Tuesday, December 29, 2009

Regional Variation in Total Knee Replacement

It has been proven than there is tremendous variation in the practice of medicine across the United States. The Dartmouth data (Wennberg et al) has documented the differences in how medical resources are used and how different physicians practice medicine, depending upon where they live. The Dartmouth studies are mainly focused on cost and outcomes and make the case that improved quality is often inversely related to the cost of care. More (expensive) care is not necessarily better care.

Now that I am recovering from a total joint replacement, I am amazed to see the differences in how physicians, doing the same surgery, treat the patient. Total knee replacement (TKA) is one of the most common orthopedic procedures done today. Despite this, the patient cannot expect the same post op care.

I am in contact with a patient in rural Minnesota who had the same surgery 8 days prior to me. Here are some differences in treatment for the same surgery (TKA):

San Francisco - Hospital Stay was 4 days. Anticoagulants were used to prevent blood clots.

Minnesota - Hospital Stay was 10 days. Anticoagulants were not used and patient suffered deep vein thrombosis and pulmonary embolus requiring 3 days in ICU and several months of blood thinners afterward.

San Francisco-Patient sent home with narcotic pain relief and encouraged to take them for comfort and good sleep.

Minnesota- Patient sent home with only enough pain pills to use at night and to stretch them out.

San Francisco-Patient given home visiting physical therapy

Minnesota- Patient given exercises to to on her own without PT.

San Francisco-Wound closed with steri-strips

Minnesota-Wound closed with staples that are present 3 weeks post op and driving patient crazy

Except for the Pulmonary embolus (potentially a fatal event!) and the increase hospital cost, these are all differences that probably do not affect the total outcome one year post op. But with such a common surgery, I can't help but wonder why these variations in care occur? The surgeon's own preferences seem to determine what happens to the patient and how much pain and disability go along with the surgery.

I am glad I am receiving my care in San Francisco.


Susan said...

May your course of healing and recovery continue to go well!

KM said...

What a hugh difference, I was shocked they didn't use
Anticoagulants and very surprised less pain med. and no home PT unless there was allot of intensive PT in the 10 day stay to balance the difference. Did different insurances have any part in the treatment?

Michael Kirsch, M.D. said...

The climate alone is reason to be in S.F. Keep up the recovery!

chrissoup said...

Minnesota's care wasn't even cheaper, just all-around more unpleasant for the patient. Makes me wonder...

Stephen Margolis said...

Hello: I am a 78 year-old male. Just had partial knee replacement at United Hospital in St. Paul MN.

I was in hospital 2.5 days, discharged to home. Have had excellent physical therapy and have reached 125 degrees two weeks post op. Fortunate that my wife, former ice skate amateur, has "encouraged" me to do PT twice a day.

My big issue is post op pain. Was sent home with Percocet, 5 mg, 6-12 per day. But prescription limited to 50 pills by DEA regulations, Percocet is schedule II narcotic, wife must go to clinic, get paper prescription, take to pharmacy, wait for prescription to be filled, bring home.

Also, Percocet has psychological side effects that we were unaware of, such as euphoria, amnesia for recent events, and personality changes such as hyperactivity. I am writing this at 3:30 AM which is very unusual for me.

I think pain management could use improvement.

Raymond Bouchayer said...

I have been thinking /hoping/praying/meditating, for all the best for you .

I have heard .....that you are one of the best , nicest , most caring MD anywhere around...so I expect the heavens to treat you with very special care

Toni Brayer, MD said...

Stephen Margolis: Your recovery sounds outstanding. 125 degrees at 2 weeks...I'm jealous.

The patient I compared was in a more rural area of Minnesota. Tonight she tells me she still has tremendous pain and is receiving no formal PT. She also is still using saran wrap on the incision to take a shower...something I have never done.

California also has strict laws about schedule II narcotic pain medications but there is no limit to the number on the prescription. We have the same issue with needing a paper Rx and it is a major hassle.

Pain control is essential for healing and for ability to increase activity so limiting it is rather barbaric!

Raymond and other well wishers: Thanks for your kind words and encouragement.