Implementation of appropriateness criteria required for elective procedures

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."

"Although implementing appropriateness criteria for total joint arthroplasty has not succeeded in the past, there are reasons why it is more likely to work now," says co-author Dr. Bruce R. Schackman, chief of the Division of Health Policy and associate professor of public health at Weill Cornell. "Opinion leaders in the U.S. orthopedics community recognize the importance of such criteria, and health information technology has developed to allow more sophisticated appropriateness criteria to be integrated into decision-support tools."

According to the researchers, criteria will enable physicians to determine which patients' surgeries are medically necessary, which ones are elective, and which ones are inappropriate, and then tie reimbursement to the analysis. Procedures deemed truly inappropriate would then not be reimbursed by health insurers. The researchers believe this would decrease the number of inappropriate procedures performed, as only a minority of patients would be willing or able to pay out of pocket for them. A secondary, but just as important, result of appropriateness criteria is the potential to enhance the overall quality of care by increasing access to the procedure for those most in need and by preventing complications that might have occurred in operations that were inappropriate to begin with.

In order for the criteria to be successful and credible to physicians and patients and not limit necessary care, clinical opinion leaders and patient representatives must be involved in developing the guidelines, the researchers say. Also, although integrating appropriateness criteria into the reimbursement and care delivery systems could help "bend the cost curve," achieving savings will depend on acceptance of the criteria by physicians and patients. The researchers believe criteria generated for total joint replacement surgery could lead the way for other elective procedures, reducing their cost and enhancing quality of care.

"Evidence-based criteria, if applied wisely and fairly, may be the most powerful tool for controlling the cost and enhancing the quality of elective procedures," says Dr. Ghomrawi.