(MedCity News) – Every professional life is a book comprised of chapters. My first chapter in orthopedic surgery began in Boston as a resident. In 1973, Dr William Harris at Mass General Hospital introduced me to a very new procedure imported from England and Dr. John Charley. The procedure was total hip replacement. Dr. Harris was one of the first to adopt it in the United States.
Our incisions were huge, at least 8 to 12 inches long. Every trochanter was osteotomized requiring them to be wired back. Blood loss was so great we used hypotensive anesthesia. Everything was cemented. We were so concerned about cement embolization that we vented the femoral canal to avoid pressurizing the cement. Two cases per day was about the maximum a surgeon could do in a day.
Postoperatively patients stayed in bed for a few days. Hospital stays of for 10-14 days were normal. Most patient were sent to a rehab center for a couple of weeks. Every surgeon had his own special protocol. There were no preoperative education classes. Surgeon reimbursement was fee for service and averaged over $5,000 per case. Patient outcomes were not routinely measured by most surgeons, and therefore could not be shared with patients.
Forty years later, we see our most recent chapter in total joints. Incisions are four inches or less. Trochanters are left intact along with muscle attachments. Surgeons perform eight cases or more a day in two operating rooms. Blood loss is minimal due to TXA and less invasive surgery. Cement in hips is rarely used. Hospitals implement programs like “Joint Camp” that create a consistent delivery system that includes classes and written educational materials.
Patients stay in hospitals for two days with most patients going home. Surgeon reimbursement is still fee-for-service, but has dropped to an average of $1,500 per case. Unchanged is that transparency is still lacking as most surgeons still do not collect patient reported outcomes.
Now, the next question is what will the next chapter in total joint replacement look like? Newer drugs and new surgical techniques will most certainty emerge. Robotics and GPS measuring systems may reduce variability in positioning implants. However, these may not be the most important advances and changes.
The reimbursement system is transitioning to a value-based system. In this system, fees are bundled together amongst all the providers for up to 90 days postoperatively. Overall costs, patient experience and outcomes will matter as well to reimbursement. As a result, every hospital must find a way to improve quality, patient experience, collect outcomes while at the same time lowering overall costs. This includes managing costs after the patients leave the hospital.
In this new world, expect a very rapid transition for patients from the hospital to directly home. The will lead toward the inevitable trend to outpatient total joint replacements, whether in an ASC or hospital. This especially for younger patients and those in good health. This will create some important issues. With increasingly less patient and family face to face time it will be quite difficult to effectively educate patients and family and monitor their performance.
Another way to educate and monitor patient compliance and progress remotely both before and after surgery is necessary. It is said that most of us must read, hear or see things five times before we really own the knowledge. This must certainty be true for patients and family who are anxious about their health.