Even as thousands of knee replacement surgeries are performed every week, scientists are looking into a revolutionary cure that may make knee arthroplasty obsolete. The National Post‘s Tom Blackwell reports:
If Dr. Nizar Mahomed and colleagues at the University Health Network (UHN) in Toronto succeed with fascinating new research, however, [knee replacement] surgery will eventually become a thing of the past.
The operations are, in fact, anything but panaceas, never really restoring people to their healthiest state, and often requiring replacement when the implant wears out, acknowledges Dr. Mahomed, head of orthopedics at the UHN’s Toronto Western Hospital.
With those limitations in mind, the UHN is pursuing research that aims to find a biological cure for joints decimated by osteo-arthritis, the most common form of the disease. Most dazzling among several experiments is a project that uses stem cells to create bone and cartilage, which researchers hope can be turned into a sort of organic joint implant that would fuse with existing tissue and regenerate diseased knees and hips.
Theoretically, the limits imposed on artificial joint-replacement patients would be forgotten.
“If we can find biological repair options, then basically we’re restoring the joint back to its native health state,” Dr. Mahomed said. “There would be no restrictions. You could go and run a marathon if you’d like. And there’s no concern that it is going to wear out, because we’ve basically restored it back to its [original] state of health.”
You can read the full National Post article here.
A new report by California Public Interest Research Group (CALPIRG) emphasizes the variation in healthcare costs across the state, including the cost of knee replacement surgery.
The prices charged for surgery in California vary from one geographic region to another. We analyzed hospital charge information provided in the California Common Surgery Cost Comparison database—a record of the prices charged for common, elective, inpatient surgeries performed at hospitals across the state—and created a charge index that can be used to compare charges for the 12 most common surgeries, such as Cesarean births, knee replacements and angioplasty. Though the database includes information on how much hospitals charged, not on how much they were ultimately paid, the observed variation in prices suggests important differences in surgery pricing.
The report observes that knee replacement costs in California were among the most variable, with prices ranging as high as $164,000:
“The typical knee replacement surgery performed in a Fresno-area hospital in 2010 was charged at $46,800, versus $127,500 in an Alameda-region hospital,” the report says, while “in the Alameda County area, which has high surgery charges,” prices “ranged from $59,800 at Alameda County Medical Center—Highland Campus to $164,400 at Washington Hospital—Fremont.”
As prices continue to rise and the gulf between different healthcare centers continues to widen, the report concludes that there are a number of avenues to help curb this trend:
- California needs better information about the reasons for charge variation. Several of the possible explanations identified in this report are worth further study to reveal the extent to which they affect prices and might be addressed to help control costs.
- Building upon the best practices of regions with lower charges could help lower charges in high-cost regions. Learning more about the reasons for charge discrepancies would enable hospitals and networks of health care providers to improve their practices, providing quality care at reasonable cost.
- Patients need information on the quality of care provided by different hospitals to help ensure the best outcomes. Reliable information about hospital quality will avoid a situation where patients use price as a proxy for quality and gravitate toward hospitals that charge more.
- Better transparency of hospital discounts and accepted payments would improve patients’ ability to choose a facility based on price and would allow researchers and policymakers to better understand how California might control the cost of providing quality health care.
Lack of transparency in healthcare prices in the United States continues to plague the system, while other countries surge ahead in healthcare cost transparency. Knee replacement prices in many countries are publicly available for patients to consider prior to undergoing care.
In the New York Times Personal Health Section, Jane Brody writes about Relief for Joints Plagued by Arthritis:
If you live long enough — that is, beyond 50 or 60 — chances are one or more of your joints, probably your knees or hips, will become arthritic. And if pain or stiffness begin to seriously limit your ability to enjoy life and perform routine tasks, chances are you’ll consider replacing the troublesome joint.
Jane Brody on health and aging.
“People with osteoarthritis are relying more and more heavily on surgery,” Dr. David T. Felson, a rheumatologist and epidemiologist at Boston University School of Medicine, told me. “The rate of knee replacement is just skyrocketing, out of proportion to increases in arthritic changes seen on X-rays, and replacement surgery is contributing greatly to the rising costs of Medicare.”
Between 1979 and 2002, knee replacement surgery rose 800 percent among people 65 and older. Although Dr. Felson described hip replacement as “dynamite” — highly effective in relieving pain and restoring function — knee replacement may be far less helpful.
“For 10 to 30 percent of patients, the improvement never comes,” Dr. Felson said.
How the Trouble Starts
Osteoarthritis results from wear and tear on the joints. (Rheumatoid arthritis, on the other hand, is an autoimmune disorder.) Some 27 million Americans have life-limiting osteoarthritis, and the numbers are rising as the population gets older and fatter.
“With every step, the force exerted on weight-bearing joints is one and a half times body weight,” said Dr. Glen Johnson, who reported on arthritis prevention and treatment at the annual meeting of the National Athletic Trainers’ Association in June. “With jogging, the force is increased seven or eight times. Thus, the most effective way to prevent arthritis in knees and hips is to lose weight if you’re overweight and to pursue non-impact activities for recreation.”
While most people think of osteoarthritis as a breakdown of the cartilage that keeps bones from rubbing together, recent studies have shown it is a far more complicated disease that also involves tissues in and around joints, including bone and marrow. Inflammation can be a contributing factor, and genetics play a role. Three genes have been identified thus far that accelerate the development of arthritis in people who carry them.
Any kind of joint injury or surgery, even if performed arthroscopically, raises the risk that a joint will become arthritic. That is why so many professional and recreational athletes develop arthritis at younger ages.
WINNIPEG, MB, May. 4, 2012, from Troy Media – Hip and knee replacement surgeries are among the most cost effective medical interventions developed, with the result that a vast majority of patients enjoy a greatly improved quality of life.
They are also among the most popular surgeries. You might be surprised to learn that Canada’s yearly 75,000 joint replacements, at an estimated $15 000 each, cost the public health system about $1.125 billion annually – not an insignificant amount.
Auto industry does it better
The expenditures don’t end there: in the first year following elective hip or knee replacement surgery, hospitalization usage can increase by as much as 50 per cent. In the 15 years following surgery, about 10 per cent of hip and knee replacements have to be redone due to wear, dislocation, infection and other problems.
So you might also be surprised to learn that this billion dollar a year industry – with follow up expenditures – has few or poor mechanisms for implant monitoring and assessment. There is no systematized mechanism in place to follow the clinical track record of new implants that come on the market, there is still difficulty predicting who will do well (or poorly) with surgery, and there is little ability to quickly identify and recall poorly performing implants.
We know this can, and should, be done. After all, the automotive industry already does a pretty good job at this.
Exact specifications for a car manufacturer’s products are readily available, the dealer’s wholesale cost is readily accessible online, organizations such as Consumer Reports and JD Power provide independent prospective assessment of vehicle quality, car dealers relentlessly bombard recent customers with satisfaction surveys, manufacturers closely track warranty repairs to identify problematic design or manufacturing issues, and customers are readily contacted should their vehicle be subject to a recall.
A similar quality loop does not exist for hip and knee replacement implants. And it should.
At present, new implants are generally tested by manufacturers using “in-house” laboratory facilities, with the results being submitted to regulatory bodies as part of a process that largely depends on the new implant being similar enough to an old implant that clinical testing isn’t required for approval.
Implant costs, while generally low in Canada overall, can vary from hospital to hospital, and region to region, and purchasing agreements typically forbid the sharing of price information. Information on a surgeon’s or hospital’s joint replacement surgery outcomes typically do not exist, are not accessible, or do not exist in a format that is meaningful to a patient or a surgeon.
What little data that exists on the clinical outcome and survivalship of a particular hip or knee replacement device typically comes from small studies conducted in highly specialized centres where one would expect above average outcomes, or from large national registries (outside of Canada) that track only the longevity of the device.
If a problem is discovered with a particular hip or knee replacement implant, identifying and contacting patients is usually an error prone process of manually reviewing hospital charts one by one. This leaves patients and surgeons vulnerable.
These issues – which can cost the public health system untold amounts, and affect patient quality of life – can all be addressed.
Regulatory bodies such as Health Canada and the FDA can require independent wear testing of new implants, along with clinical data from properly constructed trials to ensure at least clinical equivalency to current implants.
All hospitals in Canada should submit their hip and knee replacement data to the Canadian Joint Replacement Registry (CJRR) so that the longevity of the various types of implants used in Canada can be monitored. This will assist greatly in identifying both superior and inferior implants in a timely fashion, facilitate the identification of patients who may have received a recalled implant, and provide information on how provider and patient characteristics affect outcome.
Ontario has made CJRR participation mandatory, BC and Manitoba are looking to follow suit – the rest of the provinces need to get on board.
Implant cost information also needs to be more transparent; prices should not vary by hospital nor by manufacturer for similar designs. Finally, hospitals and surgeons need to ensure that good quality data on the care they provide is routinely collected, and that this data is incorporated into ongoing quality improvement. This has started in various locations across Canada, but needs to be expanded. The CJRR has started producing region and hospital specific reports, but these need to be strengthened through routine, mandatory data collection across Canada.
Hip and knee replacements are amongst the most successful modern medical interventions developed. With a bit of coordinated effort, we can continue to improve the quality and accessibility for all Canadians.
Eric Bohm is an expert advisor with EvidenceNetwork.ca and an Orthopaedic Surgeon with the Concordia Joint Replacement Group in Winnipeg Manitoba. He is also an associate professor at the University of Manitoba.