A patient profiled in the WSJ story — one of three overwhelmingly positive anecdotes. Photo Credit: WSJ/Elizabeth Leeds.
Lots of sources, lots of reporting, and lots to praise in this story. But the story would have been lots better with a few more key facts and figures and a more balanced look at traditional surgery.
For example, the orthopedist member of our team wonders: Where did the story get the idea that traditional surgery involves three hours of anesthesia? That isn’t accurate. And while the story features three glowing anecdotes, we would’ve preferred to see more emphasis on the evidence that supports same-day surgery and the various approaches discussed. Finally, we think many readers will come away with the impression that a surgery that took a little bit longer to perform was somehow not as good. That’s unfortunate. The surgery is meant to last 20 years so it’s most important to get it right and assure a good long-term outcome. The story could have emphasized this fact more.
About 332,000 Americans undergo total hip replacement in any given year, according to the Centers for Disease Control and Prevention. The operation, as one doctor quoted in the piece points out, is “still a big operation.” If a procedure is associated with less pain and a quicker recovery, that would be good for patients and their caregivers to know.
In a piece that found room to tell us how much the operating tables cost, there is no excuse for not telling us how much the competing procedures cost.
The story had lots of interesting anecdotal discussion but few numbers. “There is less muscle injury” and a patient’s early recovery is “definitely better” is one example. Those are huge claims for the story to trumpet without including any data to back them up. The story also talks about less need for pain medication but doesn’t quantify the benefit. The anecdotes are very much stacked in favor of the same-day procedure.
The story also had a link to a head-to-head comparison study. That is great. Those readers who take the time to click on the link will find interesting stuff. But while it’s a close call here, we are not persuaded that including a link is enough.
The anecdotes cited were all glowing. None included any mention of possible drawbacks. This surgery is associated with very significant risks, including risk of death–typically from a blood clot. Now, those risks are with all hip replacements–same day discharge and not–but they are never mentioned and should have been.
The story leaves readers with the impression that they might all be going home maybe 10-12 hours after surgery as the 54-year old patient profiled did (no exact timing of his day was provided in the story). How representative was that? Didn’t the age and conditioning of a 54-year old play a big factor here? What might change if he were a 64-year old or 74-year old reader of the WSJ? Or is this what gets hidden when joint replacement surgeries are increasingly marketed to younger and younger people? And when journalism fails to scrutinize that factor?
True to the spirit of this criterion, we can’t say that the news organization didn’t grasp the quality of the evidence. But we can say that they didn’t frame the story as if it grasped the tradeoffs and the uncertainties involved as the surgery evolves.
The story does link to a study as noted above, and it does feature expert voices who call for more studies and who challenge the main premise of the story — that the anterior approach and same-day procedure are faster and better than the posterior approach. But the text itself offers only anecdotes and doesn’t explore what kind of evidence the linked study offers. And it never makes clear that operating time is only one factor, and not the most important factor, that patients should care about. A shorter surgery with an approach that allows the patient to go home the same day will not be seen as a quality result if the surgery does not last as long–for example if it wears out, on average, 5 years sooner.
The figure cited without sourcing by the reporter — 340,000 hip replacements performed annually in the U.S. — is slightly above the figure cited by the Centers for Disease Control and Prevention, but not enough to justify a claim of disease mongering.
Excellent job overall. The story had eight doctors, a nurse manager, and three patients commenting for the record. And at least some of them push back, very appropriately, against the story’s general premise that the same-day procedure and anterior approach are better. The story might have clued readers in to the fact that surgeons are likely to speak highly of whatever approach it is they happen to practice. Those with faster operating times may emphasize that fact because it’s what separates them from others with whom they are competing for business.
This is one of the biggest shortcomings of the story. Before considering a total hip replacement, a patient may be advised to try alternatives that might delay or avoid surgery, such as exercise to strengthen the muscles around the hip joint, the use of canes or walkers, and medication. The vast majority of patients with hip pain, and most even with hip arthritis, do not need a hip replacement. Conservative care can be highly effective at a fraction of the cost and risk. The story did not mention those possibilities.
The story mentions that the procedure is at least 20 years old and is practiced in a significant percentage of hip-replacement operations, implying that it would not be too tough to find a surgeon who does the anterior procedure. Of course, learning a bit about what the learning curve is for this procedure and how many procedures any given surgeon has done are key questions
The story should have been clearer about what is new here. The headline implies that the newness is driven by the increasing popularity of the anterior surgical approach: “Same-Day Hip Replacement Hip replacement surgery is now an outpatient procedure due to an increasingly popular surgical technique; surgeons promise less pain and faster recovery.”
But the surgical approach is not new at all, as the text of the story acknowledges–it’s been around forever and was old even when one of us (orthopedist James Rickert, one of four reviewers on this piece) was a resident in the 1980s. What is new is the same-day discharge, which in turn is driven by new and better pain medications and reimbursement schedules that yield greater profits the shorter the hospital stay. The story didn’t zero in on this.
A news release issued last March cites the work of Dr. Davidovitch. So it’s clear that he and his institution are promoting his work with this procedure. It also cites some of the drawbacks and concerns raised above. But this story clearly went beyond any such release and includes lots of original reporting.
Systematic, Criteria-Driven
The tale of two “negative” studies. Or, how spin is applied to make research findings look more impressive. A must read. https://johnmandrola.substack.com/p/the-tale-of-two-negative-studies
The @nytimes chose to interview one of the editors of the @AnnalsofIM (publisher of this paper) who "gushed with extraordinary glee: It’s huge! There are very few things that reduce your mortality by 30%."
Turns out coffee is not one of those few things despite all that glee. https://twitter.com/garyschwitzer/status/1533202075928215558
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