When joints – and costs – become inflamed

When joints – and costs – become inflamed – health care costs

William N. Tindall

When folks complain about getting older and developing arthritis, they’re actually talking about osteoarthritis (OA). Anyone who lives long enough is likely to experience the pain or joint stiffness associated with OA, the most common form of joint disease.

Osteoarthritis can strike people as young as 30, and most 70-year-olds suffer from the disease. In the United States alone, nearly 16 million people have osteoarthritis, the majority of them post-menopausal women. Thus, the disease has serious implications for health plans and providers in the way they deal with elderly patients and manage referrals.

UNDERSTANDING OSTEOARTHRITIS

OA is a degenerative joint disease in which the shape and functioning of the cartilage between two bones is altered. Normally, the leathery, tough and resilient cartilage absorbs shock and reduces friction, but somehow it softens, deteriorates and allows the ends of the bones it protects to rub together. Without the cushioning effect of joint cartilage, the rubbing incites inflammation and severe pain.

Because paleontologists have found osteoarthritis to exist in almost every vertebrate, some believe it is not a disease at all, but a condition occurring whenever a bony skeleton is subject to trauma, stress or metabolic, genetic, endocrine or infectious triggers. Medical experts point out that friction is normally so low that joints are truly designed to last a lifetime. Further evidence suggests that this would indeed be the case – were it not for the interference of illness or trauma.

Joint cartilage consists of only S percent cells, and joint cartilage lesions do heal, both facts that strengthen the argument that OA is more complex than a simple disease. Occupations involving frequent stair-climbing or squatting are associated with a high incidence of knee osteoarthritis, and people whose jobs require heavy lifting have a high incidence of hip osteoarthritis. In addition, the increased incidence of OA in post-menopausal women indicates estrogen involvement and the increase in incidence among the obese indicates the risk to weight-bearing joints as well as non-weight bearing joints. In the absence of joint abnormalities or other risk factors, however, recreational activities such as jogging do not increase the likelihood of osteoarthritis.

SYMPTOMS AND TREATMENT

A diagnosis of OA is usually made after an assessment of its symptoms – pain, which worsens with exercise, is the primary indicator – or a simple X-ray that clearly shows thinning cartilage. Initially, only one or a few joints may be affected and inflammation may be absent.

Morning stiffness is the next complaint, but it usually lets up after a small amount of joint movement. As osteoarthritis progresses, however, joint motion diminishes and tenderness or “grating sensations” occur in the affected joint. Then, if the joint ligament falters, the joint becomes unstable and the patient experiences more pain and may develop a limp.

Osteoarthritis treatment aims to alleviate pain until surgery to replace the affected joint is required. To health plans, osteoarthritis represents a condition where relief of pain must be achieved, often over decades. Interventions, shown below from the simplest, most cost effective to the most invasive, include:

* Patient education

* Exercise

* Drugs: Acetaminophen (the drug of choice), followed by nonsteroidal anti-inflammatory drugs (NSAIDs) and, in some cases, introarticular corticosteroids.

* Surgery: Arthroscopy or total joint replacement (TJR).

According to Donald R. Lurye, MD, medical director for Meridian Medical Group of Atlanta, the best means of mitigating osteoarthritis costs are a) patient education efforts b) the use of physiatrists – physicians who specialize in physical and rehabilitation medicine – and c) the use of orthopedic physicians to provide direct care, especially for patients with intractable pain.

Calling on physiatrists early in patient care is more cost effective than involving them after a joint has deteriorated or been replaced, says Dr. Lurye. John Gastright, MD, president and CEO of Morgan Health Group in Norcross, Ga., adds that, “It may sound trite, but the best care is still acetaminophen, weight reduction, physical therapy, muscle conditioning and the proper use of canes.”

Because there are no drugs that can alter the course of the disease, the American College of Rheumatology (ACR) recommends acetaminophen (1000 mg, every four to six hours) as the preferred, first-line treatment. In its Medical Guidelines for Management of Osteoarthritis, the ACR prefers acetaminophen over non-steroidal anti-inflammatories because of side effects and toxicity associated with the NSAIDs. However, the ACR states that the best treatments are still physical therapy and exercise to minimize disability, controlling pain and other symptoms and educating patients about the disease and its treatment – including the need for overweight patients to reduce.

If pain persists after full-dose acetaminophen, however, patients may need NSAIDs or injections of corticosteroids into the affected joints. The cost effectiveness of drug treatments for OA is difficult to measure, although research clearly shows that drugs can relieve pain and improve function and quality of life. For people whose symptoms worsen and for whom standard treatments (acetaminophen, NSAIDs, physical therapy and cortisone injections) fail, it is often possible to replace diseased joints with artificial ones or to surgically reconstruct a joint.

JOINT REPLACEMENT

Formerly done almost exclusively in large teaching hospitals, knee replacement surgery is rapidly transferring to community and rural facilities. With about 150,000 total knee replacements performed yearly at a cost of some $3.5 billion, the Agency for Health Care Policy and Research conducted a study of the procedures being done on elderly patients. It found that Medicare could save anywhere from $1,560 to $6,300 per case – based on an average per-procedure cost of $8,690 – for every patient who underwent total knee replacement surgery in a small or rural hospital. The government agency also noted, however, that significant savings can occur when total knee surgery is done in a regional center that does more than nine of these specialized procedures per year. And a Canadian study found [TABULAR DATA OMITTED] that reallocating $36.9 million from teaching hospitals to non-teaching hospitals for joint replacement resulted in a savings of $6.5 million.

The increase in knee and hip replacement operations for osteoarthritic patients places great pressure on budgets of both public and private sector health plans as well as on their policies for referrals related to cost-effective and accessible surgery. “The real problem associated with joint replacements is determining when the surgery should be done,” comments Randall S. Krakauer, medical director for Heritage Medical Group Management of Garden City, N.Y. “It’s a type of surgery that a patient with severe osteoarthritis will ultimately need, and where the results for the patient are remarkable.”

Because OA is so common, patient education is extremely cost effective as a means of preventing pain and disability. In one study, investment in patient education programs about the self-management of arthritis returned a cost-benefit ratio of 12:1, indicating that such education has sustaining health benefits while reducing health care costs.

At one Kaiser Permanente plan, osteoarthritis was so common among its Medicare members that officials secured a grant to study what would happen if a group of OA patients attended educational sessions led by physicians and physician assistants, with nurses assessing each member’s condition. The results? Kaiser’s patient education program produced a dramatic decrease in the number of requests for doctor appointments – and patients wanted to continue meeting after the study ended to support each other.

Patient education – and group support – is a potent motivator. It has been found to help osteoarthritis patients exercise more, lose weight, and to promote pain relief, reduce disability and improve joint function – and to be the most cost-effective intervention for most people. One study of more than 200 patients with osteoarthritis of the knee found, for example, that they experienced less physical dysfunction and less pain following 30 to 60 minutes of education in self-care.

Patient education may also slow the progression of this worldwide condition, which has an unknown cause, no known cure and few options for pain relief. The bottom line, then, in achieving cost savings in osteoarthritis, may be the integration of patient and provider education as a crucial part of health care.

Note: For a complete list of the studies used in developing this report, please fax your request to the Business & Health editorial office at 201-722-2676.

William Tindall is executive director of the American College of Managed Care Medicine Inc., based in Glen Allen, Va. Marilyn Dix Smith and William McGhan, the executive director and founding president, respectively, of the Association for Pharmacoeconomics and Outcomes Research, also contributed to this article.

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