With the number of joint replacement procedures growing at an extraordinary rate, putting extreme pressure on already rising healthcare costs, the healthcare community must ensure it is adequately equipped to meet the demand by preparing for rising costs. and making sure there are enough orthopedic surgeons. to handle new cases. For their part, medical device companies need to design and manufacture implants with a longer lifespan to avoid revision surgeries that increase healthcare costs, while exploring alternatives to traditional joint replacement procedures.
Record growth in joint replacement surgery represents a lucrative opportunity for implant manufacturers, but with opportunity comes a responsibility to help contain increases in healthcare costs before they exceed our collective ability to pay. Medical device companies are developing new materials and procedures and working with healthcare providers on preventative measures. Still, more needs to be done to prevent joint replacement surgeries from overburdening the healthcare system.
Joint replacements, which have been performed since the late 1960s, can be very successful in relieving pain, repairing damage caused by arthritis, and helping people function normally and stay active. According to the National Center for Health Statistics, about 43 million Americans, or nearly one in five adults, have some form of arthritis pain. The knees, the largest joints in the body, are often the most painful. Since obesity is also very common, cases of arthritis begin to appear at a much earlier age in overweight people.
The number of replacements skyrockets
With an aging baby boomer generation, it should come as no surprise that the number of hip and knee replacement procedures has skyrocketed. The National Inpatient Sample (NIS) shows that primary hip replacements increased by 48%, from 153,080 procedures in 1997 to 225,900 in 2004. First-time knee replacements increased by a 63%, from 264,331 in 1997 to 431,485 in 2004. Patients received total hip replacements in 2006, and 496,077 patients received total knee replacements.
If these trends continue, an estimated 600,000 hip replacements and 1.4 million knee replacements will be performed in 2015. It is estimated that by 2030, the number of knee replacements will increase to more than 3.4 million. First substitution procedures have been increasing equally for men and women; however, the number of procedures has increased at particularly high rates among people 45 to 64 years of age.
According to Datamonitor’s 2006 report, the US represents 50% and Europe 30% of all procedures worldwide. 2005 revenue from hip implants in the US was $2 billion and $1.4 billion in Europe, while revenue from knee implants was $2.4 billion in the US and $1.4 billion. 774 million in Europe.
Demand and technology drive cost increases
With increasing demand and improvement in implant materials and surgical techniques, the cost of these procedures is also increasing. According to NIS, Medicare was the leading source of payment in 2004 (55.4% for primary hip replacements, 59.3% for primary knee replacements). Private insurance payments experienced a more pronounced increase. In 2004, the national bill for hip and knee replacements was $26 billion. The hospital cost was $9.1 billion and the reimbursement amount was $7.2 billion (28% of hospital charges or 79% of hospital cost).
Another study from Exponent, Inc. looked at Medicare data for hip and knee replacements between 1997 and 2003. It found that while filing fees increased, reimbursements actually decreased over the study period, with higher fees observed. higher for revisions than for primary replacements. Reimbursements per procedure were 62-68% less than the associated charges for primary and revision procedures. It is obvious that joint replacements have the potential to be very lucrative, but the burden on patients and our health care system must also be considered.
Behind the growth trend
The aging of the population and the increase in the incidence of obesity are the main causes of the increase in joint replacements. Nearly 65% of the US population is overweight, and arthritis is very common in this group. With more patients receiving joint replacements at a younger age, there is a much higher chance that they will survive their artificial joint.
A recent study in Wales tracked joint replacement procedures back to 2003 and found a revision rate of 1 in 75, which was considered a pretty good score. In the US, 40,000 knee revisions and 46,000 hip revisions were performed in 2004. However, knee revisions are expected to increase sevenfold and hip revisions more than double by 2030.
Revision surgeries are problematic for several reasons. In addition to the additional recovery time for patients, revisions are tougher operations that take longer and cost more. There is often a reduced amount of bone to place the new implant and there is a much higher complication rate.
Why implants fail
With hip replacements, the most common problems are postoperative instability and repeated dislocations. Surgeons must consider many risk factors before initial surgery, including age, gender, impaired motor function, dementia, and previous hip surgery. The surgical approach can also affect the risk of dislocation and leg length discrepancy, so proper preoperative planning is imperative.
The layout and positioning of components can also contribute to instability. Dislocations are often caused by movement outside of the normal range of motion, so it is important that patients take the proper precautions after surgery. A Mayo Clinic study showed that for repeat dislocations, hospital fees for treatment and revision surgery end up costing, on average, 148% of the initial replacement cost. The decision to have revision surgery is usually made based on repeat dislocations and the health of the patient. Patients who have had previous hip surgeries or who have poor abductor muscles are at higher risk of failed revisions.
Revisions of knee replacements may be required when patients experience infection, osteolysis, loosening or misalignment of the implant, knee injury, or chronic progressive joint disease. Decisions to have revisions are made based on previous knee surgeries, radiographic examinations, and current health. Patients with poor bone quality, unresolved infection, peripheral vascular disease, or deficient quadriceps muscles or extensor tendons are at increased risk of failed revision.
Precautionary measures
With the unprecedented growth of replacement procedures, steps must be taken to prevent this phenomenon from overwhelming our healthcare system. This can be achieved through better preventative care, alternatives to total replacements, and ensuring that primary replacements are successful. Reducing obesity and treating arthritis at an earlier stage will help reduce the number of procedures. In addition, many have called for a national joint replacement registry, such as those in Australia, Great Britain, Norway, Denmark, and Sweden, which track the high failure rates associated with some joint replacement procedures.
There are alternative procedures available that have improved dramatically in the last 10 years. For example, partial replacements are less invasive, with smaller scars and shorter healing times because only diseased compartments are replaced. Minimally invasive procedures are available for total replacements in some patients. There are also new options available for women who need a total knee replacement, known as “gender-specific” knees that are thinner and more contoured to more closely mimic the female anatomy. Hip resurfacing is another procedure that is gaining popularity because it preserves more bone than a traditional total hip replacement. This type of implant will last longer than a traditional hip replacement.
New biomaterials and component designs also increase the lifespan of implants, and computer-assisted surgery can improve joint replacement success by allowing more accurate and precise alignment of implants. Several studies have shown that this type of procedure is more cost-effective by avoiding the need for revision.
Looking to the future
For medical device companies, the record growth in joint replacement procedures presents a lucrative opportunity. However, manufacturers must work with the medical community to help ease the burden of this epidemic by increasing the success and longevity of their implants and exploring alternatives to traditional joint replacement procedures.
Undoubtedly, national joint replacement registries have proven useful in other countries. The medical community should demand that a registry be established in the United States and should do a better job of educating society about prevention. It is important that the medical community, including device companies, come together with a plan to prevent the potential burden that this overwhelming surgical burden could have before it impacts our health care system.