A Medical Device Daily

Many MDs probably would not pick orthopedics as a glamour specialty, but its members might have a bone to pick with anyone who turns up his or her nose at this field, especially if recent numbers from the Agency for Healthcare Research and Quality (Washington) are any indication of the vitality of this branch of medical science.

According to the report, musculoskeletal procedures were performed in slightly more than 3.3 million hospitalizations in 2004, almost 9% of all hospital stays. About 2.5 million of these were primarily for musculoskeletal procedures, the balance most often for diagnostic or exploratory purposes and secondarily for musculoskeletal procedures.

The data come from the Healthcare Cost and Utilization Project (HCUP), a group of databases that includes state hospital inpatient databases, state emergency department databases and several others.

Hospital stays for such procedures tended to run longer than the average, taking up 5 days vs. 4.6 days, and were substantially more expensive than the typical stay at $13,200 per stay vs. the overall average of $7,600. The total inpatient hospital cost for musculoskeletal procedures in 2004 was roughly $31.5 billion, accounting for more than a tenth of all inpatient hospitalization costs.

Among the procedures included in this analysis are, of course, replacement of hip and knee joints as well as spinal fusions, but it also includes amputations, deformity repairs and diagnostic and therapeutic procedures in emergency rooms (ERs) as well as non-ER work.

Knee replacements and repairs generated roughly 488,000 hospital stays in 2004 at an average of 3.9 days and a mean cost of $13,200, for a total tab of $6.3 billion. Women and girls accounted for 63.8% of all such events, the average age of such patients 66.

Partial and total hip replacements totaled 368,000 stays at an average of five days and $14,500. Average age was higher than the knee group, or 70 years, and again, women and girls were more often the subjects, making up more than 62% of such patients. Almost one in four of these patients were admitted via the ER, and the total cost was $5.3 billion.

Not surprisingly, spinal fusion also notched big numbers, accounting for slightly more than 325,000 trips to the hospital in 2004, but only 6% came in via the ER. The typical stay ran 4.1 days for an eye-popping average cost of $19,600. These patients were younger, 52 years, and slightly more likely to be men and boys, 46.1%, than the two previous groups.

Despite the trade press attention focused on hip replacement and spinal fusion, knee arthroplasty has generated far more trips to the hospital, and that trend was evident even in the first year of the survey, which was 1997. In that year, Americans underwent almost 330,000 knee procedures vs. the almost 291,000 hip replacements and 202,000 spinal fusions. However, knee surgery widened the gap over the following eight years, with preliminary figures for 2005 indicating that almost 556,000 knee surgeries were performed against the relatively static numbers for hip replacement (383,500) and fusion (349,000).

Male professional athletes are well known for knee surgeries, but in 2004, more than 20 women per 10,000 had a knee arthroplasty in 2004 vs. 12 for men. For hip replacement, the per-10,000 rates were 9.5 men and 15.2 women, but the gap closes somewhat for spinal fusion at 9.7 per 10,000 men and 10.9 per 10,000 women.

Hip replacement is most often associated with greater age than is knee arthroplasty, but the data suggest otherwise. While those aged 65 and older received hip replacements at a rate of 67.6 per 10,000, they had knee replacements at a much higher rate of 79.1. Those between the age 45 and 64 got hip replacements at a rate of 14.2 per 10,000 and not surprisingly, were more often the subjects of knee arthroplasty at 24.6 per 10,000.

The epidemiological data are not bullet-proof, but the two potential sources of error seem likely to offset each other to some extent. The data include community hospitals, but not prison hospitals, long-term care or rehab hospitals, suggesting that the data may underestimate the true total.

A "fudge factor" that would seem to trend in the opposite direction is noted in the report by the passage stating that "the unit of analysis is the hospital discharge … not a person or patient," suggesting over-reporting from many hospitals.

Those interested in financing angles might be interested in seeing the ratios of these procedures covered by the federal government and private payers. According to the HCUP report, the Centers for Medicare and Medicaid Services "bore a large burden of hospital costs for stays involving knee arthroplasty" at 57.9% and an even larger share of the hip replacements, 63.4%. As might be expected with the younger cohort receiving spinal fusion, the private sector cut the check for slightly more than half, or 52.2%.

HHS provides more health emergency funds

HHS Secretary Mike Leavitt reported that the department has provided another $896.7 million to the states, territories, and four metropolitan areas to improve and sustain their ability to respond to public health emergencies.

"The funding represents another step in our nation's effort to increase our state and local public health preparedness and emergency response capabilities," Leavitt said. "It allows state, local, territorial, and tribal public health jurisdictions to build upon preparedness gains that have been made over the past five years of federal funding."

The Centers for Disease Control and Prevention (Atlanta) is coordinating the funding to be used for preparedness and response to all-hazards public health emergencies including terrorism, pandemic influenza, and other naturally occurring public health emergencies.

The funding consists of:

• $175 million for pandemic influenza preparedness to assist public health departments in their pandemic influenza planning efforts.

• $57.3 million to support the Cities Readiness Initiative (CRI). CRI is designed to ensure that selected cities provide oral medications during a public health emergency to 100% of their affected populations.

• $35 million to improve the early detection, surveillance, and investigative capabilities of poison control centers to provide information to healthcare providers and the public to respond to chemical, biological, radiological, and nuclear events.

• $5.4 million is specifically allocated for states bordering Mexico and Canada (including the Great Lakes States) for the development and implementation of a program to provide effective detection, investigation, and reporting of urgent infectious disease cases in the three nations' shared border regions.

These funds are in addition to the $430 million made available late last month to strengthen the ability of hospitals and other healthcare facilities to respond to bioterror attacks, infectious diseases, and natural disasters that may cause mass casualties (Medical Device Daily, July 2, 2007).