Knee Replacements aren't cost effective

[DrCommonSense]

Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative | The BMJ

BMJ just released a journal article on knee replacements being mostly LOW value for the vast majority of patients in the US.

So in the last few years we have basically learned that stents, fusions, prostatectomies, etc offer "low" value to patients from our medicine colleagues.

Basically whole fields of Orthopedics, Spine Surgery, Cardiology, etc have "limited" evidence of "cost effectiveness"

I guess the only value in medicine will be the administrators who run everything.

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[willabeast]

i suspect the people who will benefit most from knee replacements are the ones who were unlucky enough to run into a surgeon in the past who told them they needed the cartilage in their knee removed.

 

[DrCommonSense]

i suspect the people who will benefit most from knee replacements are the ones who were unlucky enough to run into a surgeon in the past who told them they needed the cartilage in their knee removed.

Possibly but there was also another study coming out of England showing that hip replacement surgeries don't improve function either over the long term in the vast majority of patients who get them.

 

[VA Hopeful Dr]

Part of this is likely poor patient selection and part is that knee replacements cost way too much money.

 

[DrCommonSense]

Part of this is likely poor patient selection and part is that knee replacements cost way too much money.

Which subset of patients benefit from TKR and how large of a segment of the US population would that be?

I suspect it would only be patients with SEVERE OA of the knee joint coupled with very few comorbid conditions such as obesity, diabetes, smoking, neuropathy, poor functional status, etc.

If TKR were performed on the few patients that show clear benefit, surgeons would have very few operations per year, with huge cuts in their salaries.

Do we follow the "evidence" that aggressively?

 

[pmrmd]

Do any of the alphabet soup of pain/functional scales ask the patient if they would have the surgery again?

 

[DrCommonSense]

Do any of the alphabet soup of pain/functional scales ask the patient if they would have the surgery again?

So are you proposing a Sean Mackey type of "evidence" program like they speak about with pain/functional status basically taking a holistic approach towards benefit before coming for treatment and after over a specific period of time?
That makes the most sense to me for many pain conditions when trying to determine benefit in terms of VAS/function rather than taking a simple Owestry question sheet.

When you use VAS/Functional outcome data for QALY, TKR appears lacking in >95% of patients as does almost all of Orthopedic surgery.

 

[willabeast]

Possibly but there was also another study coming out of England showing that hip replacement surgeries don't improve function either over the long term in the vast majority of patients who get them.

methinks the English are trying to save money on this study. too many people are way too happy with their hip replacements for this to be true.

 

[Ducttape]

You are misinterpreting the conclusions.

The take home point is that there are improvements in quality of life for the most limited, and if the procedure could be limited to the most severe, the current cost of the procedure make it cost efficient at the current reimbursement.

But that isn't the American Way...


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[bedrock]

Possibly but there was also another study coming out of England showing that hip replacement surgeries don't improve function either over the long term in the vast majority of patients who get them.

I'm beginning to question the motivations of whoever is writing all these british studies. Is there another Dr. Chou over there that is being paid by the NHS to say all procedures are worthless?

Sorry, but hip replacement surgeries do improve function and significantly reduce pain in over 95% of patients who get them so I don't buy your conspiracy theory that all medical procedures are useless.

 

[nolapsych]

Put this in the ortho forum and see what happens


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[Dr. Ice]

As with everything there are secondary motivations to joint replacement. There is no generalized criteria for joint replacement other than lack of signficant response to conservative management. A lot of these large corporate practices with high monetary requirements for shareholder status incentivize surgeons to operate on individuals that may not need the surgery who may have good insurance and lower comorbidity. The volume of surgeries that these practices turn out will inevitably lead to higher failure rate and complication followed by referrals to pain management where many other potentially preventable procedures for residual pain will be carried out and the cycle continues.

The other issue is site of service where ortho groups will strike deals with struggling hospitals and bring high volume joints there with rapid turn around so the hospital maximizes and the surgeons can control flow of staff and scheduling. Perhaps the shift to asc for total joints will cut the cost somewhat.

For some reason ortho has not quite felt the burn of procedural reimbursement cut as much as other specialties and until that happens this bs will keep happening

 

[DrCommonSense]

You are misinterpreting the conclusions.

The take home point is that there are improvements in quality of life for the most limited, and if the procedure could be limited to the most severe, the current cost of the procedure make it cost efficient at the current reimbursement.

But that isn't the American Way...


Sent from my iPhone using SDN mobile

It is basically saying a VERY high percentage of them aren't cost effective.

Ergo, >95% should be eliminated as per our "efficiency" lords.

 

[DrCommonSense]

I'm beginning to question the motivations of whoever is writing all these british studies. Is there another Dr. Chou over there that is being paid by the NHS to say all procedures are worthless?

Sorry, but hip replacement surgeries do improve function and significantly reduce pain in over 95% of patients who get them so I don't buy your conspiracy theory that all medical procedures are useless.

My "conspiracy"? I just POSTED the ARTICLE from the BMJ.

Its the Chou crew in Britain. They are "experts" in analysis brah, maybe you should listen to your research superiors who are "honest".

Here is something about hip replacements:

https://www.sciencedaily.com/releases/2016/10/161023190552.htm

No functional benefit shown after hip replacement for vast majority of patients.

 

[bedrock]

My "conspiracy"? I just POSTED the ARTICLE from the BMJ.

Its the Chou crew in Britain. They are "experts" in analysis brah, maybe you should listen to your research superiors who are "honest".

Here is something about hip replacements:

https://www.sciencedaily.com/releases/2016/10/161023190552.htm

No functional benefit shown after hip replacement for vast majority of patients.

you seem to be a conspiracy theorist, in that you are arguing that virtually all medical procedures are useless.

As far as this study, it's a crap retrospective analysis. That means nothing. Show me a good prospective blinded study with an n of at least 1000, from somewhere beside britain, the demonstrates most hip replacements aren't worth it.

Until that study comes along, Dr. common sense, use your common sense. What percentage of the patients you saw as a medical student and resident (before pain fellowship) that had hip replacements, thought their life wasn't improved by the hip replacement? I know >95% of the patients I saw thought their THA was worth it. As a pain fellow, we see the failures of that and every other surgical failure, but that doesn't change the fact that THR work, particularly for patients >60 years old.

Show me a prospective study with a decent n from somewhere other than britain that demonstrates otherwise.

 

[DrCommonSense]

you seem to be a conspiracy theorist, in that you are arguing that virtually all medical procedures are useless.

As far as this study, it's a crap retrospective analysis. That means nothing. Show me a good prospective blinded study with an n of at least 1000, from somewhere beside britain, the demonstrates most hip replacements aren't worth it.

Until that study comes along, Dr. common sense, use your common sense. What percentage of the patients you saw as a medical student and resident (before pain fellowship) that had hip replacements, thought their life wasn't improved by the hip replacement? I know >95% of the patients I saw thought their THA was worth it. As a pain fellow, we see the failures of that and every other surgical failure, but that doesn't change the fact that THR work, particularly for patients >60 years old.

Show me a prospective study with a decent n from somewhere other than britain that demonstrates otherwise.

My arguments aren't "conspiracies" when they are literally published in the TOP medical journals in Britain/America. Its not like im not sourcing my arguments from TOP medical journals.

My basic discussion is that medical journals can basically show any procedure is ineffective. Depending on the variables, costs, etc., most of procedural medicine can be shown to be lacking depending on who designs the study

Also, you are using anecdotal statements about "how they are effective".

Would you say that Kypho works because you saw it "effective" in real life when seeing patients? Well NEJM published an article saying it was ineffective.

Or how about fusion surgery for spinal stenosis where NEJM basically said it was useless compared to a simple laminectomy at the most. JAMA also has countless articles about how "PT is as good as back surgery" for the vast majority of patients.

There can be an argument that "evidence based" medicine is really lacking at a "level one" basis for the vast majority of the most common procedures utilized in America.

Ergo, the "evidence based medicine" mantra is pretty much bunk for most of procedural medicine and most of big pharma.


This stuff is VERY complicated and guided by many different interests that are not exactly unbiased in MANY directions.

The argument can be applied to all of PROCEDURAL medicine instead of just Pain Medicine.

 

[Ducttape]

1. bedrock i agree, but actually, the NEJM used data from the US (and not britain). odd that they would choose to do an analysis of a different country's data.

2. additionally, drcomm you are making the assumption that they are saying most are not effective. this is a cost analysis, and determining group benefit compared to cost.

Compared with patients who did not undergo total knee replacement, generic quality of life scores (on SF-12 physical) and those related to osteoarthritis improved with performance of the procedure, with larger improvements generally in those with a lower SF-12 physical score at baseline. Changes in use of osteoarthritis pain medication and SF-12 mental scores were small and heterogeneous across the two cohorts. In a cost effectiveness analysis modeling the life courses of OAI patients with knee osteoarthritis with inclusion of utility values derived from the SF-12, current practice was more expensive and in some cases even less effective compared with scenarios in which total knee replacement was performed only in patients with lower physical functioning. At the group level, the economically most attractive strategy was performing the procedure in those with a SF-12 PCS <35, assuming a cost effectiveness threshold of $200 000 per QALY. These findings were reproduced among knee osteoarthritis patients from the MOST cohort. Extension of the use of total knee replacement to those with a SF-12 physical score of ≤40 would become financially attractive if the hospital admission costs fell below $14 000.

this study is different from your kypho study. this study is different from your fusion studies. this is a cost analysis at determining where it is cost effective, and you are confounding the two issues - whether a surgery helps, and whether how expensive it should cost to be affordable to the health care system.


3. your "Ergo" statement is a nonsequitor. there is no basis of making the conclusion that EBM is bunk based on the assumption that there is limited level 1 data.

 

[bedrock]

My arguments aren't "conspiracies" when they are literally published in the TOP medical journals in Britain/America. Its not like im not sourcing my arguments from TOP medical journals.

My basic discussion is that medical journals can basically show any procedure is ineffective. Depending on the variables, costs, etc., most of procedural medicine can be shown to be lacking depending on who designs the study

Also, you are using anecdotal statements about "how they are effective".

Would you say that Kypho works because you saw it "effective" in real life when seeing patients? Well NEJM published an article saying it was ineffective.

Or how about fusion surgery for spinal stenosis where NEJM basically said it was useless compared to a simple laminectomy at the most. JAMA also has countless articles about how "PT is as good as back surgery" for the vast majority of patients.

There can be an argument that "evidence based" medicine is really lacking at a "level one" basis for the vast majority of the most common procedures utilized in America.

Ergo, the "evidence based medicine" mantra is pretty much bunk for most of procedural medicine and most of big pharma.


This stuff is VERY complicated and guided by many different interests that are not exactly unbiased in MANY directions.

The argument can be applied to all of PROCEDURAL medicine instead of just Pain Medicine.

it doesn't matter that you source your articles from TOP medical journals. As we've discussed and demonstrated, NEJM can be biased and has been compromised in the recent past.
Beside the name on the journal doesn't matter as much as the quality of the study, or didn't they teach you that in your medical school medical statistics/journal club?

A prospective, randomized, double-blinded, placebo controlled trial with 2,000 patients published by physicians in a small swedish medical journal has much more scientific value than (for example) some retrospective, observational study on 170 people, led by a chiropractor, even if the chiro study was published in NEJM.

I agree with you that level one evidence is lacking for many common medical procedures, and for some blockbuster drugs, but that doesn't mean none of them work. And when you start attacking one of the most successful procedures in all of orthopedic surgery (THA), then I worry you've stopped applying your Common Sense, Dr.

 

[DrCommonSense]

1. bedrock i agree, but actually, the NEJM used data from the US (and not britain). odd that they would choose to do an analysis of a different country's data.

2. additionally, drcomm you are making the assumption that they are saying most are not effective. this is a cost analysis, and determining group benefit compared to cost.



this study is different from your kypho study. this study is different from your fusion studies. this is a cost analysis at determining where it is cost effective, and you are confounding the two issues - whether a surgery helps, and whether how expensive it should cost to be affordable to the health care system.


3. your "Ergo" statement is a nonsequitor. there is no basis of making the conclusion that EBM is bunk based on the assumption that there is limited level 1 data.

Cost "effectiveness" studies essentially say the same thing that the procedure is NOT worth the cost for the VAST majority of cases.

The conclusion opens the door for a "small" subset of severe OA patients that might benefit with the procedure, which I assume is a very small percentage of the current knee replacement procedures.

 

[DrCommonSense]

it doesn't matter that you source your articles from TOP medical journals. As we've discussed and demonstrated, NEJM can be biased and has been compromised in the recent past.
Beside the name on the journal doesn't matter as much as the quality of the study, or didn't they teach you that in your medical school medical statistics/journal club?

A prospective, randomized, double-blinded, placebo controlled trial with 2,000 patients published by physicians in a small swedish medical journal has much more scientific value than (for example) some retrospective, observational study on 170 people, led by a chiropractor, even if the chiro study was published in NEJM.

I agree with you that level one evidence is lacking for many common medical procedures, and for some blockbuster drugs, but that doesn't mean none of them work. And when you start attacking one of the most successful procedures in all of orthopedic surgery (THA), then I worry you've stopped applying your Common Sense, Dr.

I agree with some of this in THEORY.

However, posthoc analysis, changing goal posts of "end points", etc can easily bias even your "randomized double blinded placebo controlled studies". This isn't giving way to primary data collection corruption and lack of OPEN source documentation that journals like PLOS have called NEJM out on with NEJM calling them "data parasites" when questioned.

Just look how most of the recent "double blinded" studies in the NEJM that literally changed goal posts post hoc in many of their most recent "studies".

This isn't taking into account the fact that the vast majority of big pharma studies are done by "consultants" who collect the primary data and have their own stats guys doing the analysis. Hmm wonder if there is bias there huh?

The reality is the vast majority of procedural medicine has level 2 to 3 evidence at best with much of it proven to "lack benefit" in large "randomized control studies" depending on which ones you want to use if you analyze when doing a "meta analysis"

I am applying the same level of "evidence" towards orthopedics as is being applied to pain medicine (since we are playing the "evidence" game).

Setting up "attacking one of the most successful procedures in all of ortho surgery" doesn't change the fact that it lacks cost effectiveness evidence in the vast majority of cases as noted by BMJ.

How cost effective are knee replacements for the morbidly obese 75 year old with diabetes or neuropathy or have poor functional status? The vast majority of TKR aren't done on normal weight 65 y/o patients that have severe OA with few comorbid conditions.

More expensive procedures have a HIGHER bar to overcome to justify their cost.

 

[DrCommonSense]

it doesn't matter that you source your articles from TOP medical journals. As we've discussed and demonstrated, NEJM can be biased and has been compromised in the recent past.
Beside the name on the journal doesn't matter as much as the quality of the study, or didn't they teach you that in your medical school medical statistics/journal club?

A prospective, randomized, double-blinded, placebo controlled trial with 2,000 patients published by physicians in a small swedish medical journal has much more scientific value than (for example) some retrospective, observational study on 170 people, led by a chiropractor, even if the chiro study was published in NEJM.

I agree with you that level one evidence is lacking for many common medical procedures, and for some blockbuster drugs, but that doesn't mean none of them work. And when you start attacking one of the most successful procedures in all of orthopedic surgery (THA), then I worry you've stopped applying your Common Sense, Dr.

Here is just one discussion of the subject about how NEJM biases their "randomized" trials:

How did NEJM respond when we tried to correct 20 misreported trials?

 

[Ducttape]

first, you are making vast assumptions that are not based in fact.

the study is not the same as saying the procedure is not work the cost for the vast majority. the article in fact states that most people do have benefit.

the emphasis is on cost, not on whether the procedure works.


an example of what is being asked:
you might want to buy a treadmill. you'll gain cardiovascular conditioning. but you would get the same at the Y. now, is it worth the expense of buying the treadmill, or are you better with a Y membership....

 

[SSdoc33]

My arguments aren't "conspiracies" when they are literally published in the TOP medical journals in Britain/America. Its not like im not sourcing my arguments from TOP medical journals.

My basic discussion is that medical journals can basically show any procedure is ineffective. Depending on the variables, costs, etc., most of procedural medicine can be shown to be lacking depending on who designs the study

Also, you are using anecdotal statements about "how they are effective".

Would you say that Kypho works because you saw it "effective" in real life when seeing patients? Well NEJM published an article saying it was ineffective.

Or how about fusion surgery for spinal stenosis where NEJM basically said it was useless compared to a simple laminectomy at the most. JAMA also has countless articles about how "PT is as good as back surgery" for the vast majority of patients.

There can be an argument that "evidence based" medicine is really lacking at a "level one" basis for the vast majority of the most common procedures utilized in America.

Ergo, the "evidence based medicine" mantra is pretty much bunk for most of procedural medicine and most of big pharma.


This stuff is VERY complicated and guided by many different interests that are not exactly unbiased in MANY directions.

The argument can be applied to all of PROCEDURAL medicine instead of just Pain Medicine.

you seem to have an issue with the use of quotation marks.

reminds me of Bennet Brauer

 

[DrCommonSense]

you seem to have an issue with the use of quotation marks.

reminds me of Bennet Brauer

Cool story but im not the clown calling something a "conspiracy" while its literally published in a top British medical journal.

Let me get you the simple definition of the word:

con·spir·a·cy
kənˈspirəsē/
noun

a secret plan by a group to do something unlawful or harmful.

Now please tell me where they are doing something secret or unlawful?

Guess publishing this stuff in the top British medical journal is "secret"?

 

[DrCommonSense]

first, you are making vast assumptions that are not based in fact.

the study is not the same as saying the procedure is not work the cost for the vast majority. the article in fact states that most people do have benefit.

the emphasis is on cost, not on whether the procedure works.


an example of what is being asked:
you might want to buy a treadmill. you'll gain cardiovascular conditioning. but you would get the same at the Y. now, is it worth the expense of buying the treadmill, or are you better with a Y membership....

Thats true but at what price would it be cost effective? That has never been established either. Could be prohibitively cheap to make it work.

 

[bedrock]

Cool story but im not the clown calling something a "conspiracy" while its literally published in a top British medical journal.

Let me get you the simple definition of the word:

con·spir·a·cy
kənˈspirəsē/
noun

a secret plan by a group to do something unlawful or harmful.

Now please tell me where they are doing something secret or unlawful?

Guess publishing this stuff in the top British medical journal is "secret"?

scientific studies have absolutely no value if two things don't happen.

1- study has to be confirmed, ile. repeated by an independent group of physicians in another area/university and still get the same results
2- If not a prospective, randomized trial, it's basically worthless anyway, just a publication to advance the academic careers of those that published it, but no future clinical decisions should be based off retrospective data.


So this is why I think all these recent negative total joint studies coming from only britain are suspect. Lets see this study repeated, but in prospective fashion, in Australia, the US, or Sweden etc, before we jump to incorrect conclusions.

Again again, top journal doesn't mean that much anymore. We have to use our independent brains as physicians. If NEJM or BMJ publishes a crap study, that's what we call it, we don't kiss their ass and believe the study, just because its NEJM, Nature, or BMJ.

 

[Ducttape]

the article mentions the price point of $14,000 for the cost of the knee replacement to generate a QALY of $200k. its in the article if you read it again.

 

[DrCommonSense]

scientific studies have absolutely no value if two things don't happen.

1- study has to be confirmed, ile. repeated by an independent group of physicians in another area/university and still get the same results
2- If not a prospective, randomized trial, it's basically worthless anyway, just a publication to advance the academic careers of those that published it, but no future clinical decisions should be based off retrospective data.


So this is why I think all these recent negative total joint studies coming from only britain are suspect. Lets see this study repeated, but in prospective fashion, in Australia, the US, or Sweden etc, before we jump to incorrect conclusions.

Again again, top journal doesn't mean that much anymore. We have to use our independent brains as physicians. If NEJM or BMJ publishes a crap study, that's what we call it, we don't kiss their ass and believe the study, just because its NEJM, Nature, or BMJ.

What prospective, double blinded RCT trials do we have for total knee replacements past 1 or 2 years?

Also, what are the inclusive criteria of those studies?

You are acting like there are all these "studies" with strong long term efficacy evidence for TKR in the normal patient population that are mostly getting these procedures (obese, >65, multiple comorbidities, etc).

 

[DrCommonSense]

the article mentions the price point of $14,000 for the cost of the knee replacement to generate a QALY of $200k. its in the article if you read it again.

Yeah good luck getting the prices close to that lol