Dr. Mark Hanna practices at Emory Saint Joseph’s Hospital, identified by the Centers for Medicare and Medicaid Services as one of the nation’s best records for joint replacements among Medicare patients. He examines Terry Godbold, a candidate for knee replacement. BRANT SANDERLIN /BSANDERLIN@AJC.COM
Photo: Brant Sanderlin
Photo: Brant Sanderlin

Outcomes mixed for joint replacements at Georgia hospitals

New data show risk of complications

More than 1 million Americans now turn to surgeons every year to replace their painful hips and knees with fancy new joints made in factories.

Within weeks, many of these patients toss their canes or walkers, take family vacations and even return to tennis and golf. Other patients, though, do not walk away from these surgeries at all.

Infections and other serious complications can force patients back to the hospital within days — or even months — of a replacement. What are the odds of a replacement going wrong? That depends significantly on where a patient decides to have the procedure done, according to an Atlanta Journal-Constitution study of federal quality data.

At the state’s top-performing hospital, only 3.6 percent of hip and knee replacement patients returned to the hospital within 30 days. At 16 other hospitals across the state, the rates of re-admissions were 6 percent or higher, the AJC found.

Meanwhile, 20 Georgia hospitals had a complication rate for joint replacements that was more than double the rate of the best performer.

» YOUR TURN: Have you had hip- or knee-replacement surgery? Email cteegardin@ajc.com to tell us your story.

What can go wrong? The implants can fail — and many have. Nerves can be damaged. Life-threatening infections can develop, sometimes requiring months of medications and multiple surgeries that make the patient’s old, arthritic steps feel like a cakewalk. Rarely, a patient will die.

“All of these risks are relatively uncommon, but when you add them all up they can occur in four to five percent of patients who have an elective procedure,” said Dr. Kevin Bozic, an orthopedic surgeon who specializes in complex hip and knee replacements at the University of California San Francisco Medical Center.

To help the growing number of joint replacement patients make informed choices, the federal Centers for Medicare and Medicaid Services unveiled quality statistics for every hospital in the country that does a significant number of hip and knee procedures.

Two Atlanta area hospitals — Emory Saint Joseph’s and Emory University Hospital — were among 97 hospitals across the nation highlighted for posting the best performances for hip and knee replacements among Medicare patients. Floyd Medical Center in Rome was the only Georgia hospital listed among 95 nationally for a poor performance.

Salvatore Cassaro, 75, has had joint replacements done — and then redone after problems — on both of his knees. The Kennesaw resident said patients need more facts so they can make informed decisions about going under the knife.

“They are happy to tell you about their success stories, but nobody talks about the failure rates,” Cassaro said.

His last “revision” was in December and happened only after Cassaro found Dr. Stephen Kim, a Marietta orthopedic surgeon who finally diagnosed and fixed a knee replacement that had left Cassaro in constant pain.

“What I tell people is proceed cautiously,” Cassaro said. “When you do decide to have something done, you have to do the research on the doctor and make sure you are comfortable. The doctor has to be highly qualified. He has to be at the top of his game.”

Reducing risk

Historically, consumers have had little to go on, other than referrals from other doctors or names offered up by friends, when selecting a hospital or doctor.

“Right now consumers have almost no information about the cost or quality of health care. Because of that we have a very inefficient marketplace for healthcare, where decisions are made based on reputation and cost is not considered at all because everyone thinks someone else is paying for it,” Bozic said.

The statistics, which are based on billing data, may not be perfect, Bozic said. They cover only Medicare patients and only hospitals that do enough of the procedures to make the numbers statistically valid. The numbers cover about a three-year period, beginning in July 2009.

But the information may help patients research this procedure, which is well-suited for shopping around since it’s rarely done in a rush.

“This is an important step in the right direction of making consumers more informed,” Bozic said. “But it’s a first step and we have a long way to go.”

The statistics show Emory Saint Joseph’s was the only Georgia hospital to be rated as significantly better than the national average for both re-admissions and complications.

The surgeons operating at Saint Joseph’s reduce the risk of complications by making sure their patients are appropriate candidates for the procedure, with special attention paid to managing patients’ other health conditions, especially diabetes, said Dr. Mark Hanna, one of the orthopedic surgeons who practices at the hospital.

Hanna said he and his colleagues emphasize getting patients home as quickly as possible, because simply being in the hospital can up the risk of infection. Doctors at Saint Joseph’s and most other hospitals now shoot for a one-night stay for most joint replacements, he said, and even that might soon be considered too long.

“Outpatient total joint replacement is emerging and is now an option for some patients,” Hanna said.

Patients at Saint Joseph’s also benefit because the surgeons and the hospital handle a high volume of joint replacement cases. In medicine, practice does make perfect, as surgeons master their techniques while nurses and physical therapists know how to follow a clear set of protocols that can significantly reduce risks.

“I love doing the same thing over and over again,” Hanna said. “It allows me to be as good as I can be.”

Medical horror story

Sheriff Bill Harrell had been living with pain for years before he finally decided it was time for a joint replacement. The middle Georgia lawman’s knees has been battered from his days playing high school football in Laurens County, where he’s been sheriff for nine years. He opted for a surgeon in Savannah recommended by a doctor he knew.

“We went there, and he painted this really nice picture,” said Connie Harrell, Bill’s wife. After meeting the doctor, Connie expected Bill to be home from the hospital in two or three days and completely recovered in six weeks, finally free of the pain that had bothered him for years.

The day after he got home, Bill told his wife he wasn’t feeling well and headed back to bed. “I walked around the corner and there was a puddle of blood all the way down the hallway to the bedroom,” Connie said.

This happened on a Sunday morning. Connie couldn’t reach the doctor. She called a friend at the local ambulance service who came over and did get a doctor on the phone. He said the couple could just come to the office the next day. No big rush.

“It just went downhill from there,” Connie said.

It took a couple of weeks before they were told that Bill had a staph infection in the knee. His fever started spiking. He was packed in ice. The fever went up and down for days. The doctors took him back to surgery to try to eliminate the infection. Over six months, he underwent seven surgeries. He would go back on antibiotics. Each time, the fever came back. The infection remained.

The sheriff’s local physician became concerned and insisted on coming to see Bill at his house one evening. “He said, ‘Connie you have got to get him out of here. He will die if you don’t.’”

They were referred to an Emory University doctor known for treating infections caused by joint replacements. The doctor’s office acted fast, telling them to be in Atlanta the next day and to come prepared to stay.

After hours of surgery, the doctor told Connie that he gave Bill a 50-50 chance of either losing his leg or not surviving at all. “He said, ‘We can just pray,’ ” Connie said.

The fever didn’t come back. The infection, finally, was gone. Six months later, the doctor replaced a temporary spacer he had placed in the knee with a new artificial joint. Bill soon started campaigning for re-election. He won handily. The couple will always credit the doctor with saving not just Bill’s leg, but his life.

Stats alone not enough

The federal statistics about joint replacements aren’t just designed to help consumers select a hospital. They’re also intended to make sure hospitals know if they have a problem and pressure them to improve.

The new statistics estimated the complication rates for joint replacements at Floyd Medical Center in Rome at 5.5 percent. That’s more than double the 1.9 percent rate listed for Emory Saint Joseph’s and significantly higher than the national rate of 3.4 percent. That’s what prompted federal health officials to brand the hospital as one of the poor performers nationally.

Floyd Medical Center said it had flagged increases in its complication rate and addressed problems long before the new statistics were published on the CMS Hospital Compare website.

“This is an excellent example of why consumers should proceed with caution when looking at Hospital Compare data, but this scenario is also a good illustration of how hospitals can use CMS data to improve,” Dr. Joseph Biuso, Floyd’s chief medical officer, said in a statement to The Atlanta Journal-Constitution.

Biuso said the hospital reviewed every process involved in the joint replacement procedures, set standard orders for how the cases were handled, changed some of the clinical processes and even hired a company to help improve outcomes. “We have seen good results from this, including reductions in our readmission rates,” he said.

Dr. Stephen Kim, who practices at WellStar Kennestone Hospital and who handled Salvatore Cassaro’s most recent surgery, said consumers shouldn’t rely only on the new federal ratings — at least not yet.

Kim said he and his colleagues carefully track outcomes. He said the rates reported by the federal government for Kennestone weren’t as good as what they were actually observing. But he said that after digging into the numbers, they discovered a problem in the hospital’s coding of some cases that was skewing the numbers.

“That’s why patients have to be very cautious using that solely as an instrument for choosing which doctor and hospital,” he said.

Kim predicted the accuracy of the numbers will improve as hospitals get better at reporting. Most experts agree that the accuracy of health care quality data improves over time.

While the data may not yet be perfectly accurate, Kim said public reporting does keep hospitals and doctors focused on performance. Kim said tracking results internally is also crucial and has helped drive improvements where he practices. He listed all sorts of protocols he and his colleagues already follow to reduce complications, including requiring patients to attend classes in advance, carefully selecting the patients who get the surgeries, and limiting time in the hospital and even time in surgery itself.

Game changer

For every story about a joint replacement gone wrong, there are many tales about the ones that went right. Take Mike Blasingame. The Columbus resident had his first hip replacement in 2007, when he was in his mid-50s. With that one, he says, he probably waited a year too long. Blasingame is an active guy. He goes to the gym. He loves to fish. But the joint pain became so harsh that going on a family vacation or attending a sporting event had become extraordinarily difficult.

“I quit going to UGA football games because I couldn’t walk all the way to the stadium from the car,” he said.

He researched his options and had the first surgery done by a highly-regarded surgeon in Columbus. Everything went as planned.

“As soon as I had that replacement and went through the therapy, I was walking to and from the stadium like nobody’s business,” he said.

About a year later, his other hip started giving him trouble. This time, he came to Emory University for the surgery to try a newer, less invasive approach to hip replacement that a friend had undergone with good results.

He’s now about six weeks out, and said his recovery this time is even better. For him, the surgery has been a game changer that will make it possible for him to play catch and go fishing with his little grandson and travel with his wife.

When the pain hits and become intolerable, Blasingame says everybody faces the decision. “Do you want to try to take back control of your life, or sit back on the couch and watch golf and fishing shows?”

Dr. Thomas Bradbury, an Emory University orthopedic surgeon, did Blasingame’s last surgery. At Emory, which takes the most complex cases, Bradbury has seen first hand what can go wrong.

But Bradbury sees, above all else, what the surgeries can do for people, whether they are people in their 80s anxious to stay active or baby boomers who want to be playing golf and keeping up with the pace at work, not relying on a walker.

“These operations in general are among the biggest bang for the buck in terms of health care and in terms of improving quality of life,” Bradbury said.

Sheriff Harrell of Laurens County says he needs to have his other knee replaced. He’s just 59. The football injuries are raging in that knee, just like they were in the other one. He’s thought about the relief from pain and he’s also thought about the risks.

“I do not know,” he said, “if I ever will have it done.”

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