Direct-to-consumer marketing in orthopedics – the next wave

Issue: April 2005

Douglas W. Jackson, MD [photo] --- Douglas W. Jackson, Chief Medical Editor

During one recent week in my clinical practice, I was taken aback by another manifestation of direct-to-consumer marketing in orthopedics. I was so struck by the sudden, heightened awareness around a single issue I saw in one group of my patients – and the additional time it consumed — that I sat down and wrote this editorial.

By the time you read this another company will probably have aired a new volley of ads and I will have spent lots of patient-visit time explaining that advertisement. It is taking me some time to adjust to the impact of this effective form of marketing.

On a single day that week I discussed the possibility of a knee replacement with several patients. Eight specifically asked if I would use the “new” rotating-platform knee should they opt for a replacement. They, or someone close to them, heard about it on TV. Then, at the end of that same week I was doing preop evaluations for four patients scheduled for replacements. Three of the four asked if I would be implanting that new rotating knee.

It just so happens that I do use that particular knee replacement device by DePuy, a Johnson & Johnson Co., on occasion. I told my patients I had used it many times in the past three years and I am still trying to determine in those patients whether it offers better clinical outcomes than the fixed-bearing knee we also use.

These prospective knee replacement patients don’t really understand the concept of underside wear, or whether the patella may track better in some patients with a particular type of artificial knee. They don’t ask whether there is data available to support claims of better postoperative motion. Whatever they think they know they gleaned from the TV ad, which is that this particular knee would feel more natural because it allows more rotation.

There are questions in my mind that remain unanswered. Over the years I have not seen significant problems from underside wear in my knee-replacement patients. Nor have I seen, so far at least, that rotating platform knees offer more knee motion or greater functional outcomes. I elected not to participate in the randomized studies underway, so I base this on preliminary clinical impressions. I also listen to speakers and read the literature on the data presented in search of answers.

Now there are some additional dilemmas on this whole issue. How do I explain it all to my patients? For example, I often find that after discussing several aspects of implants with my patients, no matter what I say, a few simply announce they want the rotating platform. (Others prefer my recommendation and happily accept it.) Some of these can be very drawn out and difficult discussions because, regardless of age or activity level, patients and their families want the best replacement available. I do too, of course, and I tell them so. But I also tell them we do not have the evidence to clearly show better long-term results with this new knee. I explain we need time before we have definitive answers on which patient-selection criteria should determine the ideal candidate who might benefit from this technology.

This patient education dilemma then gets compounded because the newer technology costs our hospital $400 more per patient. We have worked closely with our hospitals to select the best knee prosthesis on a proven cost/benefit basis. Now the question becomes: Is the $400 extra taken from the hospital’s global Medicare reimbursement justified for this new technology? Like it or not, I believe the surgeons should be involved in such decisions with the hospital and not simply choose a prosthesis and leave the hospital to worry about reimbursements.

When the data was reviewed on each surgeon’s costs to perform knee replacements at our institution, we found that an extra $400 would negate the small profit margin and might even cause a loss based on the current costs for some individual surgeons. This new drain on resources would just multiply if surgeons used the rotating platform on every patient, regardless of age or selectivity. Yet, it is difficult to explain to someone that, because of age or activity level, they will receive a cheaper implant. They were pleased to hear that I had experience with this recently advertised prosthesis. But I can just imagine the discussion if I told them I was not familiar with it or used another prosthesis.

While editing this column for the last time, I received a call from an old friend in Seattle who was planning to have a total knee replacement. He said his orthopedic surgeon told him he would not do a “rotating knee” and they were not that good. My friend wanted to know if his doctor was up to date on the latest technology and whether he should get another surgeon.

And it doesn’t end there. I know another company will soon advertise new advancements for their prosthesis and stress such things as the “hyper flex” characteristics or the use of a navigated system through small incisions. That will bring more questions — why aren’t I using that prosthesis if it is better? Why am I recommending whatever it is I’m recommending, anyway?

We don’t have many of the answers we need yet. But we’ll work through this period in orthopedics and it will be an ongoing education process for patients, for us and for industry.

Hopefully, the technology will not get too far ahead of the supporting science and ethics. But it usually does. This is an example where it has, and hopefully as all the new technology is marketed directly to the patient, the dichotomy doesn’t grow. Let’s all work on the positive aspects of better informing patients and physicians, and avoid letting the choice of implant revolve around a response to a sales pitch.