as daily usage of BAP. Clearly, the choice of 

components can play a critical role in reducing load-

related harms susceptible to osseointegration and the 

long-term stability of the bone/implant coupling.46,48-

50,67-69 Initially, only a small case series showed 

differences between loading profiles applied by different 

categories of components (e.g., basic and advanced 

knee units).69 We examined mechanically passive 

components with basic functions such as single-axis or 

polycentric hydraulic knees and multiaxial foot-ankle 

units. Finally, we acknowledged that the fitting of the 

microprocessor-controlled knee (MPK) and energy-

storing-and-return (ESAR) foot was required. This 

decision was based on the best evidence available and, 

more heavily, on the alleged capabilities of these 

components to increase stability (e.g., stance and swing 

control), ease of walking (e.g., high range of motion, 

mechanically powered push-off), attenuate excessive 

loading (e.g., auto-adaptive stance and swing phases), 

and reduce falls (e.g., automatic stumble recovery).70 

Ultimately, we opted to support the provision of a 

“budget option.” This package combines a single-axis 

cadence-responsive knee, shock absorption adapter, 

tube adapter, and a dynamic foot that are commonly 

provided to QALS consumers with the highest functional 

outcomes (e.g., K4). 

Table 4: List of common and QALS barriers related to health 

service delivery (HSD) and/or health economic evaluation (HEE) 

and/or project management (PM) encountered during research 

focusing on the provision of lower limb bone-anchored prostheses 

(BAP) led by the Queensland Artificial Limb Service (QALS). ((S): 

Detailed description to be published in a Data In Brief). 

Design preliminary CUA 

Undertaking preliminary CUA came with a range of 

subsequent obstacles to overcome when choosing the 

constructs framing the analysis, including, but not limited to, 

the following: 

• Choosing a relevant perspective. First, we had to 

choose the perspective of the CUA corresponding to the 

point of view adopted when deciding which healthcare 

    HSD HEE PM 

1 QALS barriers       

1-1 Access to limited resources   x 

1-2 Deal with multiple funding allowance (S)   x 

1-3 Address ethics issues (S) x x  

1-4 New national scheme (S)   x 

  Number of QALS barriers 1 1 3 

2 Common barriers    

2-1 Face inconsistency of care pathways x x  

2-2 Sort out schedules of allowable expenses x x x 

2-3 Deal with diversity of outcome measures x   

2-4 Palliate limited standards of prosthetic care  x   

2-5 Choose health economic analysis (S)  x  

2-6 Choose type of cost-utility analysis (S)  x  

2-7 Design preliminary cost-utility analysis  x  

2-7-1 Choose relevant perspective  x  

2-7-2 Establish relevant time horizon  x  

2-7-3 Estimate costs  x  

2-7-4 Access utilities  x  

2-7-5 Estimate weight of assumptions  x  

2-8 Predict timeline of publications (S)   x 

  Number of common barriers 4 10 2 

  Number of barriers 5 11 5 

 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
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costs should be considered. In principle, a 

comprehensive analysis could include all surgical, 

medical, and prosthetic healthcare costs covered by 

taxpayers. However, Queensland State healthcare 

organizations are structured in such a way that whether 

the fitting of BAP affects medical costs has little impact 

on the QALS’ resources. We were more concerned with 

the potential reduction in the cost of prosthetic care. 

Therefore, CUAs were only conducted from the 

perspective of government prosthetic care. 

• Establishing a relevant time horizon. The second 

obstacle was to determine the relevant time horizon 

corresponding to the time over which outcomes of the 

innovation should be evaluated.71,72 Basu et al. (2019) 

stated that the time horizon must be long enough to 

capture the intended and unintended benefits and 

harms of the intervention.71 O’Mahony et al. (2015) 

indicated that it is often unclear how time influences both 

the technical adequacy of cost-effectiveness analyses 

and their correspondence to the policy choices they 

seek to inform.73 Osseointegrated implants are 

permanent, and fittings of BAP are continuous. At first 

glance, it could make sense to perform a comprehensive 

CUA using Markov decision-analytic models to look at 

multiple scenarios over scalable time horizons (e.g., 

years, decades, lifetime).44,74-78 However, O’Mahony et 

al. (2015) demonstrated that the approximation error is 

larger with the long cycle length and that the short cycle 

cost-effectiveness analyses better approximates the 

continuous-time reality.73 Furthermore, the World Health 

Organization recommended the production of generic 

cost-effectiveness analyses focusing on resources that 

could realistically be reallocated over the time horizon of 

the analysis.72 These recommendations lead us to make 

a compromise of a six-year time horizon, allowing a 

reasonable prediction of the costs over the components’ 

life cycle (e.g., two cycles of three years for a foot, three 

cycles of two years for a knee).16,18 

• Estimate costs. Expenses from the QALS financial 

system for the provision of SSP or BAP were 

unavailable when individuals became QALS consumers 

less than six years before the surgery or when surgery 

occurred less than six years before the end of the study. 

As detailed above, the total costs were estimated by 

blending actual and typical costs. A prediction variable 

corresponding to relative typical costs over the total 

costs, expressed as a percentage of the six-year funding 

cycle, was created to specify the level of uncertainty of 

the cost estimates. A prediction of 0% and 100% 

indicated that the total costs were fully extracted from 

the schedule and financial records, respectively. The 

overall cost predictions were 48±20% and 46±22% for 

the provision of transfemoral (SSP, 42±32%; BAP, 

55±27%) and transtibial (SSP, 43±40%; BAP, 49±12%) 

prostheses, respectively. 

• Access utilities. In principle, utility data may have been 

obtained from the Australian treating teams. However, 

this option turned out to be impractical (e.g., access 

limited by ethics, no state-based stratification of 

datasets) and potentially unreliable (e.g., no clinical trial 

registration). These issues were resolvable. However, 

we chose to consider the quality of life status published 

previously.7,8 Baseline QALY were extracted from SF36 

datasets converted into QALY applying regression 

model.[16, 18] We made conservative assumptions to 

determine the incremental gain of QALY between the 

SSP and BAP fitting options. 

• Estimate the weight of the assumptions. By definition, 

preliminary CUAs overlook comprehensive uncertainty 

and sensibility analyses. Therefore, understanding the 

impact of assumptions to estimate individual costs (e.g., 

creation of a schedule of allowable expenses, blending 

of actual and typical costs) and utilities (e.g., extraction 

of baseline from literature, assumptions for incremental 

gain) on both ICURs for transfemoral and transtibial 

BAPs was limited. 

The choice of the preliminary CUA turned into a facilitator 

over time. Shortcomings might limit the strength of the 

evidence of cost-utility. However, this decision was critical 

in delivering the project on budget, on time, and with added 

value. Furthermore, publications of the outcomes 

contributed to the conversation about the relevance and 

possibly the standardization of preliminary CUAs to assess 

prosthetic care innovations.38,39,79-81 

FACILITATORS 

An overview of the 18 key facilitators is presented in Table 

5. A total of 4 (22%) facilitators related to service delivery, 

10 (56%) to economic evaluation, and 8 (44%) to project 

management.  

A total of 10 facilitators might be specific to QALS (e.g., 

engage with local research teams, involve a critical number 

of consumers, access to financial data, customize 

databases, share datasets, use of free repositories). Eight 

facilitators could be transferable to other organizations (e.g., 

frame action research plan, choose preliminary CUA, adapt 

rather than create procedures, engage with social media, 

monitor impact). Next, we only detailed the facilitators 

deemed the most critical.  

Customize database 

QALS’ preliminary CUAs were facilitated by a piece of 

software purposely designed to: 

• Import historical data from 1,840 vouchers exported 

from QALS’ financial system for CUA of transfemoral 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
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ISSN: 2561-987X 
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(i.e., 1,598 vouchers) and transtibial (i.e., 242 vouchers) 

BAPs.16,18 

• Code individual expenses from 4,014 claims to identify 

whether there were for transfemoral or transtibial 

prostheses, SPP or BAP, labor (e.g., fitting prosthesis) 
or parts (e.g., prosthetic knees and feet units), 

attachment (e.g., socket, connectors), or prosthesis.16,18 

 • Compare aggregated costs for individuals and groups 

over the time horizon with SSP and BAP before and after 

surgical intervention, respectively.14,16,18 

• Create reports including tables and figures formatted for 

internal communication (e.g., quarterly budget, annual 

reports) and publications of papers (e.g., manuscript, 

supplement).14,16,18 

This database gave us the flexibility to run queries on 

demand to present the most up-to-date analyses and 

outcomes (e.g., new individual expenses to improve 

predictions). 

Use of free repositories 

Like most government organizations, QALS must make the 

outputs of the project freely available to taxpayers in 

Australia and elsewhere, in a timely manner. 

We made the point to share original research, datasets, and 

repository papers including supplements and spreadsheets 

Figure 7: Overview of evaluation framework to extract clinical benefits and harms including prosthetic load-related outcomes (SF-36: 36-Item 

Short Form Survey, Q-TFA: Questionnaire for Persons with a Transfemoral Amputation, AMPRO: Amputee mobility predictor, ABC: Activities-

specific Balance Confidence scale, TUG: Timed Up and Go test, 6MWT: 6-minute walk test, GaitRite (CIR Systems Inc, USA), Gait laboratory 

equipment (e.g., 3D motion capture, force plates), iPecsLab (RTC electronics, USA), Fitbit (Fitbit Inc, USA)).17,63 

Residuum 
integrity Infection 

Fixation 
stability 

Fixation 
integrity 

Catastrophic  
failure 

Injuries 

Interview 

Observations 

Interview Interview Interview Interview Interview 

Observations Observations Observations Observations Observations 

iPecsLab 

Pathology X-Rays 

Grading 

X-Rays / MRI X-Rays / MRI X-Rays / MRI X-Rays 

Skin loosening 
and/or  

irritation 

Superficial 

infection 

Deep 

infection 
Loosening 

Periprosthetic 

fractures 

Falls 

Breakage 

implant 

Removal of 

implant 

Sound 

limbs 

Mental and 

Physical 

Component 

Summaries 

Prosthetic use, 

Mobility, 

Problem, 

Global 

Amputee 

mobility 

predictor score 

Balance Duration Distance 

walked 

Characteristics 

spatial and 

temporal  

Inner 

 loading 

Usage of 

prosthesis 

Number of steps,     

Physical activity 

duration,  

Total energy 

expended 

K-level Prosthetic use-VM 

SF-36 Q-TFA AMPRO ABC TUG 6MWT GaitRite Gait lab iPecsLab Fitbit 

Generic Specific 

Health related quality of life 

Mobility 

Prediction 
Stability Ambulation abilities Walking abilities Activity level 

Benefits 

Harms 

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ISSN: 2561-987X 
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as well as abstracts and scientific annual reports available 

free of cost to the public, either from publishers’ websites, 

social network sites for scientists, and/or research institution 

repositories (Table 1). 

Availability of publications increased visibility and built up 

credentials. Portals provided a means to monitor the impact 

(e.g., numbers of views and downloads). In the long run, we 

hope that access to primary information will encourage 

collaboration with other promoters of BAP and facilitate 

secondary observational studies (e.g., analyses of cause-

effect relationships between confounders and provision of 

BAP) and literature reviews and meta-analyses.40 

Table 5: List of specific and transferable facilitators related to health 

service delivery (HSD) and/or health economic evaluations (HEE) 

and/or project management (PM) encountered during research 

focusing on the provision of lower limb bone-anchored prostheses 

(BAP) led by the Queensland Artificial Limb Service (QALS). ((S): 

Detailed description to be published in a Data In Brief) 

    HSD HEE PM 

1 QALS facilitators       

1-1 Engage with local research teams (S)   x 

1-2 Involve critical number of consumers (S) x x  

1-3 Access to financial data (S)  x  

1-4 Customize database  x  

1-4-1 Import historical data   x  

1-4-2 Code expenses  x  

1-4-3 Compare costs   x  

1-4-4 Create reports   x  

1-5 Share datasets (S)   x 

1-6 Use of free repositories   x 

  Number of QALS facilitators 1 7 3 

2 Transferable facilitators       

2-1 Frame action-research plan   x 

2-1-1 Gather reference group  x x x 

2-1-2 Create stakeholder matrix    x 

2-1-3 Profile case-mix x x  

2-2 Adapt rather create procedure (S) x   

2-3 Choose preliminary CUA (S)  x  

2-4 Engage with social media (S)   x 

2-5 Monitor impact (S)   x 

  Number of transferable facilitators 3 3 5  

  Number of facilitators 4 10 8 
 

Frame action research plan 

Perhaps more transferable were the lessons learned from 

the first steps of action research. Studies started with the 

planning phase, including practical tasks to define the 

project (e.g., identify problems to solve, root cause analysis, 

define objectives, profile case-mix), determine the 

deliverables (e.g., review regulatory obligations, conduct 

stakeholder’s analysis, determine reporting expectations), 

and review the literature. The following tasks were 

particularly helpful and transferable: 

• Gathering a reference group or a “think tank” including 

experts in service delivery, health economics, data 

analysis, prosthetics and clinical care, biomechanics, 

and consumer representatives that could, altogether, 

inform QALS management about the relevance and 

feasibility of research proposals. 

• Creating a stakeholder matrix to organize controllers, 

promoters, providers, and advocates who can influence 

the provision of BAP (Figure 8). The immediate benefit 

of this exercise was to identify as exhaustively as 

possible all local, interstate, national, and international 

stakeholders. This task also required to clearly define 

the “power” and “interest” of a stakeholder 

corresponding to its capacity to influence allocation of 

resources and to provide prosthetic and medical care, 

respectively. These matrices were most helpful in 

engaging and managing communication with all 

stakeholders (e.g., seek funding, present at 

conferences). 

• Profiling the case-mix involved in a study by presenting 

the distribution of consumers according to 

demographics (e.g., sex, age, height, weight, body mass 

index), amputation (e.g., time since first amputation and 

BAP, cause, level, number of amputations, length of 

residuum), and access to care (e.g., distance between 

residence to providers and QALS) characteristics. This 

information was essential to characterize potential 

confounders and their impact on the provision of BAP. 

For example, knowing the distance between a 

consumer’s residence and the closest service provider 

is critical to determine how access to care across a wide 

state can affect the quality of care. This characterization 

became valuable when discussing outcomes and writing 

papers. 

FUTURE WORK 

Future research will be undertaken in a global environment 

characterized by:  

• Stronger evidence of efficacy and safety. Since this 

project, the body of peer-reviewed literature focusing on 

rehabilitation, prosthetic fitting, efficacy, and safety has 

grown noticeably.3,5,35,65,82-99 Several studies justified 

the prescriptions of MPK and ESAR components (e.g., 

Goldilocks zone loading).62,100-102 Health-related quality 

of life tend to be reported with a small range of surveys 

easing cross-comparisons between studies.7,8,57-64 

However, there are still no straightforward standardized 

ways to report harms.48-50 Infections are graded using 

multiple nonstandardized systems.59,65 The risks are yet 

to be fully satisfactorily resolved.5,65,85,87-89 Little is 

known about long-term outcomes (e.g., influence of 

aging issues). Altogether, it is difficult to ascertain 

whether direct skeletal prosthetic attachment relying on 

percutaneous osseointegrated implants will overcome 

the “decline effect” as described by Harris (2016).103  

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• The emergence of global ecosystem. We are also 

witnessing the formation of a global ecosystem including 

a set of organizations and services integrating a value 

chain for the delivery of BAP through various 

commercial models (e.g., consumers and carers, 

providers of prosthetic solutions, administrators of 

healthcare organizations).80 The development of this 

ecosystem is stimulated by strong consumers’ appeal 

for BAP, clearer and more diverse clinical pathways 

(e.g., indications, distal weight bearing system) and 

opening the market (e.g., approval from the American 

Food and Drug Administration).17,100,104,105 However, 

some funding bodies such as government 

organizations, private health care, work cover, and 

insurance are hesitant to fully support the provision of 

BAP requiring stronger evidence from registered clinical 

trials to test the possible decline effect. 

 

Figure 8: Typical stakeholder matrix including groups of 

controllers, promoters, providers and advocates of the procedure 

depending on power (e.g., capacity to influence allocation of 

resources) and interest (e.g., capacity to provide prosthetic and 

medical care). Adapted from Frossard et al (2018).17 

Future studies could confirm whether the delivery of BAP 

changes the scope of practice (e.g., skills, risks) and 

business models (e.g., effects on incomes) for all allied 

health professionals (e.g., prosthetists, physiotherapists, 

occupational therapists). The outcomes of this preliminary 

CUAs could assist in building plausible scenarios when 

designing subsequent comprehensive CUAs relying on 

complex Bayesian or Markov state transition models (e.g., 

provision of osseointegration options compared to 

wheelchair, crutches, liners, and ischial containment and 

subischial sockets).44,72,74-79 More in-depth analyses can be 

performed from healthcare perspective (e.g. , 

reimbursement standards) including surgical (e.g., one-off 

and on-going cost for primary surgical implantation, 

refashioning of residuum, reamputation, reimplantation), 

rehabilitation (e.g., physiotherapy), medical (e.g., pain 

killers, antibiotics), and prosthetic (e.g., socket fittings, 

interim and definitive prostheses) care costs More holistic 

CUAs could reveal the true costs of infections and 

subsequent surgical revisions.2,98,99  

Future studies should also focus on societal perspective 

(e.g., the impact of BAP on employment, productivity, living 

assistance costs). Finally, future studies should also 

consider consumer perspective, often neglected but equally 

relevant (e.g., gap fees, out-of-pocket expenses, overseas 

travelling costs, prosthetic components, medication).  

CONCLUSION 

Over the last 20 years, I witnessed genuine interest in 

osseointegration morphing into international momentum, 

leading to the emergence of a global ecosystem slowly 

paving the way toward recognition of direct skeletal 

prosthetic attachments. However, there is a long way ahead 

before evidence justifies the effective and global adoption of 

bionic solutions. Hopefully, this work will be a valuable 

contribution. Practical information and benchmark figures 

are provided. We estimated that 24% of the barriers to the 

project were specific to QALS, while 39% of the facilitators 

were transferable to other organizations. Above all, we 

shared a working approach to justify and organize the 

provision of prosthetic care for bone-anchored lower limb 

prostheses from a government perspective. Ultimately, we 

hope this work will inform promoters of prosthetic 

innovations committed to making bionic solutions widely 

accessible to a growing population of individuals suffering 

from limb loss worldwide. 

CALL TO ACTION 

• Encourage authors of health economic evaluations to 

make their datasets publicly available (e.g., Data in 

Brief) to facilitate secondary observational studies as 

well as literature reviews and meta-analyses, 

 

• Inspire decisionmakers responsible of provision of 

prosthetic care in Australia (e.g., National Disability 

Insurance Scheme) and other jurisdictions worldwide to 

continue this research work and consolidate evidence-

based policies for delivery bone-anchored prostheses 

and bionic solutions,   

 

• Motivate national and international stakeholders to 

establish reference groups working toward collegially 

agreed procedure (e.g., costs, process) to support 

reasonable standards of prosthetic care for individuals 

fitted with bone-anchored prostheses and bionic 

solutions.   

ACKNOWLEDGEMENTS 

The authors wish to express their gratitude to Sally Cavenett, Barry 

Leech, Brendan Burkett, David Lee Gow, Fiona Barnett, Ross 

Powrie, Gregory Merlo, John Vasil, Luciann Ferrada, Luke 

P
o

w
e
r 

L
o

w
  
  

  
  

  
  
  

  
  

  
  
  

  
  

  
  

  
  
  

  
H

ig
h

 Controllers Promoters 

 

• State governmental 
funding agencies  

• National 
governmental funding 
agencies  

• State consumer 
support groups 

• National consumer 
support groups 

• National professional 
associations 

• Artificial Limbs 
Services in other 
States 

• State service 
providers 

• National service 
providers 

 

  Advocates Providers 

 Low                                                                        High 

Interest 

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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
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Lorenzin, Stephan Laux and Tanya Quincey for their contribution to 

the development of this project.  

DECLARATION OF CONFLICTING 

INTERESTS 

The authors are in the view that there is no competing interests 

conflicting with the content of this manuscript.  

SOURCES OF SUPPORT 

This study was partially funded by the Queensland Artificial Limb 

Service, Medical Aids Subsidy Scheme, Metro South Health, and 

Queensland Government Minister of Health. 

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experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
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experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
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Berg D, Frossard L. Health service delivery and economic evaluation of limb lower bone-anchored prostheses: A summary of the Queensland artificial limb service’s 
experience. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.12. https://doi.org/10.33137/cpoj.v4i2.36210 

ISSN: 2561-987X 
HEALTH SERVICE DELIVERY AND ECONOMIC EVALUATION OF BONE-ANCHORED PROSTHESES   

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AUTHORS SCIENTIFIC BIOGRAPHY 

Mrs Debra Berg is the 

Manager of Queensland 

Artificial Limb Service, 

Queensland Health She has 

over 30 years’ experience in 

Queensland services, 

including 20 years in delivery of 

artificial limbs. She is a strong 

advocate for bone-anchored 

prostheses in Australia for over 

a decade. Mrs Berg is 

acclaimed author of multiple 

reports and publications 

looking at the health service delivery and socioeconomics benefits 

of prosthetic osseointegration for individuals suffering from limb 

loss.   

Dr Laurent Frossard is a bionic 

limbs scientist who is passionate 

about developing ground-

breaking prosthetic solutions to 

improve the lives of individuals 

suffering from limb loss. He is 

internationally recognized as a 

researcher and an independent 

expert for his unique expertise in 

bionic limbs. He approaches 

bionic solutions from a holistic 

perspective, by integrating the 

prosthetic biomechanics, clinical 

benefits, service delivery, and health economics. Dr Frossard has 

over 25 years of experience, both in academia and in private 

industries in Australia, Canada, and Europe. He has collaborated 

with over 100 organizations worldwide. He is currently a Professor 

of bionics at the Griffith University, the Director and Chief Scientist 

Officer at YourResearchProject Pty Ltd, and Adjunct Professor at 

the Queensland University of Technology and the University of 

Sunshine Coast in Australia.   

 

 

https://doi.org/10.33137/cpoj.v4i2.36210

