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Researchers say criteria needed for elective surgeries

Sunday January 6, 2013
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To slow rising costs and the projected surge in demand after full implementation of the Affordable Care Act, the nation’s healthcare leaders and the medical community should establish evidence-based appropriateness criteria to determine which patients most need elective procedures, according to researchers with Weill Cornell Medical College.

Total joint replacement surgeries are among the most common inpatient surgeries and are a prime example of elective surgeries that could benefit from implementing appropriateness criteria, the authors wrote in the Dec. 27 issue of the New England Journal of Medicine.

Patients requesting joint replacement surgery vary from those disabled by joint arthritis to those seeking to maintain an active lifestyle without pain. Total joint replacement surgeries are expected to quadruple over the next two decades in the United States, contributing to rising healthcare costs and increasing the risk of medical complications, the researchers noted.

“The purpose behind establishing criteria is to use evidence-based metrics to prioritize patients most in need,” Hassan M.K. Ghomrawi, PhD, assistant professor of public health at Weill Cornell and an outcomes research scientist at Hospital for Special Surgery, said in a news release. “We don’t want to sacrifice necessary care when thinking of cost-containment.”

More than 1 million total joint replacement procedures were performed in 2009, according to the news release. Experts predict the number of these surgeries will grow drastically, exceeding 4 million by 2030, with more than half the patients younger than 65.

The growing obesity epidemic, coupled with an aging population, is projected to fuel increased demand for total joint replacement surgery. These projections do not reflect the increase in the number of patients who will gain health insurance coverage when the Affordable Care Act is fully implemented in 2014.

Cost-containment proposals focus primarily on payment reforms, such as pay-for-performance and bundled payments. But in their analysis, the authors posit that developing and implementing evidence-supported criteria that identify the appropriate patients who are most likely to benefit from surgery also will slow the growing costs of these procedures.

According to the researchers, criteria will enable physicians to determine which patients’ surgeries are medically necessary, which ones are elective and which ones are inappropriate, and then tie reimbursement to the analysis. Procedures deemed inappropriate would not be reimbursed by health insurers.

The researchers said this approach would decrease the number of inappropriate procedures performed, with not many patients willing or able to pay out of pocket for them. A secondary yet important result of appropriateness criteria is the potential to enhance the overall quality of care by increasing access to the procedure for those most in need and by preventing complications that might have occurred in operations that were inappropriate to begin with, the authors added.

For the criteria to be successful and credible to physicians and patients and not limit necessary care, clinical opinion leaders and patient representatives must be involved in developing the guidelines, the researchers said. Although integrating appropriateness criteria into the reimbursement and care delivery systems could help limit cost increases, achieving savings will depend on acceptance of the criteria by physicians and patients.

The researchers believe criteria generated for total joint replacement surgery could lead the way for similar criteria in other elective procedures, reducing their cost and enhancing quality of care.

The article is available at www.nejm.org/doi/full/10.1056/NEJMp1209998.


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