Dr. Hannon explains that payers often require roughly a three-month delay before approving insurance coverage for arthroplasty, but in the literature review, the guideline authors found no evidence of any benefit for such delays. However, some patients may still opt to delay due to personal, work or family reasons, or to achieve better management of other medical comorbidities.
“For patients who’d been indicated for surgery, we found that making them do another injection, for example, or have more physical therapy sessions, or NSAIDs, gave no additional effectiveness,” says Dr. Hannon. However, in some circumstances, delaying surgery to pursue one or more options may still be the right choice (e.g., delaying surgery for physical therapy in a patient actively recovering from a stroke).
Payers may be opting to postpone arthroplasty for cost considerations. However, Dr. Hannon notes that ultimately such delays may increase total cost on the healthcare system because patients may use interim treatments that would not be needed if arthroplasty were not delayed.
Although surgery always carries risks, unnecessary surgical delays also pose risks, such as the risk of acute kidney injury or cardiovascular effects in patients taking NSAIDs.
Delaying for Modifiable Risk Factors
Conditional recommendations: In patients with a BMI of 35 or higher, do not delay arthroplasty for weight reduction.
Scientists have found correlations between greater BMI and poorer arthroplasty outcomes, particularly with respect to post-surgical infection. Dr. Hannon points out. Although “studies haven’t directly proven that a high BMI is what causes infection, [a] high BMI seems to result in an impaired immune response and decreased ability to fight off infection after surgery,” he says.
Thus, some payers have used weight loss as a criterion for surgical approval of arthroplasty. However, the available literature did not clearly indicate that holding off on arthroplasty for weight loss improved outcomes.
The guideline authors separately evaluated the research literature for three different categories of BMI—35 to 39; 40 to 49; and 50 and above—but did not recommend delaying for any of these subgroups.
Clinicians should educate their patients about increased risks from obesity and encourage them to lose weight if possible, and they should support patients who do opt to postpone surgery to focus on weight loss. However, many patients do not have the medical, financial, personal or social resources to lose much weight prior to surgery.
Dr. Singh notes that many patients have significant disease comorbidities and bilateral joint disease that may severely limit their mobility, also making it harder for them to lose weight.
