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Total Joint Replacement Surgery as Cost-Effective Preventive Care
As governments and private payors wrestle with ways of paying less for more healthcare, policy makers have been discussing the value of preventive care versus the value of acute care. We have joined that debate in the past, arguing that, contrary to common opinion, there is not an imbalance in the level of resources the United States spends on primary and preventive care versus specialty care.
On reflection, however, it would stand to reason that we should especially value cost-effective therapies that address patients’ current disabilities, while further preventing even more serious longer-term disabilities and improving general health.
It’s clear to me that joint replacement is such a therapy, resolving patients’ acute pain, restoring mobility, and helping to prevent heart disease and death – all at a fraction of the cost that one might expect.
Osteoarthritis: A Leading Source of Disability
Of particular concern to policy makers is the cost of treating osteoarthritis (OA), a leading source of disability. OA has no known cure and is responsible for moderate to severe disability in over 43 million people worldwide, 27 million of whom are 60 years of age or older.1 Given the world’s aging population, payors are understandably worried.
In the United States, for example, inpatient primary total joint replacement (“DRG 470” in U.S. Medicare parlance), ranks first in number of patient discharges among all short-stay hospital DRGs.2 In 2010, Medicare spending on hospital and physician reimbursements for primary total joint replacement ran the U.S. government approximately $5.7 billion.3
In an attempt to control costs, Medicare is increasingly focusing its audits on total joint replacement, ensuring that doctors exhaust all non-surgical options before operating. This approach, which on its face appears to be common sense, assumes that many joint replacements are unnecessary – based on what evidence we do not know – and offers a too-easy answer to the wrong question.
It is primarily the high incidence of OA that drives the cost of total joint replacement. If anything, U.S. patients suffering from OA are under-treated. It is estimated that only 13% of Americans with debilitating symptoms of knee OA actually receive total knee replacements.16 Rather than merely asking how it can spend less on joint replacement, Medicare should ask whether total joint replacement improves patients’ health in a cost-effective fashion.
What is gained in the short run from total joint replacement?
At the very least, total knee arthroplasty (TKA) should first successfully address the short-term needs of advanced OA patients: reducing pain and restoring function and mobility. As most everyone associated with orthopaedics in any way knows – whether healthcare professionals, hospitals, payors, policy makers and those who work in our industry – the evidence is incontrovertible that TKA successfully addresses pain and function for most patients.6,7,8 We have addressed the effectiveness of total joint replacement in earlier blogs.
But does TKA reduce longer-term disability?
While the incidence of osteoarthritis is expected to continue to increase, it is interesting to note, as one researcher stated, that “the conditions that people have are less disabling than they used to be.” Researchers have identified a long-term trend of disability rate reduction in the U.S. population. This reduction has further been correlated with an increase in patients electing musculoskeletal surgery, including joint replacement.4,5,6,7
George, et al., showed significant improvements in function and reductions in disabilities among hip and knee replacement patients, while non-treated patient groups declined in function.6,7 The authors state:
[Total hip arthroplasty] is one likely way that medical care is contributing to declining rates of disability in the older population.6
In its Consensus Panel on Total Knee Replacement, The National Institutes of Health stated:
Functional outcome [following total knee replacement] is improved after TKR for people across the spectrum of disability status.8
Does total joint replacement contribute to improved general health?
It stands to reason that patients with improved mobility will enjoy better health. Certainly, immobility can contribute to deteriorating health. Gruber and Hunter provide a model for a continuum of de-escalating health in osteoarthritis, postulating that OA leads to limited movement, which begets weight gain, diabetes and other co-morbid conditions, and increased probability of poor clinical outcomes from eventual joint replacement surgery.9
Ries, et al., provide evidence for the theory of improved health following total joint replacement, reporting that total joint patients showed improved cardiovascular health, while the cardiovascular health declined in control groups of OA patients who did not receive joint replacement. 10,11 Ritter, et al., and Barrett, et al., also reported improved life expectancy following total hip arthroplasty. 12, 13
While these and other studies have strongly suggested that total joint replacement patients are likely to enjoy improved general health, very few studies have explored the general health benefits and attendant cost of total joint replacement in a large patient population. So Biomet commissioned a study to do just that.
The authors of the resultant study14, which was exhibited at the 2012 Annual Meeting of the American Academy of Orthopaedic Surgeons, evaluated approximately 135,000 Medicare patients suffering from OA of the knee. The patients were divided into one group that received TKA, and one that did not. Researchers evaluated the patients’ incidence of co-morbid conditions and mortality over a seven year period. The study controlled for co-morbid conditions, to ensure that both groups were matched in terms of general health condition.
The results were startling. TKA patients demonstrated a 50% decrease in the risk of death after seven years, as compared to a matched group of OA patients who did not receive total joint replacement. Additionally, TKA patients demonstrated a statistically significant reduction in the risk of heart failure.14
A surprisingly cost-effective intervention
Equally startling was how inexpensively these health benefits were gained.
The incremental cost per year for TKA patients was approximately $2,100 per year, including the authors’ estimated reduction in prescription drug use among the TKA group following surgery.
In terms of cost effectiveness, this is incredibly inexpensive by any standard. Academics and policy makers have traditionally utilized a threshold of between approximately $40,000 per year (an informal guideline used by the U.K. National Health Service)15 and over $100,000 in the U.S. (using the World Health Organization methodology)15 to gauge the cost effectiveness per year of a healthy life.
This study confirmed a theory many in our industry have long held: total joint replacement is cost-effective preventive medicine, with respect to risk of death and heart disease.
As payors search for ways to improve general health and save money, it is important to avoid the mind-set that spending is the same as cost, and that delaying expense is the same as saving money.
And as journalists, policymakers, and academics criticize the value of specialty care in general, and orthopaedic care more specifically, it is important to understand the facts. In the case of TKA, timely intervention is an excellent use of limited healthcare resources. Spending an incremental $2,100 per year to reduce the risk of death by half among patients with advanced musculoskeletal issues is a very good deal for our society. We challenge our critics to find a better one.
1. World Report on Disability,” World Health Organization, 2011, available at http://www.who.int/disabilities/world_report/2011/en/index.html
2.CMS Utilization Report, Data Compendium, 2011 Edition,available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/DataCompendium/2011_Data_Compendium.html
3.MedPAR 2010 Part A and B Utilization data, available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareFeeforSvcPartsAB/MEDPAR.html
4.Schoeni RF, et al., “Why is late-life disability declining?” Milbank Q. 2008 Mar; 86(1): 47-89.
5.Cutler, DM, “Intensive Medical Technology and the reduction in Disability,” Analyses in the Economics of Aging, August, 2005, available at http://www.nber.org/chapters/c10360.pdf?new_window=1
6.George, LK, et al., “The Effects of Total Hip Arthroplasty on Physical Functioning in the Older Population,” JAGS, 2008.
7.George, LK, et al., “The Effects of Total knee Arthroplasty on Physical Functioning in the Older Population,” Arthritis & Rheumatism, October, 2008.
8.“NIH Consensus Development Conference on Total Knee Replacement,” National Institutes of Health Consensus Development Conference Statement, December 8-10, 2003, available at http://consensus.nih.gov/2003/2003TotalKneeReplacement117html.htm
9.Gruber WH, Hunter DJ, “Transforming osteoarthritis care in an era of health care reform,” Clin Geriatr Med., August, 2010.
10.Ries, MD, et al., “Effect of total hip arthroplasty on cardiovascular fitness,” Journal of Arthroplasty, January, 1997.
11.Ries MD, et al., “Improvement in Cardiovascular Fitness after Total Knee Arthroplasty,” Journal of Bone and Joint Surgery, November, 1996.
12.Barrett J., et al., “Survival Following Total Hip Replacement,” Journal of Bone and Joint Surgery, September, 2005.
13.Ritter, MA, et al., “Life expectancy after total hip arthroplasty,” Journal of Arthroplasty, December, 1998.
14.Lovald S., et al., “Cost and Disease Outcome of Total Knee Arthroplasty Patients in the Medicare Population,” AAOS Annual Meeting Poster #P149, 2012, available at http://www.abstractsonline.com/Plan/ViewAbstract.aspx?mID=2841&sKey=a0db00f6-9850-4124-848b-b40757bb3468&cKey=96d5210b-03e3-45b6-b4fd-dd3057181ddb&mKey=BA8AA154-A9B9-41F9-91A7-F4A4CB050945
15.The World Health Organization (WHO) threshold for cost-effectiveness is defined as three times the per-capita GDP of countries within each of its six regions (Source: World Health Organization, available at http://www.who.int/choice/costs/CER_thresholds/en/index.html. UK NICE threshold available at http://www.nice.org.uk/newsroom/features/measuringeffectivenessandcosteffectivenesstheqaly.jsp, converted to 2011 U.S. dollars.
16. London NJ, et al., “Clinical and economic consequences of the treatment gap in knee osteoarthritis management,” Medical Hypotheses 76 (2011) 887-892.
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