The Epidemic No One is Talking About

When the word “epidemic” gets attached to a problem, people tend to take notice. When the same word gets attached to a serious public health issue, people tend to act. We are currently amid two such epidemics: the opioid crisis and rising obesity rates. Both problems have rightfully garnered significant attention, not only in the medical community but also in the lay press and public consciousness. While these are complicated problems not amenable to simple fixes, both the obesity and opioid epidemics have potential solutions. Better prescribing habits, behavior modification, patient and provider education, drug reporting systems, nutrition programs and other measures can be taken to reverse current trends. While neither problem will ever completely disappear, in theory narcotic addiction and obesity are, to a degree, preventable and curable. 

Meanwhile, there is a third public health issue on the rise, one that may present a larger, more difficult problem that threatens to strain the capacity of our system and further drive up the cost of care. To complicate matters, there may be little we can do to prevent or solve this particular epidemic. Despite the seriousness of this third public health issue, it fails to attract the same attention as obesity rates or opioid deaths. The intention here is not to downplay the serious health implications of obesity or marginalize the horror of drug addiction, but rather to bring some recognition to what may be an equally important looming crisis.

Arthritis affects 54.4 million US adults, about 1 in 4. It is a major cause of work disability in the United States and one of the most common chronic conditions in the nation. Arthritis is a common cause of chronic pain. -- CDC Website

Framing the Problem

The CDC estimates that almost a quarter of the US population has been diagnosed with arthritis. By the year 2040, over 78 million Americans will carry the diagnosis, many of whom will experience limitations in their quality of life and ability to perform activities of daily living. The aging of the Baby Boomer population is felt to be a major contributing factor to the increased incidence of arthritis while genetics, obesity, and prior trauma are felt to play a role in pathogenesis. Perhaps surprisingly, we are still largely uncertain as to exactly why certain patients develop arthritis. To make matters worse, the disease has no known cure and there is no way to prevent disease progression. Arthritis-related problems are common causes for primary care visits and referrals to specialists. Treatment for arthritis is mainly aimed at managing symptoms and can include physical therapy, bracing, activity modification, weight loss, and injections. However, the only “cure” for arthritis is joint replacement with hip and knee arthroplasty becoming increasingly common procedures. Government spending on surgical treatment of arthritis stands at an estimated $7 billion/year and that number will likely increase significantly as more patients are diagnosed and seek treatment. This figure does not take in to account the increasing number of younger, privately-insured patients diagnosed with the disease. Several measures have been put in to place to address the rising costs of arthritis treatment including alternative payment models, merit-based incentives, and a shift toward patient optimization to reduce readmissions and complications. While these approaches may provide some relief from the large expense of arthritis treatment, they unfortunately can do nothing to reduce the number of new diagnoses or patients seeking treatment. While arthritis is not a life-threatening condition, patients limited by joint disease can represent a significant burden to an already taxed system.

The arthritis epidemic doesn’t produce the heart-wrenching, tragic tales of the opioid crisis. It is not as immediate and obvious as the obesity problem. But its effect on the American healthcare system may represent an even larger challenge. Some have predicted a shortage of arthritis physicians which could contribute to delay in diagnosis, the need for more complex treatment, and worsening outcomes. As the age for arthritis diagnosis and treatment drifts lower, there will be a profound impact on the workforce leading to more missed days, lost income, and lost job productivity. An increase in the number of joint replacement procedures will also lead to an increased rate of revision surgeries which are complex, expensive, and often only performed by a limited subset of specialists. Patients suffering from arthritis can experience depression, chronic pain, lack of sleep, deconditioning and other systemic effects that make the problem more nuanced than just impairment of function.

The shortfall of orthopedic hip and knee surgeons is expected to be so drastic by 2016 that 72% of those who need total knee replacements and 50% of those who need total hip replacements will not be able to obtain them, according to Thomas Fehring, MD, senior surgeon at OrthoCarolina Hip and Knee Center, in Charlotte, North Carolina. -- AAOS Annual Meeting 2009

What Can Be Done? 

If arthritis is neither preventable nor curable, what can be done to address the coming epidemic? Educating patients to recognize early symptoms of arthritis, correcting misconceptions about activity limitations, and supporting wellness and activity programs can reduce apprehension and negative health effects. Digital health has largely focused on other chronic conditions such as diabetes and heart disease, but there is no question the opportunity for technology to impact arthritis treatment is immense. Wearables such as fitness trackers may help patients maintain an active lifestyle and monitor their symptoms to better manage their disease. Several studies have shown that patients who understand and take an active role in their health have better outcomes from arthritis treatment. Artificial intelligence, deep learning, and neural networks may not be able to prevent the development of arthritis or alter the natural course of disease, but they may be able to help us tailor treatment algorithms to each patient, identify those at risk for poor outcomes and complications, and guide perioperative treatment for a more personalized approach.

Biologic solutions may eventually provide an important adjunct to surgical treatment although current evidence regarding their effectiveness is lacking and more high quality research is needed.  In reality, the biggest opportunity to stem the arthritis epidemic may lie in improving arthroplasty outcomes and further reducing the cost of delivering joint replacement care. Shifting hip and knee replacement cases to lower cost centers like ASCs or specialty hospitals can save thousands of dollars per case. Reducing readmissions and complications by optimizing patients prior to surgery will help avoid the significant cost burden caused when things go wrong. Newer technologies such as robotic-assisted replacement, patient-specific implants, and joint sensors have potential but will need to prove not only their efficacy but also their cost-effectiveness.

Conclusions

Another epidemic is coming. While not as tragic as the opioid crisis or shocking as the obesity problem, the arthritis epidemic may have an even larger impact on public health. Though recent data shows some slowing of joint replacement surgery growth (due in part to inability to meet demand), the number of patients diagnosed, demand for treatment, and cost of care related to arthritis are expected to increase significantly over the next 10-20 years. Perhaps one day the genes responsible for arthritis or molecular pathogenesis of cartilage loss will be fully identified and lead to a real cure. In the interim, bringing recognition and understanding of the coming problem will help ensure much needed resources remain in place. Cost savings and efficiency must be balanced with preserving continued access to care and realistic treatment goals. Digital health and technology must be leveraged carefully to ensure meaningful impact on care delivery without increasing overall cost. Finally, all viable options including continued support for outpatient arthroplasty, specialty centers, and even physician-owned hospitals should be considered. Now is the time to recognize and prepare for the arthritis epidemic.