Hip and knee replacement surgeries are among the most cost effective medical interventions developed, with the vast majority of patients enjoying a greatly improved quality of life as a result. 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 dollars annually — not an insignificant amount.
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%. In the 15 years following surgery, about 10% 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 centers 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.
This blog is republished on Healthy Debate with the kind permission of our friends at EvidenceNetwork.ca
The comments section is closed.
Your article is very good and underscores the absolute need for data reporting. It’s no surprise this hasn’t occurred routinely and as you say, it should. Using technology today to gather and report data by docs and patients is possible and it should be implemented.
Patients are entitled to know what data there is prior to any surgery. Medications are the same. Patients erroneously think what is recommended is the best therapy that is available. They often think the doctor that is recommended is the most competent. We both know this is not always the case.
%featured%The fact we pay for a public service and the reality is that we have little information to test the system we’re in, speaks to need for a registry of competency levels by the number of surgeries, the number of errors, or lack thereof and that the recording or errors is mandatory, which by the way is shred with the patient, rather than withheld.%featured%
There also needs to be direct follow-up with the patient, independent of the hospital or the doctor so there is a review of patient outcomes provided by the patient themselves.
Your comparison to the auto industry for standards make sense but people are not cars and they react differently to substances such as implants, something cars don’t complain about!
We need coordinated efforts and quality assurance with the ISO automotive standards adjusted for human implantation, delivery and function would be a place to start..
I agree that we need more information on surgeons outcomes and devices used. I have two different types of hip resurfacings (both metal on metal) and love them, but the one that was installed here in Canada is a type that has since been withdrawn from the market (Zimmer/Durom) and I should have known better. I am, as my doctor says, one of the lucky ones, but I knew, even before I had it done that there was a bit of an issue with it due to “lip” on the device. I feel the “lip” on occasion when I’m stretching and it can be a bit painful, but it’s OK. My other hip, I had installed in Belgium where there is all kinds of information available on the doctors, the device used etc. You can know well before surgery exactly what device you are getting, the doctor”s stats, talk to other patients, etc. I found the doctor there to be forthcoming about problems, all the stats are on his website, he had all kinds of information about the particular devices available to me, and in fact I could actually talk to him by phone and email. He was willing to discuss complications, concerns, general health all before my surgery. That device (Birmingham) is the oldest resurfacing device with the best track record (over 20 years) and lots of good follow up information.
A smart patient can find out an awful lot with research on the internet, but you need to be smart enough to sift through the crap to get to the real information – but it is possible, and then you can make an informed decision.
%featured%The answer lies not only in a joint registry, but in our surgeons finding ways to actually connect with patients – taking time to talk to them openly about is going on, knowing their expectations and being honest and upfront with them about the devices being used. Simply stating that the “device of the year” is the best (and usually the only) option is not enough.%featured%
Good for you Pamela! I wish more patients were like you and took the initiative and did the research so they get the best information. I think you had a very good doctor who cared enough to talk by phone and email with you. All patients should be so fortunate to have this type of interaction. It would be a rare experience here in Canada for this to happen, at least in my experience and from those I know and converse with online.
Thank you for your article! In 2010, at age 28, I had a total hip replacement due to avascular necrosis of my femoral head. Fortunately, my surgery was “successful” and I have had no issues so far. However, being a curious, and admittedly an anxious patient, and being driven by my interest in all things healthcare, I still found myself searching for info on Canadian hip-replacements on-line. I was sorry to find that, as you say, “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.”
Recently, with the uproar over issues arising from metal-on-metal hip replacements, I realized that I didn’t even know what type of prosthesis A-Rod (as I call my replacement) was. I again wondered, if there was a problem, would I be contacted and asked to come in to check on things? Could they recall my new joint? I ended up booking to see my surgeon (even though I had been told that I never needed to come back for any kind of routine assessment) and asking about what the heck was in my leg. Luckily, I have some sort of plastic coating which seems to be holding up well.
%featured%As a patient I would be happy to be followed up on and have my information collected in the name of quality improvement, and research. Hopefully this data could help future patients.%featured%
If (and this is a big IF) our healthcare system wants to help patients become more informed and engaged in their own healthcare, then we must make information, such as that about joint replacement numbers, costs, outcomes etc. accessible and understandable not only for researchers but also for the public.
Sincerely,
Emily Nicholas
Patients Canada