Becoming Good Stewards of Orthopaedic Technology

By: John Cherf, MD, MPH, MBA


John Cherf, MD, MPH, MBA

Although I attended my first AAOS Annual Meeting more than 20 years ago, I still remember the excitement of exploring the “trade floor” and its abundance of new technology for the first time. However, my ability to access the new products at the largest orthopaedic meeting in the world was limited by my lack of clinical experience. Back then, if I’d been told I would need to become a “good steward of technology” as my career progressed, I would not have understood the importance of the role. Today, the need for orthopaedic surgeons to optimally assess new technology has never been more vital.

Times have changed. Although there’s still no shortage of new products and services on the exhibit floor at our 2018 Annual Meeting, as orthopaedic surgeons we need to recognize that good technology stewardship should be an important part of our daily lives, and particularly this week in New Orleans. It is important for our patients, our hospitals, and our communities that we are sophisticated and savvy technology adopters who constantly ask, “Do the clinical outcomes justify the price and switching costs of adopting a new technology?”

It often seems that new technology is simply a marketing term used to justify a pricing premium. There have been very few single transformative, game-changing pieces of orthopaedic surgery technology that have come to market over the past decade, despite a plethora of “new technologies.” However, every one of us can name an expensive new technology from the past 20 years that we as a profession electively adopted, only to learn that it was no better—and sadly, maybe even worse—than what it replaced. This has occurred across nearly all subspecialties in orthopaedics.

Take for example, first-generation ceramic-on-ceramic (CoC) bearings. Despite highly-touted claims of less wear and increased longevity, we saw no significant improvement in revision rates compared to ceramic-on-highly-crosslinked poly bearings. What we did see was an increased risk of fracture and squeaking in nearly 10 percent of CoC bearing recipients. Later-generation CoC bearings may be a consideration for younger, active patients. But given that CoC bearings can carry a price premium of $1,000 or more compared to conventional bearings, patient selection is paramount. A more disappointing story occurred with metal-on-metal implants.

High-flexion components for total knee replacement provide another good example of new technology branding. These products came to market with promises of increased range of motion; however, the body of evidence has demonstrated that the promise has gone unfulfilled. Similarly, did the pricing premium of gender-specific knees pay dividends? Were rotating platform knees justifiably priced? What happened to the bicompartmental knee?

Against this backdrop, hospitals face severe and unprecedented economic headwinds while new payment models (such as bundled payments) and consumerism drive the need for an evidence-based, cost-effective strategy for treating our patients to include selecting implantable devices. This is especially true for joint replacements, which typically account for 10 percent of all device costs incurred by a hospital across all service lines. Although the cumulative rate of medical inflation over the last 5 years has been 11.4 percent, the average Medicare inpatient payment rate has risen by less than 2 percent. This creates an economically unsustainable trend. As orthopaedic surgeons, we need to be part of the solution for optimizing cost of care.

The days of universal adoption of a new technology for all patients have come to an end. Paying a premium to be on the cutting edge without evidence of better outcomes is no longer justifiable. There will always be specific patients and conditions that warrant the use of the latest device or implant, but in most cases the traditional, more commoditized product is a sufficient option.

The importance of clinical evidence in evaluating new technologies cannot be overstated. We need to help answer critical questions about whether new technologies offer superior outcomes or just contribute to the rising healthcare spend. Clinical evidence provides transparency into which products are comparable based on data and attributes rather than the latest marketing collateral.

Being a good steward of technology is easier said than done in a market with nearly 500 different devices for hip and knee implants. This broad product selection is combined with the explosion in scientific knowledge that we’ve seen in recent years. I’ve seen statistics suggesting that to stay on top of current medical literature, a physician would need to read more than 17 articles a day, 365 days a year. Very few orthopedic surgeons can dedicate the amount of time required to read this amount of medical literature.

When you return home from the 2018 AAOS Annual Meeting, I recommend that you engage in an open dialogue with your health system’s clinical and financial leaders, and encourage them to take a patient-centered approach that emphasizes quality over simple cost control. With the right information, we can put aside preconceived ideas, engage in healthy discussions, and figure out as a team the best solutions for our patients.

I recognize that some of what I’m suggesting contradicts conventional wisdom. Hospital ratings, for example, often take technology adoption into consideration, essentially creating a medical technology arms race. I consistently recommend that orthopaedic leaders who’ve chosen against early adoption of a new technology draft a position statement explaining their reasons why, along with supporting data. This is particularly important for today’s patients who are confronted with direct-to-consumer marketing of orthopaedic products. By aligning key stakeholders around this message and making it publicly available, orthopaedic surgeons and our hospitals and ambulatory surgery centers can become a relevant source of information for our increasingly savvy healthcare consumers.

As we walk the exhibit/trade floor over the next few days, I encourage you to ask hard questions. How significant is this advance in technology? What value do these new features offer? Is the price premium justified by improved outcomes? Knowing the answers to these questions and using valuable new information will be essential to making better-informed device selection decisions. These are key steps to becoming the good stewards of technology we all need to be.

John Cherf, MD, MPH, MBA, is a member of the AAOS Now editorial board, the AAOS council of education, and AAOS health care systems committees.