Does Who Pays the Bill Influence Care?

In the back of their minds, patients often wonder if they would get better medical care if they were paying for their surgery themselves instead of benefiting from a public subsidy. Investigators from the Department of Orthopaedic Surgery and the Department of Physiotherapy, Singapore General Hospital, Singapore, decided to find out. Singapore has a universal health care system in which the government ensures affordable health care in the public health system—paid for through a system of compulsory savings, subsidies and price controls.

Patients seeking treatment via the public health system in Singapore also have the option of using a nonsubsidized provider and paying the medical bill themselves. This allows the patient to choose the surgeon, have more privacy and perhaps wait a shorter period of time for the surgery.

The authors retrospectively reviewed 369 patients who underwent total knee arthroplasty (TKA) between 2006 and 2010.They divided the patients into two groups: nonsubsidized (95) and subsidized patients (274). They compared outcome measures, such as range of motion, function score, knee score, Oxford Knee Questionnaire, and the Short Form 36 questionnaire, between the groups at six-month and two-year follow-ups.

The subsidized patients had good postoperative outcomes and no significance differences existed in outcome scores and range of motion between the two groups at six-month and two-year follow-up except in the mean function score, where patients in the nonsubsidized group did better. Subsidized patients had good outcomes and did not fare worse than nonsubsidized patients after conventional total knee arthroplasty, except for their knee function score.

The medical details: All patients underwent unilateral posterior-stabilized total knee arthroplasty by a single surgeon. All patients had a tourniquet applied to the operated limb throughout the surgery. Total knee arthroplasty was performed in a standard fashion for all patients. The medial parapatellar approach was used for patients with varus knees, and the lateral parapatellar approach was used for those with valgus knees. No patellar resurfacing was performed. Surgeons inserted postoperative drains in all patients and removed them on postoperative day two or when the drainage was less than 70 mL. They encouraged more resident and fellow involvement in the surgeries for the subsidized patients, although no change occurred in the primary surgeon.

All patients received standardized postoperative care, which included appropriate analgesia, pneumatic calf pumps, continuous passive motion from the first postoperative day, and daily physiotherapy assessment while they were inpatients. All patients began ambulation on postoperative day two. No patient received oral chemoprophylaxis against venous thromboembolism because a previous study originating from the authors’ institution showed a low incidence of venous thromboembolism in patients undergoing TKA without anticoagulation.

On discharge, doctors followed up patients at the specialist outpatient clinic at one- and six-month and one- and two-year intervals. At each visit, patients reported pain scores and any other concerns they had. The surgeon also examined the knee for signs of wound or joint infection. A physiotherapist conducted a detailed review six months and two years postoperatively and obtained radiographs of the knee immediately postoperatively and at one-year follow-up.

The results: Patients in the subsidized group had a longer mean operative time and a longer waiting time before receiving their surgery. Otherwise, investigators found no differences.