The COVID-19 pandemic placed an unprecedented burden on the healthcare system, creating waves of shortages and bottlenecks that reached nearly every corner of the industry. The rapid influx of critical COVID-infected patients left little room for those seeking elective surgeries. Starting in March 2020, surgeons were instructed to only perform essential procedures in an effort to alleviate the strain on hospital resources and minimize virus transmission (Bedard, 2020).
Perhaps the greatest impact on elective surgical caseload was seen in the orthopedic space, as most total knee and hip replacements weren’t deemed “essential.” These elective procedure bans canceled an estimated 30,000 total joint replacement procedures each week, forcing hundreds of thousands of patients to put their surgeries on hold (Bedard, 2020).
However, as the pandemic subsided, hospitals began to reopen their doors to these elective procedures. Unsurprisingly, orthopedic surgeons saw a surge in demand for joint replacement surgeries in the post-COVID period (McCoy, 2023). In fact, the Centers for Medicare and Medicaid Services (CMS) expects this trend to continue, projecting a 176 percent and 139 percent increase in hip and knee replacements by 2040, respectively (Shichman, 2023).
Now that elective surgeries are back in full swing, key players in the healthcare process must assess if surgery is truly the best option for patients moving forward, or if there are less costly forms of care that can move the needle even further on patient outcomes.
Evaluating costs to key stakeholders
In order to understand the impact of joint replacement surgeries, two metrics must be closely evaluated: cost and outcomes. According to Blue Cross Blue Shield claims data, the average cost of a knee or hip replacement reaches over $34,000 (BCBSA, 2019). On the whole, these surgeries represent 80 percent of total costs per patient (Trenaman, 2017). This financial responsibility falls especially heavy on the shoulders of payers and employers, yet many surgical outcomes fail to justify the cost.
A recent literature review discovered that despite overall improvements in knee function, up to 30 percent of patients are dissatisfied with the outcomes of their total knee replacement procedures (Canovas, 2018). This dissatisfaction was closely tied to a reduced quality of life, characterized by lingering pain and joint stiffness—unfulfilled expectations which may point to a misalignment between the patient’s goals and the anticipated outcomes of the procedure (Canovas, 2018). When factoring in the significant risks of surgery, including infection, stroke, and cardiovascular complications, the costs of elective joint replacement procedures may just not be worth it for some individuals (Gronbeck, 2019).
When factoring in the significant risks of surgery, the costs of elective joint replacement procedures may just not be worth it for some individuals.
Exposing the need for more shared-decision making
Addressing the problem of ineffective joint replacement surgery begins with a conversation about necessity. Historically, shared decision-making (SDM) between clinicians and patients has not been the norm in orthopedics. Many physicians fail to appreciate patients as the experts in their individual health experiences, resulting in one-way discussions about care decisions that inadequately take patient preferences into account. As a result, many orthopedic patients go to the operating room without truly understanding alternatives to surgery or how possible outcomes may or may not align with their individual goals.
Even the American Academy of Orthopedic Surgeons recognizes the lack of SDM as a critical pain point in the orthopedic space. In a review article, co-author Robert A. Probe, MD, FAAOS, highlights how widespread the problem is among fellow orthopedic surgeons: “Our experience suggests that many orthopaedic surgeons lack an understanding of how to actually engage in SDM or received insufficient communications skills training in medical school and residency. While some physicians can naturally communicate and already incorporate SDM in patient care, there are still a lot who don’t” (AAOS, 2020).
Practicing SDM is especially crucial with patients considering joint replacement surgery. These procedures are costly, invasive, and should only be used as a last resort for pain relief and functional improvement. From an evidence-based standpoint, surgery should only enter the conversation when (Gademan, 2016):
- Joint pain is not responsive to multiple types of conservative treatment
- Patients have significant functional limitations
- There is radiographic evidence of significant joint degeneration
Unfortunately, due to poor SDM as well as other factors such as insufficient non-operative care, rates of unwarranted surgical procedures continue to rise—research shows that more than 34 percent of knee replacements are considered clinically inappropriate (Riddle, 2014).
Keeping patients out of the operating room unnecessarily requires both a fundamental shift that puts patients back at the center of their treatment decisions, as well as adequate access to effective non-operative care.
Practicing SDM, or shared decision-making, is especially crucial with patients considering joint replacement surgery.
Changing gears to patient-centric, doctor-led care
When members have a seat at the table alongside their clinicians, they can more clearly understand their treatment options and choose the one that will provide the best outcomes for all involved. For many, surgery seems like the only treatment that will effectively relieve pain. However, this is typically not the case.
At Vori Health, we integrate multiple approaches to musculoskeletal (MSK) science to guide patients to the right care. When patients come to Vori, they gain convenient virtual access to a specialized doctor-led team extensively trained in non-operative treatment. Our MSK physicians, physical therapists, health coaches, and nutritionists spend time speaking to members about quality-of-life goals and preferences before personalizing treatment accordingly. As evidenced by our experience with patients with low back pain—with less than three percent referred for surgery and more than 70 percent reporting improvement in physical, mental, and social well-being—Vori Health’s patient-centered model improves outcomes while reducing unnecessary surgeries and costs.
REFERENCES
- Bedard, 2020: Bedard NA, Elkins JM, Brown TS. Effect of COVID-19 on Hip and Knee Arthroplasty Surgical Volume in the United States. J Arthroplasty. 2020;35(7S):S45-S48.
- McCoy, 2023: McCoy M, Touchet N, Chapple AG, Cohen-Rosenblum A. Total Joint Arthroplasty Patient Demographics Before and After Coronavirus Disease 2019 Elective Surgery Restrictions. Arthroplast Today. 2023;20:101081.
- Shichman, 2023: Shichman I, Roof M, Askew N, et al. Projections and Epidemiology of Primary Hip and Knee Arthroplasty in Medicare Patients to 2040-2060. JB JS Open Access. 2023;8(1):e22.00112.
- BCBSA, 2019: Planned Knee and Hip Replacement Surgeries Are on the Rise in the U.S. (2019, January 23). Blue Cross Blue Shield Association
- Trenaman, 2017: Trenaman L, Stacey D, Bryan S, et al. Decision aids for patients considering total joint replacement: a cost-effectiveness analysis alongside a randomised controlled trial. Osteoarthritis Cartilage. 2017;25(10):1615-1622.
- Canovas, 2018: Canovas F, Dagneaux L. Quality of life after total knee arthroplasty. Orthop Traumatol Surg Res. 2018;104(1S):S41-S46.
- Gronbeck, 2019: Gronbeck C, Cote MP, Lieberman JR, Halawi MJ. Risk stratification in primary total joint arthroplasty: the current state of knowledge. Arthroplast Today. 2019;5(1):126-131.
- AAOS, 2020: Shared Decision-Making Empowers Patients with Information and Options to Benefit Bone and Joint Care [Press Release]. (2020, December 8). AAOS
- Riddle, 2014: Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol. 2014;66(8):2134-2143.
- Gademan, 2016: Gademan MG, Hofstede SN, Vliet Vlieland TP, Nelissen RG, Marang-van de Mheen PJ. Indication criteria for total hip or knee arthroplasty in osteoarthritis: a state-of-the-science overview. BMC Musculoskelet Disord. 2016;17(1):463.
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