Many of the most common inpatient surgeries in the United States are performed electively. These surgeries are expected to significantly increase with the enactment of the Affordable Care Act. In a new perspectives article, published in the Dec. 27 edition of The New England Journal of Medicine, a team of Weill Cornell Medical College researchers are recommending the nation's health care leaders and medical community join forces to establish evidence-based appropriateness criteria to determine which patients are most in need of elective procedures, such as joint replacement surgery, to slow the projected surge in demand and rising costs. Currently, there are no appropriateness criteria for most of the common elective procedures.
Total joint replacement surgeries -- such as hip and knee replacements -- are among the most common inpatient surgeries in the United States and are used as a prime example of elective surgeries that could benefit from implementing appropriateness criteria. Patients requesting joint replacement surgery vary from those disabled by their joint arthritis to those who do so to maintain an active lifestyle without pain. Total joint replacement surgeries are expected to quadruple over the next two decades in the United States, contributing to the rise in health care costs and increasing the risk of medical complications.
"The purpose behind establishing criteria is to use evidence-based metrics to prioritize patients most in need," says lead author Dr. Hassan M.K. Ghomrawi, assistant professor of public health at Weill Cornell and an outcomes research scientist at Hospital for Special Surgery. "We don't want to sacrifice necessary care when thinking of cost-containment."
There were more than 1 million total joint replacement procedures performed in 2009. Experts predict that the number of these surgeries will grow drastically, exceeding 4 million by 2030, with more than half the patients younger than 65. The growing obesity epidemic, coupled with an aging population, is projected to fuel increased demand for total joint replacement surgery. These projections don't reflect the increase in the number of patients who will gain health insurance coverage under federal health care reform when the Affordable Care Act is fully implemented in 2014.
Current cost-containment proposals focus primarily on payment reforms, such as pay-for-performance and bundled payments. But in their perspective, titled "Appropriateness Criteria and Elective Procedures -- Total Joint Arthroplasty," the authors posit that developing and implementing evidence-supported criteria that identifies the appropriate patients who are most likely to benefit from surgery will also slow the growing costs of these procedures.
"Identifying patients who are likely to benefit the most from these procedures could help to combat increasing health care costs while enhancing access and quality," says senior author Dr. Alvin I. Mushlin, the Nanette Laitman Distinguished Professor and chairman of the Department of Public Health and professor of medicine at Weill Cornell and public health physician-in-chief at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. "We believe that the case of total joint arthroplasty offers a prime example of the opportunities and challenges for appropriateness criteria."