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Let's Treat Our Hips the Same Way We Treat Our Cars

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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. This is part of a process that largely depends on the new implant being similar enough to an old implant so 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 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 durability of a particular hip or knee replacement device typically comes from small studies. These are 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.

 
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