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Study finds sizeable underutilization of hip and knee replacement procedures

June 05, 2006

A Duke University study reports that of those men and women whose physicians recommended a total hip or knee replacement, a staggering 92 and 88 percent, respectively, did not take advantage of these surgical procedures, despite their safety, success rates and long-term positive outcomes. Fear of pain or worsened mobility, misperception of advances in the rehabilitation process, and lack of awareness of the full range of benefits afforded by such interventions is behind the high patient refusal rates, the study's investigators surmised.

The report by the Duke University Medical Technology Assessment Working Group is based on a survey of literature published since 1993 and findings from National Institutes of Health consensus panels held in 1993 and 2001. The Duke team studied medical device interventions for the treatment of osteoarthritis and osteoporosis-related fractures.

Despite gaps in the volume of existing literature, the researchers found total hip and knee replacement surgery to be safe, with low post-operative complications and mortality rates. In addition, implant survival rates were well above 90 percent after 10 years; patient satisfaction levels stood firm at 85-90 percent; and the procedures themselves were highly effective in relieving pain and restoring function. The study's sources did not include people who might benefit but had not visited a doctor, those who did not reveal all pain issues to their physicians, or who were not appropriate for replacement surgeries because of other medical conditions.

"Clinical results for knee and hip replacements are among the best of any procedure we've examined and the long-term benefits and improvements to quality of life are profound," said Linda George, Ph.D., professor and project director of the study. "This phase of our study has clearly indicated a dire need for an increase in public education related to medical devices and diagnostics, even via advertising, so that people better understand the benefits — and be less fearful about the process. This would lead to increased acceptance of these kinds of surgical procedures."

Researchers also found substantial disparities in utilization across race and gender lines, but were unable to pinpoint the root causes. For example, African Americans and Hispanics have no less need for hip or knee replacements than whites, but they choose them less often.

Further, women are more likely than men to have osteoarthritis of the hip, but do not undergo replacements until an advanced state of disability, which results in a longer rehabilitation and poorer outcome.

According to George, the Duke team was surprised to find how little had been done to study outcomes and the timeframes in which patients were monitored. Range of motion and pain reduction were checked in the hospital or a rehabilitation facility in the days or weeks immediately after a surgery, but not beyond.

"When you're talking about an older population, you're not looking for a return to work, necessarily, but people who can now — or continue to — take care of themselves and do their own shopping or housework may not need assisted living or nursing home services," said George. "Most data are limited to studies in one or two medical centers and does not reflect the kind of monitoring that is the norm in the average community hospital. We will be analyzing data from thousands of people from all across the country to make better estimates of levels of disability — and impacts on quality of life — resulting from joint replacements."

Team to study long-term effects on "human capital"

The on-going Duke study will use data drawn from the Center for Medicare and Medicaid Services and the National Long Term Care Survey to explore the effects of medical technology innovations such as knee and hip replacements on human capital — the economic savings in terms of productive activities.

The Duke University study is funded by a grant from InHealth: The Institute for Health Technology Studies, a nonprofit research and education organization whose mission is to examine the role, impact and value of medical technology, thereby enhancing a climate of health care innovation for public benefit.

"Clearly, there is a need for more evidence-based research on the impact of knee and hip replacements on the health and quality of life of patients," said Martyn Howgill, executive director of InHealth. "We fund grants like this to provide information and insights to patients, caregivers and health policy makers so that they can make informed decisions."

InHealth: The Institute for Health Technology Studies