CORR Insights^®: Medical Services and Associated Costs Vary Widely Among Surgeons Treating Patients With Hand Osteoarthritis

Where Are We Now?

Our profession must demonstrate that the costs of the care we provide are well justified. Becker and colleagues thoroughly examine this issue in the context of hand osteoarthritis. By assessing several variables relevant to patients receiving treatment for hand osteoarthritis against the Medicare costs incurred, this study measures cost variability and identifies predictors of increased expenditure. Their investigation is solid in design and methodology, and yet there are some clinically relevant questions that we still need to explore for future studies.

Where Do We Need To Go?

One important question that remains unanswered is whether surgery is a cost-effective option for patients who have exhausted nonoperative care or who are unable to utilize coping mechanisms and behavioral modification to accept and overcome pain. Decision aids and the optimization of coping and adaptive skills should be sufficient for many patients who are seeking evaluation and treatment for hand osteoarthritis, but further studies are needed to determine what proportion of patients might benefit from this approach, and how we might best identify them. A cost-benefit analysis of decision aids, techniques of behavioral modification, and current standard treatment in these situations has not yet been done.

We must determine the differential impact of decision aids [3] and current methods of care on healthcare quality and dollar costs. Although the surgical treatment of hand arthritis is not joint-restorative, systematic reviews demonstrating similar efficacy among commonly used surgical techniques [2, 4, 5] show that all types of surgery have similar degrees of effective results, and the absence of Level I evidence indicates that surgical treatment should not be abandoned.

If the development of hand arthritis is a normal process of aging to which the majority of patients can adapt [1], we should consider limiting alternative treatment options (and therefore, decrease variability in treatment) to those who have difficulty coping and adapting. Potentially, these individuals who fall outside the observed aging majority may be required to pay more in order to receive additional treatment.

While the majority of patients can cope with the normal aging process, others find themselves in a substantial deal of pain, and this patient population deserves our consideration. Although we can attribute psychosocial factors, as well as an individual’s coping and adaptive skills to the personal experience of pain, there may be genetic factors within the neural circuitry and processing of painful stimuli, which may be less responsive or unresponsive to official efforts to modify cognitive thinking; this requires further exploration. Additional studies will help us determine whether the quality of life gained with additional procedures or definitive surgery renders the overall value worth the direct costs and upfront dollars spent. We hold surgeons responsible for contributing to variability in costs, yet we do not actually define and study the mechanisms that are responsible for the observed variability. Finally, while there is evidence to suggest that most people adapt to the development of hand arthritis [1], it becomes somewhat of a philosophical debate whether we as a society want our government to continue to uphold the belief that treatment should be tailored to the individual patient, or to make the laws of medicine the same for everyone, for the sake of minimizing cost and variability.

How Do We Get There?

Although requisite in healthcare, defining value and measuring costs remains controversial. Deciding between a utilitarian and an individualistic approach to healthcare policy is similar to deciding between the good of society and the good of the individual. We must be candid and honest regarding what patients need and expect, and whether the costs to fulfill those needs and expectations are worth spending. Our profession should continue to measure what it is that the majority of our patients need, desire, and expect with respect to what treatment is currently available. Our policy makers should measure which of these treatment options are more likely to result in a positive cost-benefit impact upon society. The ability to measure either of these will be contingent on how our society defines “value” both in dollar units and in quality of life, the difficulty of which may be reason for an impasse, but not reason to dissuade us from trying. We will need to weigh the deeply entrenched principles of individualism upon which our society has thrived against the propositions of utilitarianism in health care that is evidently unfolding.