The Knee and the CER: A Conversation

To have or to have not. That is the question.

Patient with painful knee

Comparative Effectiveness Research (CER) – a federal agency  created by the Patient Protection Affordable Care Act to inform healthcare decision-making by  providing evidence  on the effectiveness, benefits, and harms based on research studies comparing drugs, medical devices, tests, surgeries, and ways to deliver care.

AHRQ Agency for Healthcare Research  and Quality

April 15, 2012

Knee:   I am the human knee.  Who are you?

CER:  I am a federal agency – the Comparative Research Effectiveness,  or CER for short, which is part of PCORI – the Patient Clinical Outcome Research Institute - PCORI.  You may address me, as Yes, CER.

Knee:   Yes, CER. Comparative  to what?

CRE:  Comparative  to the costs and results  of how doctors now do things and what patients want.  Why do you ask? What is your problem?

Knee:   I hurt.  I should say “We hurt. Me and my  other knee, the guy on the other side.  We usually hurt together. He who goes together hurts together.”

CER:  How much do you hurt? As Shakespeare  once said, "Have courage. You cannot hurt too much".

Knee: I don't want to be hard on the bard. But I disagree with him.  I hurt a lot, and the pain is getting worse every day.  I ache all day and all night.   I can't go up and down stairs. I can't go up and down hills. I can't play golf or tennis.  I'm taking stronger and stronger  pain pills.  And I can't live a normal life. It's not "Yes, I can." It's "No I can't."

CER:   Can't  you live with your pain? Grit your teeth.  You can take it. Just don't flex your knee.

Knee:   I suppose so, but it hurts like hell.  A lot  of my friends and relatives  have had knee replacements,  and in every case,  the operation has relieved the pain.

CER:   Why don’t you just use a cane or a crutch?

Knee: Why should I do that, when I can have the operation and do without a cane or a crutch?

CER:    Three  reasons.  One, knee replacements cost the government a lot of money.

·        One, the number of knee replacements is going up at the rate of about 15% each  year.

·        Two,  Over a million are performed each year at an average cost of $40,000 to $45,000. That amounts to roughly $40 to $50 billion.

·        Three,  osteoarthritis  of the knees,  the most common reason for replacing knees is not fatal.    Learn to live with it.

Knee:   But I want to have the surgery. I want to live a normal life.  I want to be pain-free, just like my friends and relatives who have had their knees replaced.   Besides, Medicare pays for it.

CER:  That’s exactly the problem.  Medicare costs are out of control, the number one contributor to our national budget deficit,  now $16 trillion.  And knee replacements are a big part of the cost problem with Medicare.

Knee:   So what are the alternatives?

CER:   Live with the pain. Take pain medications. Don’t move around so much. Have an endoscopy with a knee scraping.  Inject cushions or drugs into the knee.  Do one knee at a time.  Do what knees to be done.  

Or do what other countries do – get in line and wait months to have  it done.  That’s  what  the United Kingdom (U.K.) does, through a national agency called  NICE,  the National Institute for Health and Clinical Excellence,  which provides guidelines to assure high quality care. NICE is from the government, and you can always trust  government experts.

Knee:   Are you kidding? Where have you been?  Come on, what’s the catch?

CE:R No catch.  If you are eligible, NICE approves 75,000 knee replacement  per year. That would be about 375,000 in the U.S.   And you only have to wait 3 to 6 months to have the knee done.  IF,  of course, you’re approved and qualify for the operation.

Knee. Sounds like a Big IF to me.  Look, this is the U.S., not the U.K.  Here my doctor and I make the big decisions,  not the government , and here I can have it done immediately.

CER:  In the U.K.  patients are tougher. When the going gets tough, the tough keep going –without surgery if necessary. 

Kene:  That doesn’t sound NICE to me, if I may pile a pun upun your cliche.

Tweet:   Knee replacements relieve pain,  knee operations are  increasing 15% each year, but the procedure costs government $50 billion a year.