Emphasizing The Preservation Of Implant Choices For Podiatric Surgeons

Stryker Corporation recently completed its acquisition of Wright Medical, creating a behemoth medical device company.¹ Although the merger does not technically form a monopoly based on Stryker's divestiture of total ankle replacement products and finger joint implants to DJO Global, the union of Stryker and Wright Medical, combined with preferred hospital and surgery center vendor contracts that limit surgeons’ choices, does effectively monopolize the device industry.¹

"Competition is always a good thing. It forces us to do our best. A monopoly renders people complacent and satisfied with mediocrity." - Nancy Pearcey ²

A surgeon is still held responsible for outcomes despite often not being able to utilize his or her preferred implant. The problematic scenario generated by the surgeon's inability to decide what is in the patient's best interest is now lost in a blind drive toward cost containment. Maybe the surgeon's implant choice plays no role in the outcome of a given case but perhaps it does.

Evans and colleagues showed implant choice could matter.³ Their study found that one center performing total hip replacements using only one type of implant had better implant survivorship. The authors stated, "These findings suggest that the better results seen in this one hospital are not associated with the skill of the surgeon or the setup of the hospital but are associated with the choice of hip replacement."³ The study authors did make an important point regarding the findings: "A limitation is that this study is observational and conclusions regarding causality cannot be inferred."³

Surgeon education on implant cost results in significant cost containment.⁴ Wasterlain and team showed that including prices of implants on implant lists resulted in surgeons selecting the less expensive implant within the same implant class.⁴ Raising the surgeon's implant cost awareness instead of effective monopolization allows the surgeon to decide on the patient's most appropriate care.

Mergers and acquisitions within the medical device sector can potentially stifle innovation. The larger the company, typically the more significant the bureaucracy and less agile the company becomes. Between larger companies controlling facility contracts and their sheer size, the ability of smaller companies to bring new products to market becomes jeopardized.  

However, Blackburn and colleagues found that utilization of a single spinal implant vendor did not result in higher rates of 12-month revision surgery, complications, 30-day readmissions and postoperative patient-reported outcomes as measured by the five-dimension European Quality of Life (EQ-5D) and Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH).⁵ Conversely, a single vendor's cost savings to the facility were 21 percent lower in comparison to a dual vendor option.⁵ 

The United States spent over $3.5 trillion on health care in 2017, equating to 17.9 percent of the gross domestic product.6 Surgical services accounted for approximately 30 percent of total health-care expenditures.⁶ Can effective monopolization of the medical device industry reduce this financial burden? Probably but at what non-monetary cost to the patient? 

An educated surgeon and patient on same-class implant costs deciding on implant choice resonates with me. Keeping patient outcomes at the forefront, employing common sense cost analysis and allowing for market-driven innovation is a recipe for success.  

“Learning and innovation go hand in hand. The arrogance of success is to think that what you did yesterday will be sufficient for tomorrow.” –William Pollard ⁷

Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, and a Fellow of the American College of Foot and Ankle Pediatrics. Dr DeHeer is also a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery.

Dr. DeHeer discloses that he is a speaker for Paragon 28, a consultant for and stock owner in Wishbone Orthopaedics and a consultant for Flower Orthopaedics.

References

1. Rachal M. Stryker closes Wright Medical acquisition after year-long wait. MedTech Dive. Available at: https://www.medtechdive.com/news/stryker-says-wright-deal-closing-imminent-after-key-antitrust-green-lights/588353/ . Published November 4, 2020. Updated November 11, 2020. Accessed December 1, 2020.

2. Nancy Pearcey quotes. Brainy Quote. Available at: https://www.brainyquote.com/quotes/nancy_pearcey_530910 . Accessed December 1, 2020.

3. Evans JT, Blom AW, Timperley AM, et al. Factors associated with implant survival following total hip replacement surgery: a registry study of data from the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man. PLoS Med. 2020:17(8):e1003291.

4. Wasterlain AS, Melamed E, Bello R, Karia R, Capo JT, Science of Variation Group. The effect of price on surgeons' choice of implants: a randomized controlled survey. J Hand Surg Am. 2017;42(8):593-601.

5. Blackburn CW, Thompson NR, Tanenbaum JE, Passerallo AJ, Mroz TE, Steinmetz MP. Association of cost savings and surgical quality with single-vendor procurement for spinal implants. JAMA Netw Open. 2019;2(11) e1915567.

6. Malay DS. The far-reaching influence of the costs of materials and implants used in the operating room. J Foot Ankle Surg. 2019;58(3):409.

7. 10 inspiring quotes on innovation. Success. https://www.success.com/10-inspiring-quotes-on-innovation/ . Published August 2, 2019. Accessed December 1, 2020.