nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Monday, June 14, 2010

Britain's Criminally Stupid Denial Of Care For Hip Replacement

Britain's answer to the bankrupt National Health Service (NHS):  deny hip replacement to obese patients.

On the surface, this might make sense.  There are a number of studies that show obesity leads to increased wear and tear on the joints.  This increases the risk that these patients will suffer disabling pain from the destruction of the joint, requiring replacement with an artificial device.

The operation is expensive, and the NHS needs to save money.  About 60,000 people a year need the surgery.  My survey just now shows that about 2/3's of (non-obese?) people will wait about 16 weeks for the surgery, some much longer (you can look online at NHS).  There have been short-term denials of this surgery in obese patients over the last few years.  Currently on the table:  freeze all hip replacements in the obese for a year.  The plan is to put these people on a weight-loss regimen that will reduce further wear and tear.

And save money, of course, by reducing the total cost per year to the government.

Following me here?  It doesn't sound unreasonable for patients to lose weight, helping themselves along the way, before considering their surgery.

BUT, consider:
1.  The joint's already trashed.  Nothing will make it better (not those OTC pills that "build cartilage").
2.  Being overweight continues to worsen the damage.
3.  Weight reduction in the general population is notoriously ineffective.
4.  People in need of joint replacement suffer pain and disability all day, every day.
5.  Having a bad joint makes it almost impossible to lose weight.

So, why are we not operating on them?  Fixing their joint, THEN putting them in an exercise and diet regimen, when it might work?

Money...that's the primary driver.

I've written a several times (here, here, and here, for a sample) about comparative effectiveness, that it CAN be a code for cost control.  The evidence is plain that other countries use it for that purpose.  In Great Britain they are at least honest about not having the money to pay for their government-run health care system.  They just aren't honest about the reasoning...or they are criminally stupid.

I wonder when the government bureaucrats world-wide will come up with a formula for pain and suffering.  Britain has the QALY, or quality adjusted life-year, which is how much money they'll pay if it's likely the result will be another year of quality life (who gets to decide the "quality" is another story.  Hint:  it's not the patient)

I suggest we decide how much a year's worth of pain with every step should be valued in dollars.  For instance, each painful step is worth a penny.  You take 7000 steps a day (avg for a US male, see here).  Divide by 2, since we're talking only one leg here.  Then let's say you can reduce the number of steps by 20% because it HURTS.  That gives you 2800 steps per day, or ~1M steps per year.  At a penny a step, that's $10,000 per year.   If the operation costs $50K, then you will have paid your suffering dues to society in 5 years (disregarding inflation).

Given that almost all hip replacements are done in people over 65 years old, depending on when the five year clock starts, some will die before qualifying for the surgery.  With a population of 300M, there are about 1/2 million hip replacements needed per year.  If only 10% kick off before we have to pay for a joint replacement we could save $2.5 billion per year.

Now that's some kind of comparative effectiveness, yeah buddy.  We could fund all kinds of nature parks, and pork barrel spending with that much money.

[Most people will get the sarcasm in this proposal, but I have to ask...did you?]

So, that's another reason I'm very critical of comparative effectiveness:  it is not possible for the government to avoid cost as a factor in effectiveness, and as costs continue to rise it will become THE factor.  And we will see the US do the same as GB, Canada, France, the Netherlands, etc.

Let's be honest and call it Comparative Human Monetary Worth.

Doc D

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