CORR Insights®: Moderate to Severe Renal Insufficiency Is Associated With High Mortality After Hip and Knee Replacement

Where Are We Now?

The healthcare economy is shifting away from silos of volume-based, margin-seeking strategies of patient care, and the pace of evolution is accelerating. The changes are being driven by the themes of quality-, value-, and population-based healthcare. According to the Institute of Medicine, quality care should be safe, effective, patient centered, timely, efficient, and equitable [2]. The tenets of value-based healthcare include: Patients paying less for better health, providers achieving efficiencies and greater patient satisfaction, payers controlling costs and reducing risk, and suppliers aligning prices with patient outcomes [8]. Concomitantly, governments, consumer advocacy groups, and the public are requesting a population health approach that addresses the key determinants of health, is driven by evidence-based decision-making, allows for consideration of the public’s values, and holds healthcare systems accountable for key metrics [3, 6].

The orthopaedic community has made progress in quality and value-based care by identifying patient comorbidities that increase the risk of complications, costs of care, and the probability of poor results after surgery [1, 4, 7]. Improving upon modifiable risk factors, and more aggressive high touch tailored strategies for high-risk patients have been implemented to improve the results of the procedures we perform.

Jämsä and colleagues [5] have advanced our orthopaedic quality, value-based, and population health journeys by elucidating the relationship of different stages of chronic kidney disease (CKD) to life expectancy after total hip and knee replacement. They have also provided information about the inter-relationships of other common comorbidities (diabetes, coronary artery disease, congestive heart failure) in this population of patients that contribute to shortened life expectancy. In particular, patients with Stage IV/V CKD, or Stage III CKD combined with diabetes, are two types of patients that probably should not undergo elective total hip or knee replacement surgery given the high risk of mortality. The conclusions of their study will most likely modify which patients are offered total hip and knee replacement in the future, and those who are treated nonsurgically. The authors have challenged us to look more carefully at the longer-term effects and costs of our interventions on specific categories of patients rather than just the expenses and complications of acute episodes of care.

Where Do We Need to Go?

We should try to determine which elements of a patient’s demographic or medical profile are most-directly correlated with complications after surgery, gather those elements as the patients enter the surgical pipeline, and try to intervene where needed to provide each patient with the highest-possible likelihood of a successful arthroplasty.

As stated by Jämsä and colleagues [5], various combinations and severities of comorbidities should be studied to achieve a better understanding of how different categories of patients may experience specific surgical interventions in the short-term, but also for the long-term and within the context of life expectancy. Some of this information can currently be retrieved from large existing databases and registries (with their inherent flaws and gaps). In the future, real-time information extracted from electronic health records shared across large populations of patients, combined with evidence-based decision-making guidelines, should improve our understanding, counseling, and management of patients with hip and knee arthritis. Cost-effectiveness and quality-adjusted life year (QALY) studies should provide additional information as to which patients might be better served with nonoperative rather than surgical interventions. And ultimately, some decisions about the appropriateness of a care pathway may be affected by the stakeholder(s) responsible for payment of the services—either the patient, insurance carrier, and/or government.

How Do We Get There?

To achieve our desired future state for quality and value-based population healthcare, the opportunities afforded by modern technology will need to be leveraged and taken to scale. Electronic health records should become ubiquitous and must allow sharing of health data elements in real time (within the legal bounds of security for protected health information) to create universal data marts and population-scale registries. In collaboration with our expert colleagues in health-information technology, artificial intelligence, health economics, and statistics, we should pose specific clinical questions about individual types of patients and populations to design and implement personalized clinical pathways for the continuum of care. With more reliable information, expert panels will define consensus guidelines and touch points for surgical interventions. And the data marts will provide a more accurate tracking mechanism for the long-term effects of surgical interventions on health of patients and populations. Until that time, additional targeted investigations of existing large patient registries to examine different stages or combinations of patient comorbidities and their effects on specific surgical procedures will supplement our current clinical knowledge. As suggested by Jämsä and colleagues, the studies should go beyond the acute episode metrics of average length of stay, cost per intervention, and rate of complications/readmissions. Cost-effectiveness and QALY analyses of surgical versus nonsurgical pathways will produce high impact, evidence-based consensus guidelines for the treatment of our patients with hip and knee arthritis.