AAOS Commentary: Value of Orthopaedic Care


As our country revamps its health care system, it would do well to remember Hippocrates’ admonition to “first do no harm” to patients.

Orthopaedic surgeons take that oath seriously, which is why leadership of the American Academy of Orthopaedic Surgeons (AAOS) commissioned a major research project to measure the true, scientifically defensible value of what we do. It’s a fair, complex question worth discussing anytime, but in today’s political environment, where traditional notions of worth and value health care are now “in play,” it’s imperative that our work be assessed in terms of the best data possible. Otherwise, how can policymakers help us preserve an environment where medical providers can focus and adhere to the Hippocratic path?

No one can argue with the quest for value, or with a desire to be better stewards of the billions of dollars spent on health care as the Affordable Care Act is implemented. But the missing piece in the public process so far has been a measure of the indirect costs of illness, such as lost employability, income and independence, missed work days, lowered household income and disability income. High-quality surgical procedures and other treatments impact those indirect costs. The policy arguments to date have focused narrowly and relentlessly on the simple cost of procedures to patients and payers, which skews the picture.

That is why AAOS commissioned research to develop a new methodological model to fill in that gap in our knowledge and give us a more complete picture of what value means for our patients, and society at-large. The newly published report, “Modeling the Indirect Economic Implications of Musculoskeletal Disorders and Treatment,” is the most comprehensive assessment to date of the economic burden of bone and joint disorders and the impact of procedures to treat them. It also is a model for similar analyses on health care procedures and treatments beyond orthopaedics. The March 2013 study, by KNG Health Consulting, LLC and IHS Global, Inc., appears in Cost Effectiveness and Resource Allocation, BioMed Central’s open-access journal (available, free to the public).

It’s an exacting and exciting piece of work.  The researchers examined physical limitation data, such as inability to walk a quarter-mile or climb 10 steps without resting, from multiple years of the National Health Information Survey (NHIS), which included 185,000 people. Using that data and existing clinical data on patient functional ability post-surgery, the authors developed a novel method of analysis to estimate the overall value, including impact on indirect costs, of specific knee and hip replacement operations in cases of arthritis.

To summarize the outcome of their complex statistical analyses, researchers projected a significant indirect, or downstream economic benefit for patients who had total knee arthroplasty (TKA, commonly known as knee replacement) for osteoarthritis and hip replacement for intra- and extracapsular hip fractures. The benefits identified were in the form of higher household income, increased likelihood of being employed and fewer days out of work. The methodology paper is the first in a series that will publish findings from this research for a variety of conditions.

It would be impossible, ethically or practically, to analyze these questions definitively by running randomized prospective studies of patients who get surgery vs. controls who don’t. In their absence, sophisticated economic analyses that explore the complete picture retrospectively are the best evidence we have of the net benefits to society of care that manifestly benefits suffering patients. Until now, evidence directly linking treatments for bone and joint disorders to patients’ economic activity hasn’t been available.

For everyone’s sake – especially patients but also payers (including taxpayers), employers and government – the definition of value must not be dictated by the sticker price of the orthopaedic procedure or treatment.  We also need to have a clearer picture of factors such as impact on patients’ ability to remain independent, productively employed, or of avoided payments for disability or long-term care. Patients experience the value of health care based on how they feel and what they are able to do. We will always have more research to do, but we have found a way to come much closer to measuring the economic value of that experience to all of us.

Read more on the Value of Orthopaedics at www.anationinmotion.org/value/orthopaedic-care.

John R. Tongue, MD, AAOS past president