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VOLUME 4, ISSUE 2  
 2021 

 

EDITORIALS 

Raschke S.U. Editor’s perspective on health economics in prosthetics and orthotics. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.1. 

https://doi.org/10.33137/cpoj.v4i2.37135  

English proofread by: Karin Ryan, M.A., B.Sc., P.T. 

SPECIAL ISSUE 

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Raschke S.U. Editor’s perspective on health economics in prosthetics and orthotics. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.1. 
https://doi.org/10.33137/cpoj.v4i2.37135 

 

 

 
EDITORIALS 

 

EDITOR’S PERSPECTIVE ON HEALTH ECONOMICS IN PROSTHETICS AND ORTHOTICS 

Raschke S.U.* 
 

British Columbia Institute of Technology (BCIT), 3700 Willingdon Avenue, Burnaby, British Columbia, Canada. 
 
 
 

 

 

  

 

 

 

 

 

 

 

 

 

BACKGROUND 

In preparing this Special Edition, I took time to reflect on the 

importance of Special Editions in the publishing cycle of 

academic journals.  Special Editions can collect the works 

emerging from a special event such as a conference or they 

can fill gaps in the literature where a topic has been 

underserved but is, nonetheless, worthy of attention.  In this 

case it is the latter that motivated the Editorial Team. The 

idea for a Special Edition was sparked by a 60+ page long 

manuscript submitted for comment to the Editors of the 

Canadian Prosthetics ad Orthotics Journal (CPOJ) by Dr. 

Laurant Frossard, from the Queensland University of 

Technology.  The submission described a collaborative, 

interdisciplinary, payor-led project that used a novel, 

carefully considered methodology that   was   also  applied 

 

 

 

 

 

 

and practical. The goal of the project was to develop an 

economic foundation and justification for Osseointegration, 

which is the primary focus of Dr. Frossard’s team.  While not 

suitable for peer-review publication due to its length, density 

and atypical format, the work this interdisciplinary 

collaboration did to establish this economic foundation is 

novel, interesting and directly related to the long-term 

financial sustainability of the Prosthetics and Orthotics 

sector.  The thinness of literature on this topic sparked a 

discussion within the Editorial team on the critical need to 

bring attention to this topic.  It was then that we decided the 

time had come for our first Special Edition. 

Over the past 20 years the entry level to practice in 

Prosthetics and Orthotics shifted to either a Bachelor’s or 

Master’s Degree in most parts of the world, and a number 

of PhD Programs have been established.  This shift 

provided the necessary educational basis to allow 

prosthetists and orthotists to participate in and lead 

research and has led to a growth of peer-reviewed 

knowledge published in academic journals which typically 

 
OPEN  ACCESS Volume 4, Issue 2, Article No.1. 2021 

 

 

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

 

ABSTRACT 

There is a scarcity of literature exploring Health Economics in Prosthetics and Orthotics (P&O).  The 

P&O sector has, over the past decades, moved to a Bachelor’s or Masters Degree level as the 

requirement for entry to practice and, with that, there has been a growing body of research and 

knowledge generation focusing primarily on clinical aspects and engineering advances. No 

corresponding body of research has emerged on the economic aspects of P&O, creating a fundamental 

weakness in both technical and clinical research efforts to advance this field within an economically 

sustainable framework. This weakness will become critical as data driven engineering advances (e.g. 

exoskeletons, mass customizable prostheses) and clinical improvements (e.g. osseointegration, 

diabetes treatments) will make reimbursement for devices ever more complex and challenging. The 

tension between what is possible and what is fundable will increase unless what is possible also drives 

down costs. Finding the right balance in Prosthetics and Orthotics will be a challenge, as this sector 

already struggles to justify current standards of care. This Special Edition takes a snapshot of 

stakeholder perspectives and opinions on the topic of Health Economics in P&O and is organized 

around the following stakeholder groups:  End-user, Researcher (Engineering and Clinical), Prosthetic 

and Orthotic Practitioner and, of critical importance, four papers describing an interdisciplinary project 

on the Health Economics of Osseointegration that was led by a payor. Each author was also asked to 

provide a “Call to Action” in which they identify one or more key areas that need to be addressed in 

order to move forward with the barriers or opportunities they have identified in their paper. The intent of 

the Special Edition is to generate discussion and encourage more in-depth research on this topic. 

CITATION 

Raschke S.U. Editor’s perspective 

on health economics in prosthetics 

and orthotics. Canadian 

Prosthetics & Orthotics Journal. 

2021; Volume 4, Issue 2, No.1. 

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

37135 

KEYWORDS 

Health Economics, Prosthetics, 

Orthotics, Rehabilitation 

Engineering, Business Practices, 

Health Economic Evaluation, 

Evidence-Based Practices, 

Reimbursement 

 

 

* CORRESPONDING AUTHOR 

Silvia Ursula Raschke, PhD  

British Columbia Institute of Technology (BCIT), 3700 Willingdon 
Avenue, Burnaby, British Columbia, Canada. 

E-mail: Silvia_Raschke@bcit.ca 

ORCID ID: https://orcid.org/0000-0001-7964-4295 

Special Issue: Health Economics in Prosthetics & Orthotics 

https://doi.org/10.33137/cpoj.v4i2.37135
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v4i2.37135
https://doi.org/10.33137/cpoj.v4i2.37135
mailto:Silvia_Raschke@bcit.ca
https://orcid.org/0000-0001-7964-4295


 

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https://doi.org/10.33137/cpoj.v4i2.37135 

ISSN: 2561-987X 
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focus on the evaluation of clinical practices, the 

development of evidence-based measures and the 

development of more sophisticated, better functioning 

componentry.   However, a knowledge gap persists around 

objective economic and business-related issues.  The 

provision pathway of Prosthetic and Orthotic care is not 

typically thought of in economic terms.  Nonetheless, the 

economics of this provision pathway are a strong 

undercurrent that drives events and decisions both at 

practical and at policy levels.  This knowledge gap creates 

a fundamental weakness in both technical and clinical 

research efforts to advance this field.  If it is not considered 

within the research and development process, the long-term 

economic sustainability of Prosthetics and Orthotics is 

jeopardized.   

Credit must be given to researchers who have already 

begun to fill this knowledge gap, some of whom have 

contributed to this Special Edition, but more work needs to 

be done.  The most comprehensive treatment of the topic is 

the recently published comprehensive systemic literature 

review of health economic evaluations in Prosthetics and 

Orthotics done by Clark, Dillon and Shiell, who noted that, 

to the best of their knowledge, they are the first to have done 

such a review and that while some published papers exist, 

they are limited by relatively narrow focus. They point to a 

need for improving the evidence-based methodologies 

being used in Prosthetics and Orthotics to meet 

contemporary standards for rigorous Health Economic 

Evaluation (HEE) studies.1-3   

Need for a discussion on health economics in 

prosthetics and orthotics 

The identification of need for a deeper understanding of the 

underlying business and economic basis of the practice of 

Prosthetics and Orthotics comes at a critical time.  The 

accelerating, data driven digital revolution is creating 

extraordinary opportunities for innovation in medical and 

rehabilitation technology development, as well as 

supporting clinical improvements in surgical techniques 

such as osseointegration, limb reattachment and more 

effective treatments for diabetes and neuromuscular 

disorders.  Alongside this, innovative software architecture 

and infrastructure to support new business models are 

being created, such that services and products can now 

travel from maker to the customer directly or can be created 

and delivered as a hybrid virtual model. This evolving 

ecosystem, driven by objective data, supports the creation 

of novel prosthetic and orthotic solutions that are likely to 

become increasingly personalized and diverse and that 

better meet the end-user’s needs. All of these will impact 

reimbursement models and, in the wake of this disruption of 

the status quo, payors will likely continue to focus on 

generating cost savings. The tension between what is 

possible and what is fundable will increase unless what is 

possible also drives down costs.   Finding the right balance 

in Prosthetics and Orthotics will be a challenge, as this 

sector already struggles to justify current standards of care.   

This brings us back to the health economics work done by 

Dr. Frossard and his collaborators, around which this issue 

is structured.  The medical and engineering challenges that 

have been addressed by Osseointegration researchers 

worldwide are significant and inspiring.  This research 

challenges society to completely re-think amputation, 

rehabilitation and life with a prosthesis.   But, in attempting 

to allow amputees to access the benefits brought by this 

new paradigm, a substantial barrier has to be overcome, 

namely making a convincing case to payors for the value 

the approach provides vs. the cost.   In the same way, 

building a sustainable future in Prosthetics and Orthotics, 

both clinically and technologically, requires a realistic 

understanding of the economics and business constraints 

in the sector. Both researchers and practitioners must 

incorporate economic realities and constraints into their 

work if they are to have any sort of prospect of that work 

making a meaningful impact.   

Frossard et al were not the first to identify this barrier to 

novel approaches or technology in Prosthetics and 

Orthotics.  However, they are the first to do a project which 

included representation from the payor side and to develop 

an objective methodology that considered carefully a wide 

range of inputs that can be used to calculate ‘value’ and not 

just ‘cost’ of the approach.  The result is one of the most 

comprehensive treatments of the topic at this time.   

Furthermore, this was a project that was led by the payor, 

which is a critically important differentiator, as payors have 

typically been silent when it comes to providing transparent, 

objective criteria which makes clear how they determine 

what they believe has value/what they will reimburse.  

Response 

It was the recognition of the importance of generating a 

broad starting point for discussion on this topic that led to 

this Edition on Health Economics in Prosthetics and 

Orthotics.  Because of the absence of an extensive, formal 

body of research and researchers to draw on, it was decided 

that the issue take the form of a collection of by-invitation 

Stakeholder Perspective pieces.  As Co-Editor-in-Chief I 

made the decision to give contributors considerable leeway 

with respect to format, length and focus because there are 

no standard formats for this kind of cross-over research in 

Prosthetics and Orthotics.   This was done in order to make 

it easier for people to contribute to a body of work that is, in 

most cases, outside of their standard research repertoire or 

the daily work they do.  

What emerged is a collection of thoughtful and varied 

perspectives in an Edition that is atypical in look, feel and 

balance.  Contributions varying widely in style, length and 

topic as they were written by a wide spectrum of 

stakeholders, all of whom provide a unique perspective on 

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ISSN: 2561-987X 
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the topic in order to create an inclusive picture that respects 

the diversity of the people effected.   The issue is organized 

around the following stakeholder groups:  End-user, 

Researcher (Engineering and Clinical), Prosthetic and 

Orthotic Practitioner, Educator and, in a category all on its 

own, Dr. Frossard’s team’s work, which was broken down 

into four papers, in order to present as much of their work 

as possible in easier to digest portions.  I am particularly 

pleased to include the voices of two stakeholder groups that 

are very often not given much profile in academic literature 

in this edition – prosthetic & orthotic clinical practitioners and 

prosthetic & orthotic device users. Their voices are often 

excluded despite being profoundly impacted by all decisions 

made, especially at the funding policy level. The ordering of 

the papers is deliberate. The issue begins with the highly 

personal story of an end user who became involved in 

exoskeleton design when she unexpectedly became 

disabled.  The next section focuses on topics relating to the 

importance of Data and Business Intelligence. Next are the 

works for Frossard and his collaborators. Then come a 

collection of innovative thought and approaches in the 

sector, followed by a career retrospective from Professor Sir 

Saeed Zahedi, OBE that also looks forward and a final 

paper which answers Prof Sir Zahedi, and other authors’, 

call to Prosthetic and Orthotic Educators to better prepare 

graduates for the complex, data driven future that is coming.  

Interspersed throughout are perspectives from Clinical 

Practitioners who form the bridge between engineers and 

innovators and the end user. 

The goal of this Special Edition is not to create a snapshot 

of the current ‘state of the art’ on this topic, but instead to 

spark discussion where there is an acknowledged 

knowledge gap, in the hope that it will encourage more 

researchers to engage in formalized research and 

publications on this topic.  A further atypical feature is that 

each paper includes a “Call to Action”.  Each author was 

asked to consider what they have written and to identify one 

or more specific Calls to Action coming from that which they 

believe would create tangible value and to identify who or 

what institution has the authority to initiate that action.  

Sometimes those who see solutions or who ‘feel the pinch’ 

of a problem are not in a position to enable change.  

Therefore, it is important, in underserved areas, to both 

identify potential pathways toward solutions and to highlight 

who has the ability and authority to make identified changes 

happen.   

CONCLUSION 

I would like to thank all the contributors who took a risk when 

they responded positively to our invitation to contribute to 

this eclectic Special Edition.  And, I would like to thank the 

readers of this collection of works who may be challenged 

by what they read because of the atypical format and 

content.  In laying out the Edition our aim was to challenge 

readers to think outside the boundaries of their specialty, be 

it in clinical or engineering, and to spark a discussion on the 

unique challenges and opportunities that the prosthetic and 

orthotic market presents. It is only in considering 

perspectives from the full spectrum of stakeholders that a 

comprehensive understanding of the Prosthetics and 

Orthotics, as a whole, can be formed.   I sincerely hope that 

this Special Edition will inspire some readers to delve into 

this topic in a deeper way, to benefit all stakeholder 

represented in this edition. 

CALL TO ACTION  

I will end this introduction with my own Call to Action, which 

is that I ask that those persons or institutions identified as 

having the ability and authority to make change happen 

seriously deliberate on the calls and the underlying issues 

that led to their formulation and proceed to act on them.    

ACKNOWLEDGEMENTS 

I would like to acknowledge my Managing Editor, Dr. Hossein 

Gholizadeh for his support and advice. The name of a (Co-)Editor-

in-Chief features visibly in academic journals, but without the hard 

work of the Managing Editor, we would never reach the publication 

stage. Without Dr. Gholizadeh’s support and considerable effort, 

this Special Edition would not exist. 

DECLARATION OF CONFLICTING 

INTERESTS 

I have no conflicts to interest to declare. 

SOURCES OF SUPPORT 

None. 

REFERENCES 

1.Clarke L, Dillon M, Shiell A. Health economic evaluation in 

orthotics and prosthetics: a systematic review protocol. Syst Rev. 

2019; 8(1):1-8. DOI:10.1186/s13643-019-1066-9 

2.Clarke L, Dillon MP, Shiell A. A systematic review of health 

economic evaluations in orthotics and prosthetics: Part 1–

prosthetics. Prosthet Orthot Int. 2020; DOI: 10.1177/ 

0309364620935310 

3.Clarke L, Dillon MP, Shiell A. A systematic review of health 

economic evaluation in orthotics and prosthetics: Part 2—orthotics. 

Prosthet Orthot Int. 2021;45(3):221-34. DOI: 10.1097/ PXR. 

0000000000000003 

 

 

 

 

 

 

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Raschke S.U. Editor’s perspective on health economics in prosthetics and orthotics. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.1. 
https://doi.org/10.33137/cpoj.v4i2.37135 

ISSN: 2561-987X 
HEALTH ECONOMICS IN PROSTHETICS AND ORTHOTICS  

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AUTHOR SCIENTIFIC BIOGRAPHY 

Dr Silvia Raschke, PhD, is an 

applied researcher with the British 

Columbia Institute of Technology 

MAKE+ group.  She specializes in 

evaluation and product development 

projects in rehabilitation engineering 

with a focus on prosthetics and 

orthotics.  In 2013 she and 

collaborator, Dr. Michael Orendurff, 

PhD won the Thranhardt Prize for 

their paper: "Can You Tell Which 

Foot is Which?", the first double blind 

prosthetic foot evaluation that 

included community ambulation. She is currently involved in a 

diverse range of projects, including orthotic aspects of exoskeleton 

design, curriculum development and acting as a mentor to a team 

of young researchers who are doing a project examining Glass 

Ceilings in Prosthetics and Orthotics. She is Co-Editor-in-Chief of 

the Canadian Prosthetics and Orthotics Journal and Chair of the 

US Veterans Affairs Rehabilitation Research and Development 

(RR&D) Subcommittee on Rehabilitation Engineering and 

Prosthetics/Orthotics. 

 

https://doi.org/10.33137/cpoj.v4i2.37135

