Health care economics and total joint arthroplasty

Turn on the television, radio, or open your favorite newspaper or online newsfeed and you will undoubtedly come across stories on health care economics and policy. Similarly, pick up a medical journal and there is a good chance that you will come across studies on some aspect of health care economics. The recent change in the White House administration has only kept the topic of health care delivery in the forefront of the news.

Research trends will follow the issues and concerns of the day. While we have not solved the problems of infection, mechanical loosening, polyethylene wear, and osteolysis, many of these complications have become less frequent today than a decade ago. Moreover, with rising health care costs, there has been a shift in research topics with economic and health care policy topics having an increasing presence at most orthopaedic meetings and in orthopaedic journals. At the most recent American Association of Hip and Knee Surgeons meeting, 10 of 56 papers, including 2 of 3 award papers, an entire symposium, plus 10 of 20 industry-sponsored symposia were devoted to topics on health care economics or policy.

In this month’s issue of Arthroplasty Today, 5 articles focus on various aspects of health care economics.

The study by Haas and Kaplan from the Harvard Business School examined cost variation across 29 high-volume hospitals (hospitals averaged 800 total joint cases in the previous year) for an episode of care for total knee replacement. Risk-adjusted data were used. Despite similar demographics including complications and readmissions, the cost varied by a factor of 2 to 1 from the 90th percentile to the 10th percentile group. Postdischarge cost varied by a factor of 6, also from the 90th to 10th percentile, with the lowest cost quartile discharging 86% of their patients home vs less than 50% for the highest cost quartile. Whether bundled-payment programs will continue to expand remains to be seen, but their paper clearly points out opportunities for cost savings that will be important in both bundled and nonbundled environments.

The study by Joseph et al looks at the difference in cost between 2 different surgical approaches used for total hip replacements concluding that surgery done through an anterior approach (using a special table and presumably C-arm) was less expensive than a posterior approach. The authors looked at a variety of direct and indirect costs; however, it is noteworthy that there is no mention of the cost of the table, C-arm, or the personnel required to use such equipment. Additionally, some of the difference in cost could be attributed to practice patterns. While one may be critical of the methods used to assess cost, it nevertheless illustrates that certain approaches for the same end point may be more or less resource intensive.

Pelt et al showed that a simple change in staffing hours resulting in earlier mobilization by physical therapy had a modest but statistically significant reduction in length of stay (3.23 vs 3.27 days). Although this length of stay difference may not be clinically relevant, the authors also demonstrated significant cost saving when patients were mobilized on postoperative day (POD) 0. Keeping with the theme of rapid mobilization and earlier discharge, Sibia et al showed no difference in 30-day all-cause or 90-day wound-related readmission rates for patients discharged on POD 1 vs those discharged on POD 2. However, patients discharged on POD 1 were younger, had a lower body mass index, and fewer medical comorbidities. This study illustrates that a subset of patients may be discharged earlier without the penalty of readmission or increased complications.

Lastly, the article by Manrique et al looks at the variable of low body mass index and its influence on postoperative complications after knee replacement. The authors found that the underweight patients were at higher risk for surgical site infection and for requiring blood transfusion. Identification of this potentially modifiable risk factor may result in the lowering of these complications, thereby improving outcomes and lowering the cost of care.

The United States has the most expensive health care per capita in the world without necessarily delivering the highest quality or best outcomes for all patients. Because of increasing financial constraints, government, payers, and society will continue to challenge us to improve the value of care (less cost without compromising outcomes) for patients. The articles in this month’s Arthroplasty Today are certain to be of interest to those delivering total joint replacement care to their patients.