OBSERVATIONS - September 22, 2008
The Cost of Evidence-Blind Medicine and Artificial Joints
Among the advocates of evidence-based medicine (and who doesn’t that include?), it is widely believed that many billions of dollars are wasted every year on medical technologies and pharmaceuticals for which there is virtually no, or very limited, scientific evidence of benefit, or where the benefit is marginal compared to the increased cost. What’s worse, there may be an equal level of waste from failure to use medical technologies and procedures for which there is ample evidence of efficacy and safety– but no one collects and shares the evidence on a national basis.
We were reminded of this paradox by a recent piece in the New York Times on the failure of the U.S. health care system to develop a national database, or registry, to track and monitor the performance of artificial hips and knees. About the same time the Times piece appeared, The Permanente Journal reported on one of the very few – and certainly the largest – total joint replacement registries in the United States, at Kaiser Permanente. The two articles together highlight some interesting issues about the ability (or lack thereof) to make good use of clinical evidence, including comparative effectiveness evidence, in America’s highly fragmented health care environment.
In a rational, interconnected health care system, one might fairly assume that the overall performance and outcomes data on high-cost, high-tech procedures such as joint replacements ($30,000 to $40,000), would be carefully tracked and analyzed to identify and correct flawed devices or procedures. After all, The Permanente Journal notes that more than 600,000 total hip and knee replacement surgeries are performed in the United States every year, about half the world’s total. Thanks to the aging baby boomers, that number is projected to top 4 million by 2030. Hospital costs related to the procedures are projected to exceed $65 billion by 2015.
How many of those procedures involve costly product or technical flaws that result in a need for repeat surgery, or “revision”? No one knows, because no one at the national level tracks the data to develop the evidence. The Food and Drug Administration makes a half-hearted effort to warn physicians about faulty products, but few doctors report problems to the FDA.
If we could confidently track the data on all joint replacements and share the evidence among orthopedic surgeons, would it make a difference?
Yes, according to the Times, which notes that the risk in the United States that a patient may need a repeat procedure (meaning a second costly and often painful operation) because of a flawed device or technique “can be double the risk of countries with databases,” such as Australia, Britain, Norway, Sweden and others. The Permanente Journal article confirms that, noting that limited data on U.S. joint replacement revisions from the Centers for Medicare and Medicaid Services (CMS) suggests that the revision rate in the U.S. is double that of Sweden, which cut its revision rate in half following implementation of a national joint replacement registry.
As noted, Kaiser Permanente, a fully integrated care delivery system with a robust electronic health record can track, study and disseminate the evidence on joint replacements, at least within its own system. As of March 2007, Kaiser’s National Total Joint Replacement Registry (TJRR) had recorded 30,815 total knee replacements, with a revision rate of 5.5 percent, and 16,945 total hip replacements, with a revision rate of 11.2 percent. Standardized data on all total joint replacement procedures, including all pre- to post-operative information on patient demographics, implant characteristics, surgical techniques, and clinical outcomes, was contributed voluntarily by 350 participating surgeons and 50 Kaiser hospitals.
What has Kaiser Permanente and its thousands of joint replacement patients gained from having all this evidence available?
According to the report in the Permanente Journal, the registry has resulted in “significant improvement in quality and cost savings.” Those improvements include the ability to automatically identity, monitor and notify clinicians about product recalls and advisories (which in other settings often go unnoticed); significant reductions in revision rates for certain procedures; identification of surgical techniques associated with poor outcomes, followed by changes in practice; identification of patients at high risk of poor outcomes, allowing for more realistic shared decision making regarding treatment plans; and savings associated with reduced “use of new implants that are more costly but offer no difference in short-term outcomes.”
Skeptics may argue that Kaiser has the advantage of its integrated delivery system, a state-of-the-art electronic health record, and a physician culture that emphasizes the value of clinical evidence. True enough. But none of those things (excepting the commitment to evidence) is absolutely necessary to implement local, regional, or even a national registry – be it for joint replacements or any number of other expensive and widespread chronic conditions. What is needed is an ever-deeper appreciation of the value of evidence-based medicine among providers, insurers, and at least one payer -- CMS, which has to pay for about half of all the joint replacements performed in the U.S.
If you had to pay for all those well-oiled joints (not to mention the poorly oiled ones), wouldn’t you want to know a little more about them?
- Jon Stewart, Communications Director,
KP IHP
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