Thou seest I have more flesh than another man, and therefore more frailty.
Henry the Sixth, Part Three, William Shakespeare (1591)
The “web of causation” is the classic, metaphorical, epidemiologic tenet that individual and population patterns of health versus disease can be explained by a complex (spider) web of numerous interconnected risk and protective biological and social factors.1 This multifactorial relationship appears present in the unrelentingly rising tide of overweight-obesity, diabetes, osteoarthritis (OA), and lower extremity joint arthroplasty.
There is an increasing prevalence of overweight-obesity in both developed and developing countries. Worldwide, between 1980 and 2013, the proportion of adults with a body mass index (BMI) ≥ 25 kg/m2 increased from 28.8% to 36.9% in men and from 29.8% to 38.0% in women, but at markedly different rates across age ranges, time periods, and national and regional locations.2 Notably, of the 671 million individuals with obesity in the world, 62% live in developing countries.2
Between 2010 and 2030, there is expected to be a 69% increase in the adult prevalence of diabetes in developing countries versus a 20% increase in developed countries.3
Type-2 diabetes is the predominant form, accounting for at least 90% of diabetic cases.4 Type-2 diabetes thus threatens the health and economic status of all countries, but especially those in the developing world. Fueled by rapid urbanization, a transition to high-calorie diets, and increasingly sedentary lifestyles, the prevalence of type-2 diabetes has, not surprisingly, risen in parallel with the global growth in the prevalence of overweight-obesity.5
Based upon the Global Burden of Disease 2010 study, of 291 conditions, hip and knee OA was ranked as the 11th highest contributor to worldwide disability and 38th in causing disability-adjusted life-years.6 The prevalence of knee OA also continues to increase, particularly in men and women 40 to 60 years of age, likely due to simultaneously rising rates of overweight-obesity.7 While the volume of primary lower extremity joint replacements in the United States has increased dramatically over the past 20 years, the total knee arthroplasty (TKA) growth rate far exceeded that for total hip arthroplasty (THA).8,9 Between 2005 and 2030 in the United States, the numbers of performed primary THA are projected to grow by 174% to 572,000, whereas the numbers of primary TKA are projected to grow by 673% to 3.48 million procedures.10
EVOLVING PRACTICE PATTERNS AND HEALTH CARE ECONOMICS
In an effort to increase quality, efficiency, safety, and patient satisfaction, thereby maximizing the value of delivered health care, a series of interrelated perioperative strategies are being implemented, including fast-track surgery, standardization of care, and pay-for-performance programs.
Fast-Track Surgery and Standardization of Care
The use of an evidence-based fast-track approach to surgery has been demonstrated to improve a number of surgical outcomes.11 A detailed description of such a fast-track “setup” and its components for THA and TKA has been published.12 Jørgensen and Kehlet13,14 have applied this standardized fast-track approach to THA and TKA, with optimized perioperative care that included spinal anesthesia, opioid-sparing multimodal analgesia, early mobilization, and discharge to home targeted to be 2 to 4 days after surgery. These Danish investigators observed that 90% of 3020 consecutive, unselected fast-track THA and TKA patients were discharged within 4 days of surgery.13 However, patient age >80 years, the preoperative use of a mobility aid, living alone, and preexisting cardiopulmonary disease were independently associated with a length of stay (LOS) >4 days. Advanced age, impaired functional status, and cardiopulmonary disease were also independently associated with readmission within 90 days after surgery.13
Standardization of perioperative care seeks to reduce unwanted variability and attendant waste.15 Pioneering efforts at robust evidence- and consensus-based standardization of care has been achieved by the Total Joint Replacement Perioperative Surgical Home at the University of California Irvine.16 The Perioperative Surgical Home at the University of Alabama at Birmingham has likewise focused specifically on THA and TKA patients.17 Such disruptive innovation will likely be needed to successfully navigate the rapidly changing health care economic landscape.
In the United States, under the provisions of the 2010 Affordable Care Act, the Center for Medicare and Medicaid Services (CMS) established its Hospital Readmissions Reduction Program, which requires CMS to reduce payments to acute care hospitals with excessive readmissions (after adjustment for case mix index), effective for discharges beginning on October 1, 2012. For the federal fiscal year 2015, CMS has expanded this program to include patients undergoing elective THA and TKA, with a 3% maximum penalty for excessive readmissions.18 This inclusion by CMS of THA and TKA patients will likely further motivate hospitals and their clinicians to optimize their perioperative management.
In February 2013, Blue Cross Blue Shield, one of the largest commercial payers in the United States health care market, implemented its national Blue Distinction® Specialty Care Program, which designates hospitals that demonstrate expertise in delivering specialty care safely, effectively, and efficiently, including for THA and TKA. Certain United States employers are offering health plans that require participating employees to pay significantly higher out-of-pocket costs if they do not use a Blue Distinction® center for their spine surgeries, and hip and knee replacements.19
Established by the Pacific Business Group on Health in 2013–2014, the Employers Centers of Excellence Network is a first of its kind, multipurchaser collaborative that seeks to provide employees access to the highest quality care for hip and knee replacement surgery at no cost to them.20 An initial handful of large United States employers (e.g., Walmart and Lowe’s) are the pioneering group of members. Their employees who participate receive 100% coverage for their surgical care, with no deductibles or copayments, as well as travel, lodging, and living expenses for the employee and a caregiver, if they undergo their THA or TKA at 1 of 4 “Centers of Excellence” (currently, Johns Hopkins Bayview Medical Center in Baltimore; Kaiser Permanente Orange County Irvine Medical Center in Irvine, California; Mercy Hospital in Springfield, Missouri; or Virginia Mason Medical Center in Seattle, Washington). Each employee is assigned to a “patient advocate” who schedules the surgery, selects the center, and assists with insurance claims. The Center of Excellence also assigns a “patient navigator” to guide the patient while he or she is in its clinics, hospital, and other facilities.20
Fast-Track Arthroplasty Surgery in Type-2 Diabetics
Against this backdrop of evolving practice patterns and health care economics, Jørgensen and colleagues21 report in this month’s issue of Anesthesia & Analgesia on their cohort study of 890 type-2 diabetics and propensity score–matched nondiabetics, who underwent THA or TKA, using a standardized fast-track approach, at hospitals in the Danish Lundbeck Foundation Centre for Hip and Knee Replacement Collaboration. Their undesired postoperative patient outcomes included a hospital LOS >4 days, 30- and 90-day readmission, mortality within 90 days, and a composite outcome of “diabetes-related morbidity” that included cardiac arrhythmia, acute congestive heart failure, myocardial infarction, prosthetic or wound infections, renal insufficiency, cerebral attacks (transient ischemic attacks or cerebral stroke), pneumonia, and urinary tract infection. The enrolled type-2 diabetic patients had a mean BMI of 30.9 (interquartile range: 27.7–35.1). Although more type-2 diabetic patients (11.3%) than nondiabetic patients (8.1%) had a hospital LOS >4 days (P = 0.001), there was no significant association between type-2 diabetes and a hospital LOS >4 days after adjusting for covariates (adjusted odds ratio of 1.19; 95% confidence interval, 0.93–1.54; P = 0.172). After covariate adjustment, no significant association was found between type-2 diabetes and postoperative 30- or 90-day readmission or all-cause mortality. After covariate adjustment, only insulin-treated type-2 diabetes was associated with increased odds of the composite outcome of “diabetes-related morbidity” (adjusted odds ratio of 1.95; 95% confidence interval, 1.13–3.35; P = 0.016). Jørgensen and colleagues21 conclude that type-2 diabetes per se has limited influence on postoperative morbidity and mortality in fast-track THA and TKA. This current paper by Jørgensen et al.21 is especially timely and pertinent given the evolving practice patterns and health care economics of joint replacement surgery.
Collectively, the seminal work by Kehlet and his Danish colleagues12–14,22,23 appears to support that a fast-track approach can be successfully applied to the overwhelming majority of THA and TKA patients, with no resulting increase in morbidity, mortality, and hospital readmission, including in OA patients with the common comorbidity of type-2 diabetes.21 However, the need for insulin for adequate glycemic control may result in increased postoperative morbidity in type-2 diabetic patients undergoing THA or TKA. Pending further testing, their promising findings may not be validly extrapolated to other more diverse patient populations, including those with a greater prevalence of morbidly obese patients with a BMI ≥40 kg/m2. Furthermore, such best-practice and evidence-based protocols will undoubtedly continue to evolve, especially in response to the changing expectations of patients, providers, and payers.
Name: Thomas R. Vetter, MD, MPH.
Contribution: This author helped write the manuscript.
Attestation: Thomas R. Vetter approved the final manuscript.
Name: Gerald McGwin, Jr, MS, PhD.
Contribution: This author helped write the manuscript.
Attestation: Gerald McGwin, Jr, approved the final manuscript.
This manuscript was handled by: Franklin Dexter, MD, PhD.
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