Of Hip Replacements, the Cost of Care and the Price of Cars

Apr 01, 2013

New last week: Attempts to comparison shop for a total hip arthroplasty demonstrate the muddle in health care pricing. Also, a case study of an IV drug user who turned up with myalgias, arthritis, and pain, and a population-based link between glucocorticoids and pancreatitis.

Last week's articles on rheumatology topics in the major nonspecialty journals

Practice management issues

What Does a Hip Replacement Cost? The Transparency Imperative in 2013JAMA Intern Med., Mar 25, 2013 (Full text $30)

Availability of Consumer Prices From US Hospitals for a Common Surgical ProcedureJAMA Intern Med., Mar 25, 2013 (Full text $30)

Price information for total hip arthroplasty (THA) is difficult to get, but patients can save significantly if they persist. A researcher called 20 top-ranked orthopedic hospitals from the US News and World Report rankings, and also two randomly-selected hospitals from each state, saying that her grandmother had been recommended for THA, would pay out of pocket, and was seeking the lowest complete cost (hospital plus physician fee). About 60% of hospitals provided the information, although it took up to five calls.

Prices varied 12-fold, ranging from $12,500-105,000 (mean $53,140) in top-ranked hospitals and from $11,100-125,798 (mean $41,666) in the others. Some of the top-rated hospitals had the lowest total prices. (This study is similar to a 2011 Government Accountability Office report,  Meaningful Price Information Is Difficult for Consumers to Obtain Prior to Receiving Care, GAO-11-791)

In a commentary, Ezekiel Emanuel compared the availability of pricing information on health care to the automobile market in the 1950s: exorbitant charges, phony “preparation fees,” and market inefficiencies. Price information is of almost no value without quality information, he wrote. predicting that both will be available for health care expenditures within the decade.

Rheumatological complications of IV drug use Case 10-2013 - A 30-Year-Old Man with Fever, Myalgias, Arthritis, and RashN Engl J Med, Mar. 28, 2013 (Full text $15)

Now@NEJM: Arthritis and Rash N Engl J Med, Mar. 29, 2013. (Free)

An IV drug user, 30, presented to Massachusetts General Hospital with fever, myalgias, arthritis, and rash, and severe pain in arms and legs. The differential diagnosis  considered three causes:

(1) Levamisole, a veterinary drug, a common adulterant of cocaine, which can lead to vasculitis with thrombosis, leukocytoclasis, and necrotizing lesions in blood vessels, associated with “a confusing array of autoantibodies,” and easily confused with warfarin-induced necrosis and granulomatosis with polyangiitis (formerly Wegener’s);

(2) Hepatitis C virus, which is associated with positive rheumatoid factor; and

(3) Hepatitis B virus, which in some patients causes a syndrome resembling serum sickness, starting with inflammation of the joints and jaundice, followed by urticaria, both of which resolve in days to weeks.

Adverse effects of glucocorticoidsAssociation of Oral Glucocorticoid Use With an Increased Risk of Acute Pancreatitis: A Population-Based Nested Case-Control StudyJAMA Intern Med., Mar 25, 2013 (Full text $30)

In a population-based case-control study of the entire Swedish population, the use of oral glucocorticoids increased the risk of acute pancreatitis with odds ratio (OR) 1.53, after adjusting for alcohol abuse, gallstone disease, and other known risk factors. The risk was increased only between four and 30 days after the patient began treatment. The risk was greatest between four and 14 days, during which period increases ranged from OR 1.42 for prednisolone to  OR 3.53 for betamethasone.  Unfortunately, the Swedish Prescribed Drug Register does not provide information about drug dosage or indication.