Professor of Economics Jonathan Goldstein had to replace his hip a while back. While he was checking out prospective surgeons, he met a doctor in Maine who boasted that he had done 2,900 total hip replacements. Goldstein’s response was quick and professional: “You’re sitting on a lot of data that should be analyzed.”

This encounter inspired Goldstein to analyze, with Maine Medical Center’s assistance, the cost-effectiveness of different hip replacement techniques. He recently discussed his sabbatical research project at a faculty seminar talk.

Total hip replacement surgery is an increasingly common medical procedure. In 2010, 332,000 total hip replacements were performed in the United States at a cost of $12 billion, and that number is predicted to grow to 572,000 a year by 2030. “Hip arthritis is pervasive and growing,” Goldstein said. He added, “…you should be concerned that many of these operations are being performed by hospitals that don’t do many of them, and by surgeons that do less.”

After recovering from his operation, Goldstein began seeking answers on the costs and patient outcomes of various hip replacement techniques, and whether a surgeon’s or a hospital’s experience with a particular technique makes a difference on outcome and expense. He had help from Andrew Millar ’16, who carried out a project called “Total Cost Savings Analysis of the Anterolateral Method of Total Hip Replacement” last summer as a Kaufman fellow, funded by the Matthew R. ’72, P’02 and Marcia A. Kaufman P’02 Family Fund. “Andrew was fully involved in all aspects of the project,” Goldstein said.

Within the medical community, a debate is raging on which hip-replacement technique is best for both the patient and the hospital. A couple of newer procedures that are minimally invasive and less traumatic on patient muscles hold out a lot of promise, according to Goldstein. Yet, the typical advice given to patients by their primary care physicians is to go with the old, tried-and-true procedure — the posterior technique, Goldstein said.

Doctors will say that “it doesn’t much matter what surgeon you choose or what hospital you go to. Choose a surgeon you have a good rapport with and who operates in a convenient location,” Goldstein cited. “That is wrong, wrong, wrong,” he added.

The posterior technique has been the go-to technique since 1969, and today, 65 percent of hip-replacement operations nationally are done by this technique.

To conduct his analysis, Goldstein collected data on 1,700 Mainers who had total hip replacements in 2011. He found, contrary to received wisdom, that surgery technique does make a big impact on cost and outcome. He also discovered that a doctor’s or hospital’s experience with these newer, alternative techniques is critical.

For example, the cost of the “anterolateral muscle sparing” technique — one of the less traumatic procedures — by an experienced surgeon reduced the cost compared to the posterior technique by about $6,000. The hospital stay for patients who had this muscle sparing technique was also shorter: 1.34 days versus 3 days. And the technique lowered the likelihood a patient would have to stay at a nursing facility following surgery.

But Goldstein found that the positive outcomes of the muscle sparing technique evaporated when performed by less experienced surgeons. Indeed, the costs significantly increased compared to the posterior technique by as much as $13,671. And the hospital stay for patients lengthened by an average of .67 days.
The “learning curve exists and is steep,” Goldstein concluded, “and practice matters.”