Study: It Pays to Undergo Orthopedic Surgery (Literally)
The jokes began well before the Big Reveal. NBC Nightly News anchor Brian Williams—of all people—led the lampooning, making light of his high school football career during a mid-July visit to “The Late Show with David Letterman.” The habitually straitlaced journalist facetiously recounted his ill-fated stint with the Mater Dei High School Seraphs in Middletown, N.J., more than three decades ago, calling himself “110 pounds of steaming Irish Catholic fury.”
Williams was an offensive end/defensive outside linebacker for the Seraphs—a position he intended to reform à la New York Giants legend Lawrence Taylor’s “standing approach to the edge of the line.” Williams, however, lacked the future Hall of Famer’s constitution—he looked more like Olive Oil than Bluto, and had a neck size to match (“rail-thin buddy, rail thin,” Letterman observed after sharing a 1976 Seraphs team photo with his Late Show audience).
Clearly, Williams was prime intervention fodder, but he was too bullheaded and fearless at the time to recognize his physical shortcomings. Fearless, that is, until the day an opposing offensive back charged head-first into his right knee and ended his high school football career. “It reversed my knee—they don’t recommend that,” Williams, 54, later quipped on his Nightly News program. “You know, I loved every minute of football. But I’ve paid a very high price for what’s been confirmed to be the single worst New Jersey High School Catholic League football career in history.”
A high price indeed: three prior knee surgeries (all unsuccessful); a shortened femur; gobs of pins, rods, and screws; and severe osteoarthritis. As the anchor of television’s top-rated evening news show, Williams certainly has the financial wherewithal to pay for any orthopedic repair work he needs—including the $20,000-$70,000 total knee replacement procedure he underwent on Aug. 6. But the real tally for his pubescent shot at gridiron glory goes well beyond such tangible items as orthopedic hardware, hospital stays, anesthesia and physical therapy; it also comprises abstract concepts like lost sleep, missed workdays, physical disabilities and poor quality of life—factors that only help exacerbate the already hefty cost of musculoskeletal (MSK) care.
Over the last several decades, dozens of studies have quantified the economic burden of MSK disorders and the escalating cost of surgical treatment. European researchers, for instance, have linked the severity of MSK diseases to early retirement, while U.S. labor officials have detected higher absenteeism among workers—roofers, particularly—with lower back or upper extremities disorders (the average number of missed workdays is 11). Employees with acute knee osteoarthritis are sidelined for nearly as long (up to 10 days) and earn approximately $9,500 less than their colleagues with replacement or healthy joints. Clinicians on both sides of the Atlantic, though, agree that total joint arthroplasty virtually can eliminate the high absenteeism and reduced income associated with MSK disorders. Recent analyses have shown that successful hip replacements can boost employment prospects by 28 percent, augment annual household income by $5,400-$6,200 and reduce truancy rates by up to 22 days. Similarly, total knee replacements can increase job probability by 21 percent, hike annual household income by $4,300-$4,700 and cut absenteeism by six days.
Yet none of the data contain an explicit treatment valuation. Research unequivocally has shown that osteoarthritis and similar diseases are a societal albatross, costing Americans more than $705 billion in lost wages and medical care (hip and knee replacements alone cost $18,200 and between $22,611-$25,872, respectively)—commensurate to 4.9 percent of the nation’s gross domestic product—but few studies have assessed the true worth of prevention and care.
The American Academy of Orthopaedic Surgeons (AAOS), however, is attempting to correct the oversight with a comprehensive analysis of the societal value of MSK treatment. The association commissioned research last year to develop a new methodological model on the indirect cost of MSK disorders and the economic benefits of their therapies. Results, published earlier this year in the journal Cost Effectiveness and Resource Allocation, suggest that physical impairments associated with MSK diseases reduce household income and the likelihood of employment while boosting absentee rates and disability pay for job-holders. The data also found that appropriate treatment significantly can reduce the indirect costs of disease.
“Our hypothesis was simply that orthopedic surgery provides the best value of all specialties in medicine,” said John R. Tongue, immediate past AAOS president. “From the perspectives of the patient, employers, and society, the ‘value’ of appropriate medical treatment extends well beyond current and future medical expenditures and includes things like whether people can maintain their own independence, remain productively employed, avoid payments for disability or long-term care, and have an overall improvement of their quality of life. With this new methodology, we are able to examine, for the first time, MSK care as it relates to specific conditions, and uncover the societal and economic benefits currently overlooked in the larger health care value discussion. In an increasingly cost- and quality-conscious health care environment, this analysis provides critical insight into what the true value of orthopedic care means for patients.”
To determine the true value of orthopedic surgery, researchers examined physical limitation data—such as the inability to walk a quarter-mile or climb 10 steps without resting—from more than 185,000 people involved in a National Health Information Survey. They measured the relationship between the physical limitations of MSK disorders and indirect indicators of cost, incorporating employability, missed days of work, household income and disability income. Then, using the Survey’s findings and data from clinical studies, the researchers estimated the overall value, including the impact on indirect costs, of five orthopedic disorders: total knee arthroplasty, hip fractures, disc herniation, rotator cuff repair and ACL repair.
The conclusions are as follows:
Total Knee Arthroplasty
The average total knee replacement surgery generates indirect cost savings of $39,565—more than offsetting the $20,635 price tag of the operation itself, according to AAOS research. The average net lifetime societal benefit ranges between $10,000 and $30,000 (with a mean savings of $18,930) and provides patients with an additional 2.4 quality-adjusted life years (QALY), a measure of disease burden, including both the quality and quantity of life lived. Eighty-five percent of the savings comes from higher income either through wage hikes or an increased probability of employment while the remaining 15 percent stems from lower absentee rates and disability payments.
Though the procedure is beneficial for all ages, the savings from surgery is largest in younger working patients because they accrue benefits over a greater number of years than their counterparts closer to retirement age, the AAOS research concluded. The difference in societal savings between the oldest age group (80 years) and youngest group (40-44 years) was $174,364 over a lifetime, with the boost for patients under 60 ranging from $85,263 (ages 55-59) to $177,342 (ages 40-44). The only savings accrued for retired patients involved lower disability benefits, which were relatively small compared with earnings.
Conversely, the difference in total direct medical costs between surgical and nonsurgical treatment increased with age, the data show. For patients between 40 and 44 years old, the lifetime direct medical costs of surgery were $19,232 greater than the direct medical costs of nonsurgical treatment. For patients 80 and older, the difference went up to $22,339.
Perhaps the most important takeaway from the research, however, is not the give-and-take between generations of knee replacement recipients but the $12 billion (in 2009 dollars) in total lifetime societal savings generated by the 600,000 total knee arthroplasties performed in the United States four years ago.
Hip Fractures
Surgical repair of displaced intracapsular and extracapsular hip fractures costs about $20,000 but the treatment saves society roughly $60,000 per patient (mostly in nursing home care). The remedy also gives patients 1.9 to 2.8 additional QALY, (1.9 for extracapsular hip repairs and 2.8 for intracapsular patch-ups), and produces $15 billion in savings for society, AAOS’ research indicates. The higher QALY translates to an additional $18 billion in societal savings when each QALY is valued at $50,000. “The annual societal savings is projected to increase significantly in the future due to an aging population and increasing life expectancy,” noted Pete Mandell, immediate past chairman of the AAOS Council on Advocacy. “When total societal savings are considered, surgery is the dominant treatment strategy for hip fractures because it achieves better quality of life at less cost.”
Disc Herniation
Discectomy patients experienced a 0.31 gain in QALY and a $14,202 hike in direct medical costs, but the expense was offset by lifetime societal benefits of $24,024, including $23,121 from both higher wages and better job prospects. Roughly $600 came from fewer missed work days. The net societal savings per discectomy patient was $9,822 over a four-year period, though researchers contend disc herniation treatment could generate a total net societal savings of $2.1 billion compared with non-surgical treatment.
Rotator Cuff Repair
Surgical repairs of the rotator cuff save society $16,409 (in 2012 dollars) compared with non-surgical treatment and add 0.62 QALY to patients’ lives, according to AAOS data. As with most other MSK treatments, younger patients benefited most, with those younger than 40 saving an average of $71,088. Researchers estimated the 250,000 rotator cuff repairs performed nationwide in 2009 saved society around $4.1 billion. “Rotator cuff repair is both less costly and more effective,” said Chad Mather, M.D., orthopedic surgeon at Duke University Medical Center and co-founder of for[MD], a website (formd.com) where doctors can exchange info in a “pure environment.”
ACL Repair
AAOS investigators concluded that surgical treatment for ACL tears is less costly and more effective than rehabilitation, generating short- to mid-term society cost savings of $4,503 and $50,417 in long-term savings (2012 dollars). The average lifetime cost to society for patients undergoing ACL repair is $38,121—less than half the $88,538 in associated rehabilitation costs. Improved QALY is negligible (0.18) and the overall cost to society ranges from $7.6 billion to $17.7 billion annually, but the treatment saves the nation $10.1 billion per annum, and more notably, prevents 6,400 patients from developing symptomatic osteoarthritis and 5,000 TKAs.