Jan. 2 —
Using evidence-based guidelines to identify those patients who might benefit most from elective procedures—which could result in payers not covering services for patients who do not meet the criteria—presents considerable opportunity to reduce healthcare costs and improve clinical outcomes, according to a Dec. 12, 2012, article in the New England Journal of Medicine
Other countries routinely rely on such criteria in nonemergency settings to control overutilization, note the article’s authors, citing total joint arthroplasty as “a prime example of the opportunities and challenges involved in creating and implementing appropriateness criteria.”
Elective total hip and knee arthroplasties for the treatment of advanced osteoarthritis are among the most common inpatient surgeries in the United States, with more than 1 million such procedures performed in 2009. A wide variety of patients undergo the procedure, ranging from those requesting surgery to facilitate their highly active lifestyle to those who require surgery in order to perform routine activities of daily living.
Authors of the article
, “Appropriateness Criteria and Elective Procedures—Total Joint Arthroplasty,” note that the growing obesity epidemic coupled with aging of the population will almost certainly accelerate the demand for these procedures, with some estimates predicting demand for the procedures will quadruple by 2030, exceeding 4 million operations, and more than 50 percent of patients will be younger than 65 years of age.
Using appropriateness criteria has considerable promise to slow the increase in utilization, the authors contend, given that other countries have found that only 60 to 80 percent of total joint arthroplasties are considered appropriate according to the evidence-based criteria established by those countries,
The article’s authors—Hassan M.K. Ghomrawi, PhD, MPH; Bruce R. Schackman, PhD; and Alvin I. Mushlin, MD—further note that there are two potential sources of reductions in use. First, the one-time decrease could occur when the appropriateness criteria are implemented. For instance, if procedures deemed to be inappropriate are not reimbursed by health insurers, only a minority of patients not meeting the criteria will be willing or able to pay out of pocket for them.
Second, if payment going forward is contingent on meeting the criteria, the upward trend can be expected to slow down from that point on. Basing payment on appropriateness criteria also has the potential to enhance the overall quality of care by preventing complications that might have occurred in operations that were inappropriate to begin with.
That said, the authors admit significant challenges to implementing appropriateness criteria must still be overcome. Most notably, consensus must be reached about the criteria themselves.
Clinical opinion leaders and patient representatives must be involved in developing appropriateness criteria so that they are credible to physicians and patients and don't limit necessary care, according to the authors.
Publication Date: Wednesday, January 02, 2013