Joint Enterprise

Retired teacher Walter Altobelli decided to get his hip replaced when he could no longer play his young grandson’s favorite chase-and-catch game.

“I think that’s what really did it,” he said while perched on an exam table in the doctor’s office a week before his Nov. 23 surgery. “I couldn’t play gonna gitcha.”

The 66-year-old Medical Lake resident is one of hundreds of people in the region who receive artificial hips each year. In fact, Spokane has one of the highest rates of hip replacement surgery in the nation, 50 percent higher than the national average.

We’re among the top 13 cities where hips are hip. Others include Idaho Falls; Duluth, Minn.; and Bend, Ore.

It’s part of our “surgical signature” and has more to do with the local doctors’ preferences than with medical need, according to Dartmouth Medical School researchers who study regional variations in health care. (The rankings are based on surgical rates per 1,000 Medicare enrollees, so it doesn’t matter whether a region has more or fewer senior citizens.)

Hip replacement is an expensive, proven treatment that relieves the pain and immobility of osteoarthritis. It’s an elective surgery, so patients and doctors have lots of discretion. There aren’t crystal-clear answers about who should have the surgery and who is better off without it.

If you live in a place – like Spokane – where there are a lot of orthopedic surgeons doing a lot of hip replacements, you’re more likely to have one than if you lived somewhere else.

Medicare pays for most hip replacements, which cost from $18,000 to $20,000, so regional variation is a public policy issue, said Dr. James Weinstein, chairman of the Department of Orthopaedic Surgery at Dartmouth Medical School.

“Joint replacement is one of the most effective procedures done in medicine,” Weinstein said. “But just because it’s really good, should it be overutilized? Or utilized at the rate that it should be?”

The trouble is: No one knows how many is too much.

Spokane’s hip replacement rate, according to the Dartmouth Atlas of Health Care, is 4.5 surgeries per 1,000 Medicare enrollees. The national rate is 3 per 1,000. The lowest rate in the nation is in Honolulu, with 0.8 per 1,000.

Spokane has more orthopedic surgeons per capita than most other places, double the national average, according to the American Academy of Orthopaedic Surgeons.

There are 46 orthopedic surgeons listed in the Spokane County Medical Society directory. They outnumber pediatricians. They outnumber kidney doctors. They outnumber obstetrician-gynecologists.

Orthopedic surgeons consider many factors when deciding where to locate, including culture, environment and how many surgeons are already in a community, according to the academy. In 1998, the academy polled new surgeons about where they would most want to live. Washington state made it into the top 15.

Marketing joint surgery

Spokane orthopedic surgeon Dr. David Scott, of Orthopaedic Specialty Clinic, replaced Altobelli’s hip. He does 100 to 150 hip replacements a year.

“This is all I do: hip and knee replacements,” Scott said. “I just see more and more patients who need my services.”

Scott thinks Spokane’s high rate of hip replacements could be tied to a higher level of awareness and education about the surgery, which he helps promote. He also wondered whether osteoarthritis could be more prevalent here because of heredity or nutrition.

“I strongly doubt that it is because orthopedists in Spokane are more likely to operate than elsewhere,” Scott said via e-mail.

Scott holds a seminar one evening a month at his office. After the seminars, the appointment desk is open and patients sometimes sign up for a first appointment right then.

Scott’s presentation covers risks and alternative treatment approaches, but is generally positive about hip replacements.

“It never ceases to amaze me how little a hip replacement has to hurt,” Scott told the 15 people who came to his November seminar.

Scott said he operates only on patients who have lost so much cartilage that their hip joint is “bone on bone.” His patients also must have suffered for a long time and feel that their quality of life is impaired. They also must have tried other options, such as medication, exercise and weight loss.

Scott said he always discusses risks with patients during appointments. Patients also sign a surgical consent form that lists risks, “and they also review and sign a multi-page summary that I have prepared of all the issues, problems, risks, etc., and, last, they watch a video on hip replacement, which includes a discussion of the risks.

“The discussion of the risks is exceedingly important,” Scott said in his e-mail. “The more knowledgeable my patients (are), the better for everyone.”

Some Spokane hospitals also market new hips and knees.

Three years ago, Sacred Heart Medical Center and Holy Family Hospital purchased a Florida company’s ideas for revamping hospital joint replacement programs. The Florida company, TVC of Clearwater, Fla., sells its hospital cost-efficiency and marketing ideas as a product called Joint Ventures.

The Joint Ventures program includes ways to get operating rooms to run more efficiently and ways to get patients to recover faster and go home more quickly. It also includes marketing items such as framed posters for hospital walls.

The two Spokane hospitals saw an increase in the number of hip replacement surgeries around the same time their Joint Ventures programs started.

“Hospitals buy this program with hopes of increasing volume and decreasing cost,” said Ron Gaunt, vice president for orthopedics at the company. Hospitals are told they can expect to increase the number of patients coming to them for joint surgeries “in the range of 20 percent,” he said.

Some of that increase will be patients lured away from other hospitals, Gaunt said. But some of that is new business generated by happy patients telling friends who may not have considered surgery otherwise.

Altobelli, the retired teacher and grandfather who recently had his hip replaced, said word of mouth influenced him.

“I was talking to the pharmacy lady and she said, ‘You gotta see Dr. Scott.’ Coincidentally, the next evening, Dr. Scott comes on the TV (news) using a computer to do his hip surgeries.”

Altobelli made an appointment.

Informed decisions

Arthritis of the hip affects an estimated 3 million Americans. Although it’s not a normal part of aging, it does affect more older people than younger people.

Arthritis damages the cartilage and bone of the hip joint. Instead of sliding smoothly, the ball and socket joint of the hip becomes stiff and painful.

For people with very painful arthritis, there are two basic options, both viable. There’s hip surgery combined with physical therapy. And there’s pain medication combined with exercise.

Most doctors agree that patients should make their decisions knowing all the risks and benefits. But is it enough to show patients a videotape? To thoroughly discuss options face to face? Do patients need to know the statistics on how long artificial joints last? Or how many people die after surgery?

The Foundation for Informed Medical Decision Making produces thorough videotapes and booklets for many procedures, including hip replacement surgery. One study showed that patients who viewed the back surgery videotapes chose surgery 22 percent less often than patients who didn’t see the video.

The hip surgery videotape features interviews with patients who chose surgery and patients who didn’t. It gives facts about risks and benefits, including:

• 1 in 100 patients, age 65 and older, will die of complications during the first 90 days after surgery.

• 90 out of 100 people say their pain was greatly or completely relieved after surgery; 10 out of 100 say their pain was somewhat relieved, the same or worse.

• Without surgery, people risk becoming inactive and raising their risk of heart disease.

Dartmouth doctor and researcher Weinstein, a clinical adviser for the videotape, said if more patients were making fully informed decisions there would be less regional variation in surgical rates. “Now it’s based on who the surgeon is and their beliefs,” Weinstein said. “I’m arguing it needs to be turned around to the patient’s beliefs.”

Altobelli’s surgery, to the uninitiated eye, looked surprisingly like carpentry. Scott, the surgeon, used a mallet, a screwdriver, a power drill, a power saw and power reamers to prepare Altobelli’s bones for the artificial titanium hip joint.

Before Scott closed the incision, he lined up the patient’s knees to do a rough check on leg length. Scott also checked alignment with a computer-assisted navigation system. Uneven leg lengths are a complication of hip surgery, affecting fewer than 1 in 100 people.

After the surgery, Scott met with Altobelli’s wife, Carol. He reassured her that all went well.

“Is he going to be taller now?” Carol Altobelli joked. “He keeps shrinking.”

“You should have told me that before the case,” Scott joked back.

That afternoon, Altobelli walked, with assistance, for a short distance in the hospital hallway. The next day, he had his first physical therapy session in a room with eight other joint replacement patients: four knees and four other hips.

The patients grimaced as they worked their joints, but they also smiled at the encouragement of two physical therapists.

“Do you have buns of steel yet, Walter?” physical therapist Dave Ewell Altobelli asked.

Altobelli spent four nights in the hospital and went home on a Saturday. By the next Monday, he was feeling well.

“I’m 99 percent better,” he said. “I’m telling you, I can’t believe it.”

Asked what he would tell friends considering hip replacements, he said: “Go out and find a doctor you can trust and that you feel comfortable with. Try to get the latest technology you can and don’t be afraid of it.”