Part 2 – Best practice and improved surgery outcomes
As the population ages, total knee replacement surgery is becoming commonplace. It is one of the most expensive surgical procedures. Most replacements are performed as elective surgery in private hospitals. Those patients who must rely on the public system are waiting longer than ever.
In Part 1 of this paper, the variations in frequency of knee replacement were considered. Given that most such procedures are cnducted in the private sector, the dependence on private health insurance creates disparities in access. Little information is available on preferred prostheses.
Part 2 considers patient satisfaction with knee surgery, access to rehabilitation after surgery and the broader consequences of knee surgery for national productivity.
Following the Evidence
The Australian Commission on Quality and Safety in Health Care estimates that only 43% of people with osteoarthritis receive care that is in accordance with evidence-based guidelines. and that physiotherapy and other non-pharmacological treatments are under-utilised.
While even a little weight losses can improve symptoms and mobility, fewer than 10% of patients have weight loss incorporated into their treatment. However, conservative management should not be taken so far that pain relief is inadequate, functionality is significantly decreased, and surgical benefits and outcomes are compromised,
How happy are the customers?
Australian research shows that orthopaedic surgeons often overestimate the benefits of their work and underestimate the harms. The patient satisfaction rate for total knee replacement is about 80%: a significant number of patients do not have their post-operative expectations about relief from pain and restoration of function fulfilled. Disappointments are aggravated if there are complications and an early need for revision (revision rates for knee replacement currently average 10.9% at 10 years).
There is currently no national system for collecting patient-reported outcome measures for joint replacement surgery, although this has been proposed by the NJRR and, most recently, by the Productivity Commission. Routine measurement of treatment outcomes and patient preferences would help identify the groups of people who will benefit most from surgery, as well as those who are unlikely to benefit.
Rehabilitation and Health Literacy
Whether or not patients receive rehabilitation after surgery and the type of rehabilitation received is a key factor in the success of their surgery. Currently only a minority of patients receive the physiotherapy recommended by best practice evidence. The Surgical Variance reports show that 43% of patients having knee replacements surgery in the private sector are transferred to inpatient rehabilitation, despite evidence that, for the majority of patients, out-patient rehabilitation is just as effective and considerably less costly (on average $374 compared to around $9,500 for an additional 7-14 days in hospital).
More needs to be done to improve health literacy for Australians with conditions that may lead to total knee replacement to help ensure better treatment choices and outcomes. This will also help these patients manage their overall health as many will have associated co-morbidities, with higher levels of cardiovascular disease and mental health problems particularly noted. The use of complementary and alternative therapies is high in this population, driven by aversion to the side effects of conventional medicine and failure to engage in exercise; users need to be more fully informed about evidence of efficacy for these approaches.
Increasingly stem cell treatments are being offered for people with osteoarthritis. These are expensive and usually not covered by PHI, but injections may seem an attractive alternative to surgery. However, when these involve injections of the patient’s own cells, a loophole in the regulations means that they are not subject to the usual scientific and medical oversight for experimental treatments. This, and the fact that the hype is ahead of the evidence for effectiveness, has led experts to caution about dangerous side effects and state that such treatments should only be done in the context of a clinical trial.
How productive is knee replacement?
Examining knee replacement in the context of the recent Productivity Commission report Shifting the Dial provides fresh insights. The Commission’s proposals, if implemented effectively, would deliver improved management and treatment options for patients, reduce unnecessary and inappropriate services, ensure increased coordination of care, give greater weight to patients’ needs, make better and more transparent use of data to drive quality and safety, and improve Australians’ levels of disability and subsequently their productivity in the workplace and participation in society.
But the Productivity Commission fails to address a key area – reducing inequalities in access to needed care, including knee replacement surgery. This will entail recognition of – and then addressing – the consequences of allowing the majority of elective orthopaedic surgery to be done in the private sector, which is inaccessible to many Australians on the basis of geography and cost.
This paper concerns how we might the most effective, efficient, affordable and accessible care for just one important procedure, and how this is increasingly complicated by a two-tiered healthcare system where ability to pay over-rides need.
There are many procedures out there best with the same problems. Much remains to be done to meet the challenges of and older, more demanding population, expensive treatment options and the expectation that health care will be a potent contributor to improved national productivity.
DrLesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney.
Lesley Russell has worked as a political advisor on health to Democrats in the US Congress and the Labor Party in the Australian Federal Parliament. She is an Adjunct Associate Professor at the Leeder Centre for Health Policy, Economics and Data at the University of Sydney.
Comments
One response to “LESLEY RUSSELL . How knee replacement surgery highlights issues of access, affordability and best practice in Australia’s two-tiered healthcare system – Part 2”
Lesley Russell’s two-part piece is most informative, especially regarding costs.
She refers to an article in The Conversation by Prof Justine Nylor, in which Prof Nylor reports:
“We phoned people 35, 90 and 365 days after surgery and asked for details about their recovery and the types of rehabilitation they had. People who received in-patient therapy reported similar knee-joint pain, and similar function and quality of life. Patients and their carers also took the same time off work regardless of the rehab option. …The main implication of our study is, given the cost difference between rehabilitation options, community-based (non-inpatient) alternatives seem to be better value.”
The recent report by the Royal Australasian College of Surgeons concludes:
“The data shows significant variation between surgeons as to whether they send their patients to inpatient rehabilitation or discharge them home (potentially for home-based, community-based or outpatient rehabilitation). Consequently, a large proportion of surgeons sit outside the 95% confidence interval (both above and below). Therefore we would caution against use of the 95% confidence interval to identify outliers from normal or indeed best practice.”
Seeing these data from a patient’s point of view, I cannot interpret them. Post-operative pain after knee replacement surgery is considerable. I don’t know how incapacitated the patients in Prof Nylor’s survey were in this regard, nor how ambulant they were. I wonder about the confounders affecting utilisation of community rehabilitation – the proximity of the patient’s home, access to or egress from their home (steps, hand-rails etc), the availability of a spouse or another to drive a car, ability to get in or out of a car. Did Nylor’s survey cover ‘feasibility’ of access to out-patient care. The RACS survey of orthopaedic surgeons did not consider this ‘patient-centred’ factor. It might explain a lot.