April 5, 2011
A new BBC report states, “Surgeons have described the delays faced by patients as ‘devastating and cruel.’ Peter Kay, the president of the British Orthopaedic Association (BOA), says they've become increasingly frustrated that hip and knee replacements are being targeted as a way of finding savings.
The same situation could be happening in the U.S. and develop further as cuts to Medicare are proposed and minimum requirements for some health insurance companies to provide timely interventions could signal similar extended waiting time for conditions considered non-life threatening.
Alex Waring, a patient in Warwickshire, England was told he was being referred for an urgent knee replacement in August of last year. Now he looks at that letter with bewilderment as more than seven months later he is still waiting for surgery.
Mr Waring has already had one successful knee replacement and says he is in daily pain waiting for this second operation.
"It's excruciating sometimes to put it mildly. And it affects you at the times when you're not expecting it. I get off my mobile scooter and nearly fall over because my knee is gone, the pain, you've to sit there until the pain just goes away."
This writer’s experience is not as extreme as Mr. Waring; however my condition was exacerbated by not having health insurance until qualifying for Medicare last February. From a diagnosis on x-rays on February 3, 2011, osteoarthritis of the hip was described as severe resulting in leg length shortening and scoliosis. I waited two months for an appointment to see orthopedic surgeon and then was given another wait time of eleven weeks for surgery. The doctor said I could have surgery in one month, but the scheduling nurse said there were no openings for eleven weeks.
Does Wait Time Effect Outcomes?
Both of these cases beg the question on how important quality of life, urgency, or if severity of condition is considered in the scheduling process in the U.K and U.S..
In the U.K. the moves are part of the NHS drive to find £20bn efficiency savings by 2015. With cuts in Medicare expected in the U.S., similar budgetary constraints could be in the future for Americans, particularly elder Americans needing hip and knee replacements, which are not categorized as life threatening.
A study in the U.S. by The National Institute of Health in September of 2009 revealed actual waiting time was four to eight months and ideal waiting time was two months. The most frequent reasons for maximum acceptable waiting time were pain, quality of life and needing time to prepare for surgery. A longer wait time was associated with younger age, group (waiting), a longer self-reported waiting time, better EQ-5D index, an acceptable waiting time, a perception of fairness and a view that others worse off on the list should go ahead.
Conclusions of Study: Patients' views of acceptable waiting times are important for a fair process of establishing waiting time benchmarks for joint replacement.
The savings to a health care system might be a temporary fix; however, the costs of prolonging wait times for surgery could mean severity of condition becoming more serious and costlier. When surveyed in the U.K., surgeons reported “that simply delaying surgery by one means or another does not improve the outcome for patients as their condition can deteriorate.”The double jeopardy is that patients wait longer in pain, and when they have the operation, the result might not have been as good as it otherwise would have been had they had it early. "
Surgeons in the U.K. say patients in some parts of England have spent months waiting in pain because of delayed operations or new restrictions on who qualifies for treatment.
In several areas routine surgery was put on hold for months, while in many others new thresholds for hip and knee replacements have been introduced.
Trends In Utilization of Hip and Knee Replacement
Anthony M. DiGioia III, MD (from The Journal of Bone & Joint Surgery, Volume 89-A, Number 12, December 2007)
The upward trends in the utilization of total hip and knee replacement between 1969 and 2003 detail the national need for these procedures.
~ The age and gender-adjusted incidence per 100,000 person-years significantly increased from 1971 to 2003, representing a greater than 400% increase in the incidence of total knee replacement (as compared with a 55% increase in total hip replacement during the same period). It is noteworthy that the largest percentage increase was in patients less than fifty years old.
The volume of revision total hip replacements is projected to grow from 40,800 in 2005 to 96,700 in 2030 (a 137% increase).
~ It is projected that the number of primary total knee replacements will increase from 450,400 to 3.48 million by 2030, compared with a growth in the number of primary total hip replacements from 208,600 to 572,100 during the same interval.
The continued and rapid growth of utilization of total knee replacement reflects a trend that will require additional resources in the future supplied by private insurance companies, not less which is what some proposed Medicare reductions now suggest.
Additionally, given the growth in the number of procedures in the younger, more active patients, implant longevity will require further enhancement of replacements as they wear out which makes younger people candidates for replacements throughout their life time into elder hood.
In conclusion whether in the U.K. or the U.S., this dramatically increased demand for replacement procedures will require additional discussions regarding the distribution of economic resources; the allocation of surgeons, facilities and resources; and improved operative efficiency that reduces wait times and has the flexibility to consider patients’ views of acceptable wait times and quality of life.