Joint Replacement? Do It Right the First Time - NYTimes.com

THERE is nothing like a new hip or knee to put the spring back in your step. Patients receiving joint implants often are able to resume many of the physical activities they love, even those as vigorous as tennis and hiking. No wonder, then, that joint replacement is growing in popularity.

In the United States in 2007, surgeons performed about 806,000 hip and knee implants (the joints most commonly replaced), double the number performed a decade earlier. Though these procedures have become routine, they are not fail-safe.

Implants must sometimes be replaced, said Dr. Henrik Malchau, an orthopedic surgeon at Massachusetts General Hospital in Boston. A study published in 2007 found that 7 percent of hips implanted in Medicare patients had to be replaced within seven and a half years.

The percentage may sound low, but the finding suggests that thousands of hip patients eventually require a second operation, said Dr. Malchau. Those patients must endure additional recoveries, often painful, and increased medical expenses.

The failure rate should be lower, many experts agree. Sweden, for instance, has a failure rate estimated to be a third of that in the United States.

Sweden also has a national joint replacement registry, a database of information from which surgeons can learn how and why certain procedures go awry. A registry also helps surgeons learn quickly whether a specific type of implant is particularly problematic. "Every country that has developed a registry has been able to reduce failure rates significantly," said Dr. Daniel Berry, chief of orthopedic surgery at the Mayo Clinic in Rochester, Minn.

A newly formed American Joint Replacement Registry will begin gathering data from hospitals in the next 12 to 18 months.

Meanwhile, if you are considering replacing a deteriorating knee or hip, here are some ways to raise the chances of success and avoid a second operation.

EXPERIENCE COUNTS Choose — or request a referral to — an experienced surgeon at a busy hospital. "The most important variable is the technical job done by the surgeon," said Dr. Donald C. Fithian, an orthopedic surgeon and the former director of Kaiser Permanente's joint replacement registry.

Ask for recommendations from friends who have had successful implants and from doctors you know and trust. When you meet with the surgeon, ask how many replacements he or she does each year.

VOLUME MATTERS A study published in The Journal of Bone and Joint Surgery in 2004 found that patients receiving knee replacements from doctors who performed more than 50 of the procedures a year had fewer complications than patients whose surgeons did 12 procedures or fewer a year.

The researchers documented a similar trend when it came to hospital volume. Patients at hospitals that performed more than 200 knee replacements a year fared better than patients at hospitals that performed 25 or fewer.

ADJUST EXPECTATIONS Not everyone with joint pain will benefit from a joint replacement.

An implant can help reduce pain and improve mobility if the joint surface is damaged by arthritis, for instance. But a new joint will not help pain caused by inflammation of the surrounding soft tissue, said Dr. Berry, who is also vice president of the board of the American Academy of Orthopaedic Surgeons.

Some people with mildly arthritic joints, for instance, can manage well with the judicious use of medication. "Surgery comes with complications and risks, and should not be approached lightly," Dr. Berry said.

Joint replacement is not a minor operation. If you have uncontrolled high blood pressure or another serious chronic condition, a joint operation may simply be too risky for you.

NARROW YOUR OPTIONS "There is no one best joint," Dr. Berry said. "A successful replacement depends on selecting the right implant for the patient."

A good surgeon will recommend an implant that makes sense for your age, activity level and the shape of your joint. Younger or very active people who place more physical demands on the implant, for instance, may benefit from newer hard-on-hard bearing surfaces, like those made of ceramic, said Dr. Joshua J. Jacobs, chair of orthopedic surgery at Rush University Medical Center in Chicago.

In general, be wary of the latest, most advanced new joint. There is little evidence to support the use of more expensive designs over basic ones, said Dr. Tony Rankin, a clinical professor of orthopedic surgery at Howard University. One recent study found that premium implants fared about as well as standard implants over a seven- to eight-year period.

Be skeptical, too, of advertising gimmicks. "I had a 78-year-old patient with a perfectly good knee replacement come in and ask if she should have gotten the 'gender knee,' which she had seen advertised on TV," Dr. Rankin recalled. "She was doing well, but was swayed by the idea of a knee made just for women."

GATHER THE DATA Once you have a recommendation or two from a surgeon, find out how well the joint has performed in others and if there are known complications. The newer metal-on-metal hip implants, for instance, are somewhat controversial and may cause tissue and bone damage in certain patients.

Ask if the hospital has a registry that tracks joint replacements. If so, ask to see the data on the implants you are considering.

It is also helpful to understand what the operation involves, including the materials that will be used and how the surgeon plans to fix the joint to the bone. You can learn more about your operation at the American Academy of Orthopaedic Surgeon's patient information Web site, orthoinfo.org.

If you want to delve deeper, look at a large national registry from another country, like Australia (which can be found at dmac.adelaide.edu.au/aoanjrr/publications.jsp). The annual report of Australia's registry lists knee and hip implants that had a "higher than anticipated revision rate."

A caveat: the information can be difficult to parse for a layperson. "A surgeon can provide perspective on information that, taken out of context, could be misleading," Dr. Rankin said. So discuss it with your surgeon.

PLAN YOUR RECOVERY To avoid complications during your final stage of recuperation, discuss with your doctor in advance the support you will need when you return home, Dr. Berry advised.

Recovery takes a different course for each patient, depending on the type of procedure and implant. In general, expect mild to moderate pain for the first few weeks. Some patients are able to return to work in one to two weeks, but full recovery can take six to 12 months, Dr. Jacobs said.

Make sure you have the help you need in the initial stages of recuperation. Since you may have difficulty getting around and won't be able to drive right away, you may want to have a friend or family member stay with you. You may even need to hire an aide or visiting nurse.

Follow your doctor's orders, and don't rush your recovery. You don't want your new joint to fail because you couldn't resist carrying loads of laundry up and down stairs, or felt compelled to rearrange the patio furniture.

If the new joint is given time to heal, you will find plenty of opportunities for all that in the future.

http://www.nytimes.com/2010/07/03/health/03patient.html?hpw=&pagewanted=print

Health overhaul may mean longer ER waits, crowding - Yahoo! News

Emergency rooms, the only choice for patients who can't find care elsewhere, may grow even more crowded with longer wait times under the nation's new health law.

That might come as a surprise to those who thought getting 32 million more people covered by health insurance would ease ER crowding. It would seem these patients would be able to get routine health care by visiting a doctor's office, as most of the insured do.

But it's not that simple. Consider:

_There's already a shortage of front-line family physicians in some places and experts think that will get worse.

_People without insurance aren't the ones filling up the nation's emergency rooms. Far from it. The uninsuredare no more likely to use ERs than people with private insurance, perhaps because they're wary of huge bills.

_The biggest users of emergency rooms by far are Medicaid recipients. And the new health insurance lawwill increase their ranks by about 16 million. Medicaid is the state and federal program for low-income families and the disabled. And many family doctors limit the number of Medicaid patients they take because of low government reimbursements.

_ERs are already crowded and hospitals are just now finding solutions.

Rand Corp. researcher Dr. Arthur L. Kellermann predicts this from the new law: "More people will have coverage and will be less afraid to go to the emergency department if they're sick or hurt and have nowhere else to go.... We just don't have other places in the system for these folks to go."

Kellermann and other experts point to Massachusetts, the model for federal health overhaul where a 2006 law requires insurance for almost everyone. Reports from the state find ER visits continuing to rise since the law passed — contrary to hopes of its backers who reasoned that expanding coverage would give many people access to doctors offices.

Massachusetts reported a 7 percent increase in ER visits between 2005 and 2007. A more recent estimate drawn from Boston area hospitals showed an ER visit increase of 4 percent from 2006 to 2008 — not dramatic, but still a bit ahead of national trends.

"Just because we've insured people doesn't mean they now have access," said Dr. Elijah Berg, a Boston area ER doctor. "They're coming to the emergency department because they don't have access to alternatives."

Crowding and long waits have plagued U.S. emergency departments for years. A 2009 report by the Government Accountability Office, Congress' investigative arm, found ER patients who should have been seen immediately waited nearly a half-hour.

"We're starting out with crowded conditions and anticipating things will only get worse," said American College of Emergency Physicians president Dr. Angela Gardner.

Federal stimulus money and the new health law address the primary care shortage with training for 16,000 more providers, said Health and Human Services Department spokeswoman Jessica Santillo.

But many experts say solving ER crowding is more complicated.

What's causing crowding? Imagine an emergency department with a front door and a back door.

There's crowding at both ends.

At the front door, ERs are strained by an aging population and more people with chronic illnesses like diabetes. Many ERs closed during the 1990s, leaving fewer to handle the load. The American Hospital Association's annual survey shows a 10 percent decline in emergency departments from 1991 to 2008. Meanwhile, emergency visits rose dramatically.

At the back door, ER patients ready to be admitted — in hospital lingo, ready to "go upstairs" — must compete for beds with patients scheduled for elective surgeries, which bring in more money. "If you've got 10 ER patients and 10 elective surgeries," Kellermann asked rhetorically, "which are you going to give the beds to?"

That's why easing crowding will take more than just access to primary care. It also will take hospitals that run more efficiently, moving patients through the system and getting ER patients upstairs more quickly, Kellermann said.

Ideas that work include bedside admitting, where a staffer takes a patient's insurance information as treatment starts.

That and other strategies are being tried at St. Francis Hospital and Health Centers in Indianapolis. There, the performance of nurse managers is measured by how long admitted patients wait in the emergency department for a bed upstairs.

And to stave off inappropriate ER visits, the hospitals have opened after-hours clinics staffed by primary care doctors to handle patients who can't leave work to see a doctor, said Indianapolis hospital executive Keith Jewell. ER wait times have fallen.

A Chicago hospital, too, is readying for the onslaught of ER patients. On the city's South Side, Advocate Trinity Hospital handles 40,000 emergency visits a year and is expecting more because of the new law.

Greeter Stephanie Bailey makes sure patients don't get frustrated while they're waiting. She can take their vital signs and inform staff if the patient is about to leave without treatment.

Inside the emergency department, a giant sheet of paper hangs on a wall. It's hand-lettered in orange and purple, and tracks daily progress on hospital goals: How many patients left before they were treated? How many minutes did patients stay in the ER?

On a recent day, the note said "0.0 percent" of the patients left without treatment. Someone had added a smiley face. But there was no smiley face next to the average ER length of stay for the same day — nearly four hours. The hospital's goal is three.

http://news.yahoo.com/s/ap/20100702/ap_on_bi_ge/us_med_er_crowding_8

U.S. scores dead last again in healthcare study | Reuters

Americans spend twice as much as residents of other developed countries on healthcare, but get lower quality, less efficiency and have the least equitable system, according to a report released on Wednesday.

The United States ranked last when compared to six other countries -- Britain, Canada, Germany, Netherlands, Australia and New Zealand, the Commonwealth Fund report found.

"As an American it just bothers me that with all of our know-how, all of our wealth, that we are not assuring that people who need healthcare can get it," Commonwealth Fund president Karen Davis told reporters in a telephone briefing.

Previous reports by the nonprofit fund, which conducts research into healthcare performance and promotes changes in the U.S. system, have been heavily used by policymakers and politicians pressing for healthcare reform.

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http://www.reuters.com/article/idUSTRE65M0SU20100623

Hallucinations in Hospital Pose Risk to Elderly - NYTimes.com

No one who knows Justin Kaplan would ever have expected this. A Pulitzer Prize-winning historian with a razor intellect, Mr. Kaplan, 84, became profoundly delirious while hospitalized for pneumonia last year. For hours in the hospital, he said, he imagined despotic aliens, and he struck a nurse and threatened to kill his wife and daughter.

"Thousands of tiny little creatures," he said, "some on horseback, waving arms, carrying weapons like some grand Renaissance battle," were trying to turn people "into zombies." Their leader was a woman "with no mouth but a very precisely cut hole in her throat."

Attacking the group's "television production studio," Mr. Kaplan fell from his hospital bed, cutting himself and "sliding across the floor on my own blood," he said. The hospital called security because "a nurse was trying to restrain me and I repaid her with a kick."

Mr. Kaplan's hallucinations lifted as doctors treated his pneumonia. But hospitals say many patients are experiencing such inexplicable disorienting episodes. Doctors call it "hospital delirium," and are increasingly trying to prevent or treat it.

Disproportionately affecting older people, a rapidly growing share of patients, hospital delirium affects about one-third of patients over 70, and a greater percentage of intensive-care or postsurgical patients, the American Geriatrics Society estimates.

"A delirious patient happens almost every day," said Dr. Manuel N. Pacheco, director of consultation and emergency services at Mount Auburn Hospital in Cambridge, Mass. He treated Mr. Kaplan, whom he described as "a very learned, acclaimed person," for whom "this is not the kind of behavior that's normal." "People don't talk about it, because it's embarrassing," Dr. Pacheco said. "They're having sheer terror, like their worst nightmare."

The cause of delirium is unclear, but there are many apparent triggers: infections, surgery, pneumonia, and procedures like catheter insertions, all of which can spur anxiety in frail, vulnerable patients. Some medications, difficult for older people to metabolize, seem associated with delirium.  

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http://www.nytimes.com/2010/06/21/science/21delirium.html

A Pacemaker Wrecks a Family's Life - NYTimes.com

One October afternoon three years ago while I was visiting my parents, my mother made a request I dreaded and longed to fulfill. She had just poured me a cup of Earl Grey from her Japanese iron teapot, shaped like a little pumpkin; outside, two cardinals splashed in the birdbath in the weak Connecticut sunlight. Her white hair was gathered at the nape of her neck, and her voice was low. "Please help me get Jeff's pacemaker turned off," she said, using my father's first name. I nodded, and my heart knocked.

Upstairs, my 85-year-old father, Jeffrey, a retired Wesleyan University professor who suffered from dementia, lay napping in what was once their shared bedroom. Sewn into a hump of skin and muscle below his right clavicle was the pacemaker that helped his heart outlive his brain. The size of a pocket watch, it had kept his heart beating rhythmically for nearly five years. Its battery was expected to last five more.

After tea, I knew, my mother would help him from his narrow bed with its mattress encased in waterproof plastic. She would take him to the toilet, change his diaper and lead him tottering to the couch, where he would sit mutely for hours, pretending to read Joyce Carol Oates, the book falling in his lap as he stared out the window.

I don't like describing what dementia did to my father — and indirectly to my mother — without telling you first that my parents loved each other, and I loved them. That my mother, Valerie, could stain a deck and sew an evening dress from a photo in Vogue and thought of my father as her best friend. That my father had never given up easily on anything. 

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http://www.nytimes.com/2010/06/20/magazine/20pacemaker-t.html

Geisinger, a Health Insurer, Pays More to Save More - NYTimes.com

Like a lot of doctors, Patrick Kilduff has too many patients and too little time. He and the five other physicians in Shavertown, Pa., oversee the care of about 12,000 people, and a typical office visit lasts just 15 minutes.

Because health insurers pay him as little as $45 per visit, Dr. Kilduff and his colleagues say they have little choice but to squeeze as many patients as they can into their day. That makes it virtually impossible to spend time explaining to patients the importance of keeping their blood sugar under control or how to take their medicine. But the insurers' penny-wise approach can lead to as much as $1 million in hospital bills, if a person with under-treated diabetes has a heart attack.

That is why some of the nation's insurers are now trying to avoid those high medical bills by taking the longer view. They are giving primary care doctors more help — and more money — to take care of the sickest patients and help prevent them from becoming sicker.

Otherwise, insurers know they risk being overwhelmed by rising health care costs as an older, sicker population copes with serious chronic conditions.

"The essential business model of medical insurance will have to change," said Dr. Glenn D. Steele Jr., the chief executive of Geisinger Health System, which operates a network of clinics and hospitals in Pennsylvania.

Geisinger is known nationally for its innovative approaches to delivering high-quality care at lower cost. It also owns a health insurance plan that covers about 250,000 people — including many of Dr. Kilduff's patients in Shavertown.

As an insurer, Geisinger now pays the salaries of extra nurses in doctors' offices, whose full-time job is to help patients with chronic diseases stay on top of their conditions and, ideally, out of the hospital. The doctors, including Dr. Kilduff, help hire the nurses, who work closely with the doctors to oversee the patients' care.

The nurses make sure patients who need quick appointments are squeezed in, and they alert the doctors to any early indications of trouble by keeping in close contact with the patients and looking out for the results of patients' lab tests.

One of Dr. Kilduff's patients, Rose Ann Cox, 69 years old, began working a few years ago with a Geisinger-paid nurse, Karen Thomas, to control her diabetes, talking by phone at least once a week. Ms. Cox had gone to the emergency room when her blood sugars were too low, but she has not been in the hospital for about three years now.

"You don't always think you should call the doctor," Ms. Cox said. But she has no qualms about reaching out to the nurse.

The initiative is part of an overall effort by Geisinger and other insurers to create a so-called medical home — the place where patients' care is carefully coordinated by a doctor and staff, with particular attention given to the chronically ill.

Geisinger began experimenting with this approach three and a half years ago and now uses it in 37 practices, most of which are part of its own network of doctors' offices.

But five of the doctors' offices, including Dr. Kilduff's, are independent practices that accept Geisinger as one of several insurance plans. Under the arrangement with the outside doctors, Geisinger pays for the nurses and shares with the doctors any savings they can achieve by reducing medical expenses. So far, Geisinger says it is pleased with the early results. In an unpublished review of 2008 data, Geisinger experienced an 18 percent drop in hospital admissions; overall medical expenses fell 7 percent. Geisinger expects to publish a study on its results later this year.  

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http://www.nytimes.com/2010/06/22/business/22geisinger.html?th&emc=th

Surgeon vs. Knee Maker - Who’s Rejecting Whom? - NYTimes.com

It was a long, fruitful medical marriage that is fast becoming an angry public divorce, one that offers a rare look at a clash between a top-shelf consultant and his corporate patron over patient safety.

For years, Dr. Richard A. Berger designed surgical tools and artificial joints for Zimmer Holdings, trained hundreds of doctors to use its products and talked it up wherever he went. In return, Zimmer, an orthopedic implant maker, helped enrich Dr. Berger, portraying him as a master surgeon and paying him more than $8 million over a decade.

Those days are gone. Dr. Berger started complaining to Zimmer a while back that one of its artificial-knee models was failing prematurely, and he went public recently with a study that he says proves it. Zimmer told him that the problem was not the artificial knee, but his technique, and pointed to data overseas indicating that the knee was safe.

Last year, Zimmer did not give Dr. Berger a new contract. The company says it routinely rotates consultants.

"I trained hundreds of doctors for them and made them tens of millions," Dr. Berger said in interview here, in which he also lambasted Zimmer executives as dissembling, out-of-touch bureaucrats. "So was this just a coincidence? Maybe it was. Maybe it wasn't."

Zimmer executives declined to be interviewed. The company said in a statement that it had thoroughly investigated Dr. Berger's complaints in 2006 and that he had disagreed with its findings.

Amid the booming use of artificial joints in the United States, the breakup between Dr. Berger and Zimmer highlights what experts say is a troubling situation for patients and doctors: when disputes arise about orthopedic implant safety, there are no independent referees or sources of information because no one tracks the performance of the devices.

"There is no way of knowing who is right because we don't have the data," said Dr. Kevin J. Bozic, a professor of orthopedic surgery at the University of California, San Francisco.

While producers of implanted heart devices have a voluntary system in which outside panels investigate problems, American makers of orthopedic devices do not. Many of the artificial joints that surgeons like Dr. Berger use, including the Zimmer knee at issue, are cleared under law by the Food and Drug Administration for sale without testing in patients. In addition, no one in the country tracks the long-term performance of artificial hips and knees, a $6.7 billion annual business that surged as baby boomers reached middle age.

THOSE with the most to lose are the hundreds of thousands of people who receive an orthopedic device each year.

One patient, Lisé Markham, said she underwent surgery recently to replace a flawed hip just two years after getting it. She said the experience awakened her to how little patients can find out about an implant's track record.

"My doctor knew everything about me, every personal detail, but what did I know on the other side?" said Ms. Markham, who lives in San Diego.

Two years ago, another top Zimmer consultant, Dr. Lawrence Dorr of Los Angeles, alerted surgeons that a company hip model was failing after a few years. Zimmer shot back, saying the problem was Dr. Dorr's technique, not the device. Along with briefly halting sales, it also provided the F.D.A. with data from 12 surgical centers showing that the hip was working well. Based on that, the agency decided to close its investigation, said an F.D.A. spokeswoman, Mary Long.

But in interviews, two doctors who provided Zimmer with supportive data in 2008 said the hip started failing soon afterward in their patients, too. One, Dr. Richard Illgen of the University of Wisconsin, said he now realizes that Dr. Dorr's technique was not the issue, but that Dr. Dorr had just started using the Zimmer hip before other surgeons. Zimmer still defends the product, which is known as the Durom hip.

These days, companies like Zimmer have fewer consultants, part of the fallout from settlements in 2007 by several companies, including Zimmer, of Justice Department charges that consultant payments were used to disguise kickbacks to surgeons. However, relationships with Dr. Berger and Dr. Dorr were not called into question.

ABOUT a decade ago, when the relationship between Dr. Berger and Zimmer began, it was filled with promise. The surgeon, a tall, balding man with a boyish manner, was finishing his fellowship at the Rush University Medical Center in Chicago at the time, one of the country's top centers for joint replacement. The center has had long ties to Zimmer, whose headquarters is about two hours away, in Warsaw, Ind., and the young surgeon quickly came to the company's attention.

"Rich has a very clever set of hands, and because of that he is enabled with the ability to innovate surgical techniques," said Roy Crowninshield, who was Zimmer's chief scientific officer.

Dr. Berger's skills matched Zimmer's marketing strategy. To distinguish itself from competitors, the device maker had started promoting minimally invasive surgery, a technique that uses smaller incisions than traditional surgery. Zimmer trained doctors in the procedure, using its device.

Soon, Dr. Berger, who was then pioneering a type of small-incision surgery that allowed patients to leave the hospital on the day of surgery, became a linchpin of Zimmer's efforts. In 2002, he was prominently featured in a press release about Zimmer's plans to build a training facility for minimally invasive surgery.

"We are clearly excited about Dr. Berger's data," J. Raymond Elliott, the company's chairman and chief executive at the time, stated in the release.

Over the next few years, the physician estimates, he helped train hundreds of surgeons on Zimmer's behalf. His star also rose: he and his technique were featured on "World News Tonight" on ABC, and he was soon performing about 1,000 hip and knee replacements annually, nearly all with Zimmer devices.

But Dr. Berger, who is 47, with energy and self-confidence to spare, also became a lightning rod. Other doctors questioned whether his technique of using such a small incision could be broadly adopted, and interest in his approach fell. The concern was that such a tiny opening left doctors with little room for error.

Dr. Berger brushes off complaints, saying that many surgeons do not have the skill or the patience to learn his technique. "There are lots of reasons that people don't want to do something new," he said.

As he tells it, his relationship with Zimmer frayed over a version of a widely used Zimmer knee, known as the NexGen. The model at issue, called the NexGen CR-Flex, is designed to provide a greater range of motion than the standard NexGen.

Most surgeons implant an artificial knee using a cement-like adhesive to bond the thigh bone to the portion of the device that bends. But some specialists, like Dr. Berger, try to avoid adhesives because the cement can break down and cause device failure. So Zimmer also sells an uncemented version of the CR-Flex that relies instead on the bone naturally fusing with the implant.

Dr. Berger says that he gave the device, which is supposed to last about 15 years, to about 125 patients in 2005, the first full year he used it. But by early 2006, some X-rays showed lines where the implant met the thigh bone, an indication that the device was loose and had not fused completely. Patients could walk, but they were reporting pain, apparently a result of the loose joint.

He says he soon brought the problem to the attention of Zimmer officials, including the company's new top scientist, Cheryl R. Blanchard. Zimmer executives pointed to the success of the NexGen, but the company did not have separate test data on the uncemented flexible model because the F.D.A. had not required the company to study it in patients before selling it.

Later, as more patients complained about the device and Dr. Berger had to replace some of them, he spoke to Ms. Blanchard again, he said. This time, he said, she and other Zimmer officials suggested that his technique was the problem because no other surgeon had complained.

"Suddenly, I went from someone who was their master teacher to someone who didn't know what he was doing," he said.

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http://www.nytimes.com/2010/06/20/business/20knee.html?pagewanted=print