As Orthopedic Procedures Rise, Surgeons Debate the Meaning of Necessity
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Dr. Bart Ferket’s study of knee replacements begins with a few eye-popping facts. Since 2000, the annual rate of that surgery has more than doubled in the United States. More than 640,000 are now performed each year, at a cost of more than $10 billion.
But in some cases, Ferket found, the patients receiving them had relatively mild symptoms, and derived limited physical benefits. Published in BMJ, his study concluded that surgeries on such patients were “economically unjustifiable.”
“If a procedure is expensive and it’s used a lot, you would think the evidence would be very solid,” said Ferket, a professor of population health at the Icahn School of Medicine at Mount Sinai “That’s not the case for knee replacements.”
But that evidence gap — one study estimated one-third of knee replacements in the US are inappropriate — is not limited to this one procedure. It is present in several orthopedic surgeries that are performed at high volumes despite research showing they are either overused or altogether ineffective. That discrepancy is fomenting conflict within the field, and among individual physicians, over how to ensure that the decision to operate is grounded in clinical necessity.
Some surgeons argue the very notion of an evidence gap, or an over-reliance on surgery, is flawed. They say individual patient circumstances vary so significantly that creating hard-and-fast rules or a target for an optimal level of procedures is futile and potentially dangerous.
“I always cringe when I see the suggestion that cardiac or orthopedic surgeons are doing too much of X, Y, or Z,” said Dr. David Jevsevar, chair of the council on research and quality at the American Academy of Orthopaedic Surgeons. “It’s challenging to determine what the right amount is because every patient is unique and every patient has his or her own set of situations and expectations.”
The debate is especially relevant amid the nascent policy shift toward value-based care, which seeks to cut costs by rewarding physicians for the value — instead of the volume — of care they provide to patients. Tom Price, the health and human services secretary under President Trump and a former orthopedic surgeon, has repeatedly criticized the implementation of such reforms under President Obama and has said he will re-evaluate their use in Medicare. There is bipartisan support for changing the way care is delivered and compensated, but little agreement over how to accomplish that.
Meanwhile, physicians are still operating under the traditional fee-for-service payment system that ties their compensation at least in part to the number of procedures they perform. “You hear a lot in the news about the emergence of value-based health care,” said Howard Luks, an orthopedic surgeon in Westchester, N.Y. “But it is not emerging.”
He noted that most hospitals are still signing long-term fee-for-service contracts with insurers. Under such arrangements, physicians are often assessed using “relative value units,” or RVUs, that reward them for performing more surgeries.
“You get one RVU for seeing someone in the office. You get 20 for operating on them,” Luks said. “Unfortunately, that affects peoples’ decision making.”
Luks said those dynamics have led to “low touch, high tech” medical encounters in which an MRI shows a tear, a patient believes it must be fixed, and decisions to operate are eventually made without a clear understanding of the underlying problem or the potential benefit. In many cases, he said, the pain the patient is feeling might not be related to the tear. “Without diving into a history of how it’s affecting them and their quality of life, you don’t know how to put this into perspective,” Luks said.
One of the most frequently scrutinized procedures is surgery to repair a torn meniscus, a layer of cartilage that acts as a shock absorber in the knee. A study published in the New England Journal of Medicine in 2013 concluded the procedure, partial meniscectomy, offered no discernible benefit over sham surgery. Another found it provided no benefit compared to exercise for those with meniscal tears and no osteoarthritis. Still, it is performed more than 700,000 times a year in the US, at a cost of about $4 billion.
Dr. James Rickert, an orthopedic surgeon at Indiana University Health, said the surgery does help patients when used in the right circumstances. “It’s just been broadened so much, to where it’s used now routinely on people when the literature says it won’t help them.”
Rickert, a member of the Right Care Alliance, which advocates judicious use of medical services, has developed his own list of procedures of dubious merit. In addition to meniscus repairs, it includes:
Vertebroplasty. The procedure, which involves injection of a special cement into fractured vertebrae to decrease pain and improve mobility, has been shown in multiple studies, including one published in NEJM, to offer no clear benefit over sham treatment.
Clavicle fracture repair in adolescents. Rickert said the surgery has some utility in adults, but that there is no evidence to show it would benefit children. He noted that clavicle, or collarbone, fractures are most common in adolescents. “The potential market is so large, there’s this push to extend the indication to kids, but I don’t see any evidence for it.”
Rickert said the situation is the same for ACL repairs in low-risk patients, rotator cuff repairs in elderly patients, and knee replacements. While those surgeries offer potential benefits, the question of when and whether to operate is discretionary and requires a detailed conversation between doctors and patients. But that conversation doesn’t always happen.
“Patients, and sometimes doctors, have unrealistic expectations of the benefit,” Rickert said. “There is an intrinsic optimism or hope we all have that can skew decision making. Patients always feel the risk is lower than it actually is.”
And given the financial incentives to operate, surgeons might have too much of a conflict to have an objective discussion. Rickert is working with Blue Shield of California to develop a decision guide for joint replacements aimed at facilitating the conversation and reducing unnecessary procedures.
“This is a little bit heretical for a doctor,” he said. “But the people who pay the bills have the incentive to give patients the very best information to make sure they don’t undergo unnecessary procedures.”
Jevsevar, of the American Academy of Orthopaedic Surgeons, said such guides are helpful as long as they are based on evidence. But even then, individual circumstances muddy the waters. He mentioned a recent consultation of his at Dartmouth-Hitchcock Medical Center in which the patient had moderate to severe osteoarthritis.
The patient had managed his symptoms for years without surgery, but was told he will lose his job in six months. “He wants to have a knee replacement now because next year he’s not going to have health insurance,” Jevsevar said. “That’s a situation that no guideline can address.”