Should Hospitals Limit Joint Replacement Procedures as a Cost Saving Measure?
It has recently been reported that financial pressures within the NHS in the UK are leading some CCGs (Clinical Commissioning Groups) to consider limiting joint replacement procedures in the hospitals within their areas by 12% for hip and 19% for knee arthroplasties respectively. They will do this by treating only cases where the “patient’s pain and disability should be sufficiently severe that it interferes with the patient’s daily life and/or ability to sleep”, using the patient’s Oxford Hip Score as a determining factor.
There has been criticism of the proposal from orthopaedic surgeons, both from a financial as well as a clinical perspective. Grant Shaw, Consultant Orthopaedic Surgeon at the Alexandra Hospital in Portsmouth, UK acknowledges that “joint replacement surgery is an expensive and complex, invasive operation with significant risks” but he is adamant that these are far outweighed by “the huge potential benefits for the patient.” He says “In order to realise these benefits the surgery has to be done at the right time and for the right reasons for each individual patient.”
Steve Cannon, Vice President of the Council of the Royal College of Surgeons describes hip and knee replacement procedures as 'one of the most successful operations for improving patient's quality of life'. In a statement he voiced his concern that “Delaying access to surgery also adversely affects a patient’s quality of life and surgical outcomes, meaning the operation may not be as beneficial as if it had been carried out earlier.”
This view is echoed by Sebastian Sturridge of Frimley Park Hospital in Surrey. He also feels that “joint replacements probably pay for themselves within a year” when all the ancillary costs of caring for the patient, providing pain medication and physio are taken into account. Mr Sturridge adds that arthroplasty is “one of the few medical interventions offering patients a potential ‘cure' for their condition.” During his fellowship in Australia in 2009, Sebastian Sturridge witnessed the consequences for patients in the public sector of a 12 month wait for outpatient appointments and a further 12 month waiting list for surgery. He says
“By the time patients came through for their surgery, they had begun to lose bone around their joint making surgery technically more difficult, occasionally requiring more complex and expensive components, and with generally poorer outcomes as they would have lost a significant amount of muscle bulk by that stage.”
Grant Shaw feels that “Having carefully weighed the risks against the benefits for a patient and arranged surgery, the most serious issue is to ‘get it right first time’. And preoperative planning has a place in improving the quality of surgery, which benefits the CCG as well as most importantly the patient.” Mr Shaw is an advocate of digital pre-operative planning for increased efficiency and effectiveness in orthopaedic surgery. He says “Without planning, the case can run into uncertain or unexpected areas, which slows things down or leads to suboptimal results for the surgery.” There are also operational cost savings to be made by templating and planning in advance of surgery.
“Hip and knee replacements, when planned and carried out correctly, provide highly effective modern medicine and contribute to maintaining a patient’s independence.” Mr Shaw continues, “If the joint replacement is not done then the patient is condemned to a future of increasing pain and disability with mounting care requirements and costs. The cost of care alone quickly outstrips the cost of a joint replacement.” Says Mr Shaw. He also points out that the Oxford hip and knee scores “are validated for comparing the progress of an individual patient” not to compare one patient’s pain to another’s as an indication for surgery. And lastly, Mr Shaw also stresses that the time of surgery is important. “If left too long, patients (especially the elderly) can lose muscle strength and joint mobility, which in turn results in loss of confidence and function. In elderly patients this function does not always return if the surgery is delayed too long.”
Without a doubt, the financial pressures on hospitals in the UK can make the idea of saving money by limiting joint replacement procedures seem appealing in the short term. However, as outlined above, there are several reasons why it is likely to be counter-productive and lead to more costs overall, as well as leading potentially to a less effective outcome for the patient.