Knee Replacement Complication Rates

No one wants to be in the small percentage of people who have knee replacement complications after surgery. So anything that helps protect consumers is a good thing-right?

Recently, CMS (Centers for Medicare and Medicaid Services) released data from 2009 through 2012 on readmissions within 30 days following knee replacement surgeries as well as knee replacement complication rates for all of the following adverse events by hospital:

• Acute myocardial infarction
• Pneumonia
• Sepsis
• Surgical site bleeding
• Pulmonary embolism
• Mechanical complication
• Joint infection
• Death

The raw data is available here  in a very unhelpful format. Techie Alert: Any database people out there who could pull the raw data on just knee replacements?

CMS recently released a table, based on this data, of the 97 best and 95 worst hospitals as compared to the national averages for complications and readmissions.

I’ve color coded this chart and you’ll be able to download it in a PDF format for easy viewing and printing at the bottom of this blog post.

However, being mindful of the quote

“Lies, damned lies and statistics”

Let’s try to put this data in perspective by looking at real numbers for national complication rates as opposed to just relationship data.

From the AAOS website (American Academy of Orthopedic Surgeons):

“The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery.”

A more detailed look at complication rates complied from government and clinical sources and presented by healthline is available below.

Overall rates of complications were 6.1% during a hospital stay and 7.5% within 90 days of surgery based on 1.82 million patient records. Data breakdown into smaller categories reveals the following:

Generally speaking, 90 days post-surgery, you will have a less than 2% chance of having a knee infection, less than 4% chance of blood clots and a 4.3% chance of mechanical complications. Very good odds really.

Now that we know some of the real numbers, lets go back to the CMS story.

CMS is getting ready to launch on initiative in the fall of 2014 that will penalize hospitals 3% percent of their Medicare reimbursement rates for each patient stay for those hospitals that do not meet acceptable benchmarks.

CMS is already penalizing 2,225 hospital for unacceptable rebound rates for pneumonia, heart attacks and heart failure. Joint replacement data will be factored into the decisions to financially penalize institutions soon.

If the government is in control I can’t think of anything that will go wrong, can you?.
Of course, they wouldn’t politicize their penalties for hospitals that don’t play ball according to their dictates. Now that…. would NEVER happen. No worries there.

Beside the fact that there is definitely something creepy about a government “penalty program”, I can think of a number of ways this can go wrong.

What about unintended consequences like…

Institutions refusing to perform knee replacement surgery on high risk patients to pad their stats and ensure full reimbursement.

How about the best hospitals denying replacements to diabetics, the obese and those with heart issues -groups that are most likely to have complications.

Or even refusing to do bilateral knee replacements which tend to have greater complication rates.

In fact, I already know that this type of thing is happening at the home health level. As they impose these penalties corporations are not dumb.They avoid or dump the sickest people when profits and reimbursements are at stake.

Additionally it is not always the institution’s fault that things go wrong. Human beings don’t always do what you tell them to do and penalizing institutions because patients are non-compliant is about as intelligent as penalizing teachers for students not learning.

I know, I know now I am getting into much deeper waters. The fact is you need to use your brain.

I am passing on this chart about  “the best and worse” hospitals because I want you to have every available tool to assist in making quality decisions, but don’t use it blindly.

Remember the following caveats:

1. This data was compiled for years 2009-2012. Many of the worst hospitals have already made improvements in advance of penalties and conversely other hospitals rated superior may have had changes that caused their numbers to fall.
2. Some hospitals that are excellent may have been consistently treating a sicker or less compliant clientele although CMS purports to account for this with statistics
3. Personally, if you really trust your doctor and know what to look for in picking a top quality knee replacement surgeon, I wouldn’t let the hospital rating deter you. (I would definitely discuss it with the surgeon and he may be able to give you more insights)
4. Perfection is not available in medicine. What are the human costs, time costs and unintended consequences of trying to drive rates of infection down to say .5%? As laudable a goal as that first appears to be, massive government intervention and super-quantification of medicine are not benign forces.

Remember ratings are compared to national averages. Here is the coding for the chart.

—— =results met national averages
“better”= results were better than national averages
“worse”= results were worse than national averages

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