Can Arthroplasty's Costs Be Contained?

Try ‘bundled payments, accountability, and consumer involvement,’ one surgeon advises

Managed Care Magazine—March 17, 2011

New knees, hips, wrists, shoulders, and ankles are increasingly common in America’s aging, obese population. Every year, nearly 775,000 of us have a knee or hip replaced, reports the National Institute of Arthritis and Musculoskeletal Diseases.

The American Association of Orthopedic Surgeons (AAOS) cites a projection that by 2030, total hip and knee replacements will approach four million — that’s double the number of hip procedures and five times as many knee replacements, compared to the number in 2005.

Can surgical and clinical refinements, or new approaches to diagnosis and tracking, control expenses while maintaining efficacy?

Making Surgery Safer

To combat infection, a major cause of implant failure, the Hospital for Special Surgery (HSS) has installed dedicated “laminar flow rooms” for all joint replacement procedures. “The only people inside this room-within-a-room are members of the surgical team, wearing personal exhaust systems, which resemble space suits,” explains Mathias Bostrom, MD, attending orthopedic surgeon. “The bacterial counts are amazingly low.” (So is HSS’s 0.1 percent infection rate for hip replacement, according to state health department statistics.)

Because of the expense, few institutions have laminar flow rooms. “It’s worth it, though, for the hospital and the payer,” says Bostrom. “Infections are incredibly costly, no matter who’s paying. Cutting infection rates makes great financial sense.”

Securing the implant is crucial. For total knee replacement, HSS is now reducing the amount of cement it uses. Bostrom expects the reduction “to help the new joint last longer, and hopefully get patients up sooner, potentially shortening hospitalization or rehab time.” New materials to foster bone growth “open several implant design options that we didn’t have before. Trabecular metal from Zimmer Inc. is the first of many materials that will improve fixation of metal to bone.” Zimmer is a manufacturer of orthopedic equipment.

Minimally invasive surgery has raised awareness of how to handle tissue to minimize trauma, says Bostrom. “This modification of existing techniques helps short-term outcomes and lowers wound complications.”

Deeper understanding of pain management is affecting length of stay at HSS. “With an increased amount of optimal pain medication, people are up and around faster. The patients are happier and can leave the hospital sooner. Our acute pain management team — anesthesiologist, nurse practitioner, and nurse — combines oral, anesthetic, neurospinal, and neuro blocks, tailored to the specific patient.”

This story originally appeared at ManagedCareMag.com.