What is the value of joint replacement and why is this important during and after the pandemic?

 Creating a Value Dashboard for Orthopaedic Surgical Procedures

Value-based health-care delivery is a framework for restructuring our health-care systems with the goal of providing better outcomes for patients at lower cost. Value is determined by the quality of the outcome for the patient per dollar spent. Assessing the value of health care is of huge and ever increasing importance during this era where the ability to give patients the care they need is and will continue to be severely strained by the costs and limitations imposed by the COVID19 pandemic. 

These authors developed a dashboard for assessing the value of surgical procedures.

Quality metrics included patient reported outcomes, complication rate, periprosthetic joint infection (PJI) rate, and 30-day readmission rate. 

Cost was defined as direct cost—i.e., all costs directly tied to the joint replacement. 

Interestingly, when comparing the relative quality and relative cost for five total hip surgeons from the same institution, spending more money did not yield better outcomes. In fact the lower cost providers had relatively better outcomes.

Comment: In the world of shoulder arthroplasty, quality of outcome for the patient can be measured in the same way, including patient reported outcomes, complication rate, periprosthetic joint infection (PJI) rate, and 30-day readmission rate. Direct costs include those related to imaging, implants, operating room time, length of stay, surgical fees, anesthesiologist fees, pharmacy and therapy. With the continuing advent of new technologies, this framework offers the opportunity to determine whether spending more money yields a better result for the patient.

Here's a recent related post:

Rethinking How We Spend Healthcare Dollars During—and After—the Pandemic

The coronavirus pandemic is having a profound effect on healthcare economics. A recent article in Health Affairs1 estimates that the median direct medical cost of a single symptomatic COVID-19 case can exceed $3,000 during the course of the infection alone. As of this writing, there have been almost 2.5 million confirmed cases in the US,2 with the number of known cases doubling every 2 months.3 These numbers suggest that the direct medical costs of the pandemic could easily exceed $8 billion. In addition, federal legislation enacted to help mitigate the effects of the pandemic is estimated to cost more than $480 billion over the next 10 years.4

Independently, the application of new technologies has also been pushing healthcare costs upward for decades. Long before the pandemic, a 2008 report from the  Congressional Budget Office concluded that “the bottom line from all these analyses is that the single most important factor driving the long-term increase in health care costs involves medical technology” and that “technological advances on average have brought major health improvements, but they often then get applied in settings where their benefits seem much less obvious.”5

In orthopaedics, we are strongly attracted to technology. In some cases – such as arthroscopy – technological advances enable less invasive, more effective, and safer treatments. In other cases, the patient benefits “seem much less obvious.” A recent review article makes the following observations about technology use in arthroplasty:

• Computer-assisted technologies that are used in arthroplasty include navigation, image-derived instrumentation, and robotics.
• Computer-assisted navigation improves accuracy and allows for real-time assessment of component positioning and soft-tissue tension.
• It is not clear whether the implementation of these technologies improves the clinical outcome of surgery.
• High cost and time demands have prevented the global implementation of computer-assisted technologies.

If we take shoulder arthroplasty as a general example, we see that prior to the introduction of routine preoperative CT scans, 3D planning, patient-specific instrumentation, metal-backed and augmented glenoid components, and short-stemmed and stemless humeral components, the results of anatomic total shoulder replacement for osteoarthritis were excellent, with 10-year revision rates under 5%.6,7 Such outcomes do not leave much room for improvement from newer technologies, each of which carries incremental costs of research, development, clearance by the FDA, marketing, learning curves, and potential product recalls and unanticipated long-term adverse effects.8 As Rosenthal et al. recently pointed out, “Since 3D planning and intraoperative navigation is more costly than 2D planning, and augmented glenoid components are more costly than standard glenoid components, the cost-benefit of these changes with respect to mid-term and long-term clinical outcomes and implant survival has not been ascertained.”9

Robust clinical data are needed to establish the incremental benefit to patients of each new technology in order to justify its associated incremental costs in comparison to legacy approaches that have been in place for years.

As a more specific example, the average cost of a preoperative shoulder CT scan ranges from $625 to $8,400,10 yet it remains to be demonstrated whether application of this technology leads to better shoulder arthroplasty outcomes in comparison to results obtained with conventional preoperative radiographic imaging.11 Agyeman et al.(see this link) recently concluded that  “although CT scans are associated with greater financial cost and exposure to radiation than radiographs, the literature has yet to describe the additional clinical value and/or potential cost-value benefit as a result of improved outcomes provided by the use of CT scans in patients undergoing total shoulder arthroplasty, even when integrated with virtual planning software and generation of patient specific instrumentation.” If a preoperative shoulder CT scan costs $1,000, the very low end of the aforementioned range, avoiding routine preoperative CTs in 3 shoulder-arthroplasty patients would save an amount of money equal to the average direct medical cost of a patient with COVID-19—$3,000.

We conclude that this is a good time to seriously reconsider how we apply new technologies in orthopaedics by asking a simple question: Are we spending our more-precious-than-ever healthcare dollars in ways that best serve the population as a whole?

References

1. Bartsch SM, Ferguson MC, McKinnell JA, O’Shea KJ, Wedlock PT, Siegmund SS, et al. The potential health care costs and resource use associated with COVID-19 in the United States. Health Aff (Millwood). 2020;39(6):927-35.
2. John Hopkins University CSSE. COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at John Hopkins University (JHU). 2020 Accessed June 28, 2020. Available from: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6.
3. Hernandez S, O’Key S, Watts A, Manley B, Pettersson H, CNN. Tracking Covid-19 cases in the US. CNN, 2020 Accessed June 28, 2020. Available from: https://www.cnn.com/interactive/2020/health/coronavirus-us-maps-and-cases/.
4. Congressional Budget Office. The budgetary effects of laws enacted in response to the 2020 Coronavirus pandemic, March and April 2020. 2020 Accessed June 28, 2020. Available from: https://www.cbo.gov/system/files/2020-06/56403-CBO-covid-legislation.pdf.
5. Congressional Budget Office. Technological change and the growth of health care spending. 2008 Accessed June 28, 2020. Available from: https://www.cbo.gov/publication/24748.
6. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Annual report 2019: Hip, Knee & Shoulder Arthroplasty. Total Shoulder outcomes over two decades. Figure ST22, Page 16. 2019 Accessed June 28, 2020. Available from: https://aoanjrr.sahmri.com/documents/10180/668596/Hip%2C+Knee+%26+Shoulder+Arthroplasty/c287d2a3-22df-a3bb-37a2-91e6c00bfcf0.
7. Neer CS, 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319-37.
8. Somerson JS, Neradilek MB, Hsu JE, Service BC, Gee AO, Matsen FA, 3rd. Is there evidence that the outcomes of primary anatomic and reverse shoulder arthroplasty are getting better? Int Orthop. 2017;41(6):1235-44.
9. Rosenthal Y, Rettig SA, Virk M, Zuckerman JD. The impact of preoperative three-dimensional planning and intraoperative navigation of shoulder arthroplasty on implant selection and operative time: a single surgeon’s experience. J Shoulder Elbow Surg. 2020;Epub ahead of print.
10. Poslusny C. How much does a CT scan cost? New Choice Health, Inc., Pensacola, FL, Accessed June 28, 2020. Available from: https://www.newchoicehealth.com/ct-scan/cost.
11. Matsen FA, 3rd, Whitson A, Hsu JE, Stankovic NK, Neradilek MB, Somerson JS. Prearthroplasty glenohumeral pathoanatomy and its relationship to patient’s sex, age, diagnosis, and self-assessed shoulder comfort and function. J Shoulder Elbow Surg. 2019;28(12):2290-300.

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Total joint replacement and smoking don't mix.

Smoking Increases the Rate of Reoperation for Infection within 90 Days After Primary Total Joint Arthroplasty

These authors sought to investigate the association between smoking and readmission and/or reoperation within 90 days of total joint arthroplasty among 15,264 patients (6,749 male and 8,515 female)  who underwent 17,394 primary total joint arthroplasties between 2000 and 2014. Of these patients, 1,371 (9.0%) were current smokers, 5,195 (34.0%) were former smokers, and 8,698 (57.0%) were nonsmokers. Former smokers reported a median of 22.2 years (range, 0.2 to 60 years) of abstinence prior to the surgical procedure.

Current smokers were significantly younger (57.7± 10.3 years) than nonsmokers (63.2± 11.8 years). 

Current smokers were significantly more likely than nonsmokers to undergo reoperation for infection (odds ratio [OR], 1.82 [95% confidence interval (CI), 1.03 to 3.23]; p = 0.04). 

Former smokers were not at significantly increased risk (OR, 1.11 [95% CI, 0.73 to 1.69]; p = 0.61). 

Packs per decade were independently associated with an increased risk of 90-day nonoperative readmission regardless of smoking status (OR, 1.12 [95% CI, 1.03 to 1.20]). 

Comment: This well controlled study indicates that in this cohort, active smoking almost doubled the risk of reoperation for infection. In that total joint arthroplasty is an elective procedure and in that smoking is a voluntary activity, surgeons need to consider whether it is reasonable to perform joint replacement on active smokers. We suggest that smoking is not only directly harmful to the patient's health, but it is also an indication of a patient's voluntary disregard for their own well-being.

We've discussed this phenomenon in prior posts:

Effect of smoking on complications following primary shoulder arthroplasty

These authors reviewed 1834 shoulders in 1614 patients (814 smokers and 1020 nonsmokers) having primary TSA or RSA at the Mayo Clinic between 2002 and 2011 and had a minimum 2-year follow-up. Smoking status was assessed at the time of surgery: non-smokers, former smokers (no smoking in the month before surgery), and current smokers (smoking within a month before surgery).

Complications occurred 4% of the cases, 5.4 % in smokers and 3.0 % in non smokers.

Multivariable analyses showed that
-in comparison to non-smokers, the risk of periprosthetic infection was 7.3 times higher in current smokers and 4.6 times higher in former smokers.
-in comparison to non-smokers, the risk of postoperative fracture was 7 times higher in current smokers.

The overall complication-free survival rate for the three groups is shown below.

Comment: It is of interest that 44% percent of the patients in this series were classified as smokers. It is also of interest that the risk of postoperative fracture was dramatically less in those that had stopped smoking a month or more prior to surgery, whereas the effect of smoking cession was less pronounced for the risk of infection.

Smoking has often been made to seem glamorous

but it not only compromises health, but also is a marker for individuals that tend to put themselves at increased risk. 

The interested reader will also want to check out these two related posts:
Cigarette smoking affects bone, cuff repair, surgical risk and more
Pain and smoking

as well as this article:

Tobacco use is associated with increased rates of infection and revision surgery after primary superior labrum anterior and posterior repair.

These authors used the PearlDiver Patient Records Database, a for-fee insurance-based database of patient records, to explore the relationship between tobacco use and the adverse outcomes of arthroscopic superior labrum anterior and posterior (SLAP) repairs. The cohort of primary SLAP repairs was then divided into tobacco use and non–tobacco use cohorts using ICD-9 code 305.1 (tobacco use disorder). It is not known how accurate this coding is and how it reflects the different uses of tobacco (inhaled, chewed, etc).

They found that the incidences of revision SLAP repair or revision to a biceps tenodesis (P = .023) and postoperative infection (P = .034) were significantly higher in patients who used tobacco versus matched controls.

They suggest that tobacco’s negative effects on poor wound healing and the development of postoperative infection may results from a combination of factors. "On a cellular level, tobacco use reduces cutaneous blood flow, impairing soft tissue oxygenation, resulting in increased anaerobic metabolism in healing tissues. Simultaneously, thrombi are generated as a result of increased platelet aggregation, which compounds an already hypoxic environment, leading to decreased healing potential. This reduced perfusion impairs the delivery of critical lymphocytes to areas undergoing healing or prone to infection. Furthermore, systemic nicotine has been shown to have a negative immunomodulatory effect on T-cell function, resulting in cells that are more susceptible to infectious pathogens. Finally, and perhaps most specific to tendon healing required for a successful SLAP repair, the synthesis of collagen has been shown to be greatly impeded in smokers, leading to impaired wound and soft-tissue healing."

Comment: The same factors that impair success in SLAP repairs must apply to the healing of rotator cuff repairs, Bankart repairs and subscapularis healing in In addition to its effect on healing (see this link), tobacco use is also associated with increased pain (another cause of 'surgical failure')  as shown here and here .

The prior post also emphasizes the risk.

There is another association of importance than may account for some of the surgical failures in smokers, and that is the observation that smokers tend to take more risks than non-smokers (see this post). Here is a compelling quote from that article.

"The fact that smoking is bad for people’s health has become common knowledge, yet a substantial amount of people still smoke. Previous studies that sought to better understand this phenomenon have found that smoking is associated with the tendency to take risk in other areas of life as well. The current paper explores factors that may underlie this tendency. An experimental analysis shows that smokers are more easily tempted by immediate high rewards compared to nonsmokers. Thus the salience of risky alternatives that produce large rewards most of the time can direct smokers to make bad choices even in an abstract situation such as the Iowa Gambling Task. These findings suggest that the risk taking behavior associated with smoking is not related to the mere pursuit of rewards but rather reflects a tendency to yield to immediate temptation."

Now here's a quiz. This paper comes from Virginia. Can you name the top five tobacco producing states in order? The answer can be found here.

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Consultation for those who live a distance away from Seattle.

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Joint replacement - how many does a surgeon need to do to be 'experienced'? Jimi Hendrix

Three Hospitals Hope To Spark A Reduction In Surgeries By Inexperienced Doctors

We quote directly from this recent article:

"The largely unfettered ability of surgeons with minimal expertise to perform high-risk procedures — particularly at hospitals that lack experience caring for significant numbers of patients — has been the subject of a contentious, long-running battle known as the volume-outcome debate.

A groundbreaking 1979 Stanford study found that patients who underwent operations at hospitals that did more of those surgeries had significantly lower death rates than those treated at hospitals where they were done infrequently. That finding has since been replicated repeatedly across many specialties and found to apply to surgeons as well as hospitals. Last month, a large study found that the risk of complications was far higher among surgeons who performed only one thyroid removal annually than among those who did 25 or more of the tricky procedures per year.

Recently the volume battle was reignited when a trio of prominent health systems — Johns Hopkins, Dartmouth-Hitchcock and the University of Michigan — pledged that they will require their surgeons and 20 affiliated hospitals to meet minimum annual thresholds for 10 high-risk procedures. The three systems have asked other hospital networks around the country to join them.

Under the terms of the volume pledge, believed to be the first of its kind, surgeons must perform at least five pancreatic cancer surgeries annually in hospitals where 20 such operations are done each year. For knee or hip replacements, the requirement is 25 per surgeon and 50 per hospital. There are provisions for emergency surgery and for surgeons who sometimes do not meet the threshold because they were on leave; such surgeons might be required to perform a certain number of procedures under supervision."

Comment: The surgeon is the method.

For any person, it takes time to acquire a new skill - whether it is painting, golf, woodcarving or a surgical procedure new to that surgeon. The manner in which the skill level moves from beginner to advanced is referred to as the 'learning curve'. This learning curve is different for every person and every skill. 

The learning curve has been well documented with respect to the acquisition of surgical skill. We like to say, 'the surgeon is the method'. It matters who holds the surgical tools, just like it matters who holds the paint brush.

Jimi Hendrix asked the question "Are you experienced" as shown in this link.

It also takes a certain volume of cases to maintain skill at a mastery level, as shown in these posts

   Effect of surgeon volume on the result
   Effect of surgeon volume on cost and outcome
   Effect of surgeon volume on cost
   Effect of surgeon experience on outcome
   Effect of surgeon experience on complications
   Effect of surgeon experience on result 1
   Effect of surgeon experience on result 2
   Effect of surgeon volume on revision rate
   Effect of provider volume
   Effect of surgeon volume on shoulder arthroplasty result
   Effect of hospital volume

At present, only a few hospitals have taken the 'volume pledge', so it falls to the patient to inquire about the experience of the surgeon

In a prior post we suggested that patients considering surgery ask the following questions of their surgeon:

1 What is my diagnosis?
2 What is the name of the surgery you propose?

3 Do you have any financial relationships with the companies making the products that will be used?

4 Is their any rush in doing this surgery, or is it elective?

5 What are the alternatives to this surgery?

6 How many of these surgeries have you personally performed?
7 Are you fellowship trained to perform this operation?
8 What complications have you and others experienced with this procedure?
9 What are the usual results of this operation in your hands?
10 What is the likelihood that I will have lingering pain, limitations or disability?
11 What special care, rehabilitation will I require for the period after surgery?
12 How long is it likely to be before I can return home, return to work, return to my recreational activities?
13 Do you consider me a good candidate for this surgery in your hands?

14 If I wanted to get a second opinion, will you provide me with all my records to take to another surgeon?

We suggest patients take this 'check list' to their surgeon for the preoperative discussion.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Narcotic pain medications and joint replacement surgery JBJS - Oxycontin

A recent study in the Journal of Bone and Joint Surgery compared the results of total knee replacement for patients who chronically used narcotic pain medications with those who did not.

The authors found that chronic users of narcotics had much more difficulty recovering, longer hospital stays, more post-surgical pain, a higher rate of complications, and were more likely to need additional procedures than patients who were not opioid-dependent.

While this study did not directly concern patients having shoulder joint replacement, there is every reason to believe that similar findings might be found with patients having total shoulder arthroplasty.

It is important that surgeons and patients recognize this potential relationship and consider a formal approach to narcotic management over the long haul, detoxification to use of alternative forms of pain management, and considerations of withholding this elective surgery until the pain management program was firmly in place.

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.