Doctors may refuse to operate on smokers

Here's why trend will grow
Research shows that smokers have more complications than non-smokers after spinal surgery or joint replacement.
Research shows that smokers have more complications than non-smokers after spinal surgery or joint replacement.

CHARLOTTE, N.C. — An irate man contacted me recently to complain he’d been turned down for back surgery because he’s a smoker.

“It’s just not right,” said the Charlotte man, who suffers from chronic hip and leg pain. “I need this surgery. It’s to the point where I can’t walk around the block with my dogs.”

He acknowledged smoking is a “bad habit,” but after 35 years, he’s not sure he can quit. And he doesn’t think he should have to.

“It didn’t used to be this way,” he said. “Everybody’s got on their little righteous path…. My grandfathers on both sides smoked their entire lives. They didn’t die until one of them was 92, and one of them was 88.”

No doubt, genetics play a huge role in how healthy we are and how long we live. But personal behavior is also a big factor.

Most of us know that smoking is linked to heart disease and cancer. But in recent years, research has shown that smoking also inhibits wound healing because it decreases blood flow. As a result, smokers don’t do as well as non-smokers after having spinal fusion surgery and joint replacements.

One study found that smokers who got joint replacement surgery had an 80 percent higher chance than nonsmokers of needing repeat surgery because of complications from infection.

For this reason, surgeons who do those procedures have begun asking patients to quit smoking — or at least stop for four to six months before and after surgery. (Note: The doctors quoted in this story were not the smoker’s doctor.)

“We want the best results possible,” said Dr. Bryan Edwards, head of orthopedic surgery for Novant Health. “We’re not denying you a surgery. We’re preventing you from having a complication.

“If you’re doing surgery, you’re trying to get the bones to unite, and if you don’t have good blood flow, the results aren’t as good,” Edwards said. “I tell patients, ‘Complications from surgery are far worse than whatever condition you have now. If you’ve got an infected back that doesn’t fuse, you don’t want that.'”

Unlike the man who said he was turned away by a surgeon, most patients are counseled about the risks and referred for help, such as smoking cessation classes. They’re not expected to quit cold turkey.

“I expect there may have been a miscommunication” in the case of the irate patient, said Dr. Leo Spector, a specialist in spine surgery at OrthoCarolina. “A lot of things obviously boil down to the physician and patient conversation.”

Smoking isn’t the only behavior patients may be asked to change as part of “surgical optimization” — the doctors’ term for getting patients in the best health possible before an operation to improve the outcome. Obesity and diabetes also decrease the chances of a successful surgery.

Spector said it’s part of a national trend for doctors to run down a checklist of behaviors in preparation for elective surgery. Before spinal fusion, Spector said he might tell a patient: “Listen, I want you to stop smoking, but if you can’t stop smoking, at least cut it in half. A two-pack-a-day smoker is going to have a higher risk (of complications) than a two-cigarette-a-day smoker.”

If patients are overweight or have diabetes, he might refer them for nutrition counseling and even bariatric surgery to help them lose weight and get their glucose levels under control. Spector said he’d ask patients with back pain to stop smoking and try physical therapy for three months to see if the pain would go away without surgery.

“Have I refused to operate because they wouldn’t stop smoking?” he asked. “Yes.”

Helping patients achieve better surgical outcomes will also help doctors as the health care payment system continues to evolve.

Today, most doctors continue to be paid in a fee-for-service system, which means they’re reimbursed for each appointment, test or procedure. Perversely, they make more money if a patient has complications and requires extra care.

In Charlotte, some surgeons who perform spine surgery and knee and hip replacements have begun using a “value-based” system that means accepting a single “bundled payment” for each patient encounter. This gives doctors an incentive to provide the best care for each patient.

If all goes well and care is delivered for less than the contract price, the doctor or hospital keeps the savings. If there are complications and the patient needs more care, the doctor or hospital absorbs the extra cost.

So, operating on smokers, with potentially expensive complications, could hurt the bottom line for physicians.

At OrthoCarolina, Spector said doctors agree that all patients who register for the bundled payment plan must go through “surgical optimization” so they’re as healthy as possible before surgery. At some point, insurance companies may even begin to refuse to pay for elective surgeries on smokers.

“A year from now, I’ll probably be at a point where I would require all my patients to stop smoking,” Spector said. “Currently, I evaluate it on a case-by-case basis. Over time, we’re going to feel comfortable being a little more stringent with our patients about these modifiable risks.”

Edwards said he finds many patients “don’t take it well at first” when he advises them to quit smoking or lose weight. But many of them thank him later.

“Everybody needs something in their life to motivate them,” he said. “Usually, if the patient makes the commitment to stop and gets through the procedure, I find the majority of them just stop smoking.”

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