Dina Raphael

BACKGROUND: The numbers of people requiring total arthroplasty is expected to increase substantially over the next two decades. However, increasing costs and new payment models in the USA have created a sustainability gap. Ad hoc interventions have reported marginal cost reduction, but it has become clear that sustainability lies only in complete restructuring of care delivery. The Perioperative Surgical Home model, a patient-centered and physician-led multidisciplinary system of coordinated care, was implemented at UC Irvine Health in 2012 for patients undergoing primary elective total knee arthroplasty or total hip arthroplasty. This observational study examines the costs associated with this initiative. METHODS: The direct cost of materials and services for a random index sample following the Total Joint-PSH pathway was used to calculate per diem cost. Cost of orthopedic implants was calculated based on audit-verified direct cost data. Operating room and post-anesthesia care unit time-based costs were calculated for each case and analyzed for variation. Benchmark cost data were obtained from literature search. Data are presented as mean ± SD where possible. RESULTS: Total per diem cost was $10,042 ± 1,305 for TKA and $9,952 ± 1,294 for THA. Literature-reported benchmark per diem cost was $17,588 for TKA and $16,267 for THA. Implant cost was $7,482 ± 4,050 for TKA and $9869 ± 1,549 for THA. Total hospital cost was $17,894 ± 4,270 for TKA and $20,281 ± 2,057 for THA. In-room to incision time cost was $1,263 ± 100 for TKA and $1,341 ± 145 for THA. Surgery time cost was $1,558 ± 290 for TKA and $1,930 ± 374 for THA. Post-anesthesia care unit time cost was $507 ± 187 for TKA and $557 ± 302 for THA. CONCLUSIONS: Direct hospital costs were driven substantially below USA benchmark levels using the Total Joint-PSH pathway. The incremental benefit of each step in the coordinated care pathway is manifested as a lower average length of stay. We identified excessive variation in the cost of implants and post-anesthesia care.

In the introductory chapter of his essay on Utilitarianism, John Stuart Mill says his aim is to contribute towards the understanding of utilitarianism and towards ‘such proof as it is susceptible of’. He immediately adds that ‘this cannot be proof in the ordinary and popular meaning of the term’ because ‘ultimate ends are not amenable to direct proof’. A proof that something is good has to show that it is ‘a means to something admitted to be good without proof’. But, he goes on, this does not imply that a formula of ultimate ends can only be accepted on ‘blind impulse, or arbitrary choice’. It can be rationally discussed and subjected to proof in a wider sense of that word. ‘Considerations may be presented capable of determining the intellect either to give or withhold its assent to the doctrine; and this is equivalent to proof.’

Treatise on Nature and Grace by Nicolas Malebranche, translated with an introduction and notes by Patrick Riley Oxford: Clarendon Press, 1992. Pp. xviii + 226. £30.00. ISBN 0–19–824832–6 Queen Christina of Sweden and Her Circle. The Transformation of a Seventeenth‐century Philosophical Libertine by Susanna Akerman, Brill's Studies in Intellectual History, 21 Leiden, E. J. Brill 1991, Pp. xv + 339. $82.86 John Locke: A Letter Concerning Toleration in Focus edited by John Horton and Susan Mendus, London: Routledge, 1991. Pp. viii + 196. Cloth £35.00 ISBN 0 415 02205 3. Paperback £10.99 ISBN 0 415 06082 6 The Pillars of Priestcraft Shaken: The Church of England and its Enemies, 1660–1730 J. A. I. Champion Cambridge Studies in Early Modern British History, Cambridge University Press, 1992. Pp. 268. £35.00 ISBN 0–521–40536 X. Philosophy, Religion and Science in the Seventeenth and Eighteenth Centuries edited by John W. Yolton, Rochester, New York: Rochester University Press, 1990. Pp. xx + 539. ISBN 1–878822–02–2. Philosophy, Science and Religion in England 1640–1700 Edited by Richard Kroll, Richard Ashcraft and Perez Zagorin Cambridge: Cambridge University Press, 1992. Pp. xv + 287. £37.50 ISBN 0–521–41095–9. Opinion and Reform in Hume's Political Philosophy by John B. Stewart Princeton: Princeton University Press, 1992. ISBN 0–691–08626–5. The Enlightenment by Roy Porter (Studies in European History) London: Macmillan, 1990. Pp. xi + 95. Adam Smith and His Legacy for Modern Capitalism by Patricia H. Werhane New York: Oxford University Press, 1991. Pp. xiv + 219. £27.50. D'Artagnan und die Urteilstafel: über ein Ordnungsprinzip der Europäischen Kulturgeschichte (1, 2, 3/4) by Reinhard Brandt Stuttgart: Franz Steiner Verlag, 1991. ISBN 3–515–05905–0 Frege Philosophy of Mathematics by Michael Dummett London: Duckworth, 1991. Pp. xiii + 331. Price £35. ISBN 0 7156 0886 X. Pierre Duhem: Philosophy and History in the Work of a Believing Physicist By R. N.’D. Martin La Salle: Open Court, 1991. ISBN 0–8126–9160–1. (Paper) $19.95. ISBN 0–8126–9159–8. (Cloth) $44.95.

Everybody supports freedom—even authoritarians, though what they call freedom looks suspiciously like bondage. Rousseau begins The Social Contract with a flourish: ‘Man is born free, and everywhere he is in chains.’ He ends up by trying to persuade us that the chains, the restraints of law and organized society, are necessary for true freedom. He wants us to believe that true freedom, the freedom essential for human existence, is not the happy-go-lucky freedom of Liberty Hall, do as you like, but the straight and narrow path of duty, of conformity to law. The universal popularity of the idea of freedom does not mean that everybody is really agreed about it. Plato, Rousseau, Hegel and his followers—they all talk of a true or genuine freedom, but they oppose this to Liberty Hall, to doing as you please.

We hear nowadays in literary criticism of a type of novel that is an ‘anti-novel’ and of a type of hero who is an ‘anti-hero’. I recently read an article which argued, rather well in my opinion, that the later philosophy of Wittgenstein is an anti-philosophy. One could say the same of the philosophie positive of Auguste Comte, who is often called the father of sociology. The principle with which Comte starts off his philosophy, ‘the fundamental law of mental development’, would put an end to philosophy as traditionally conceived, and would replace it by science. According to Comte, human inquiry goes through three stages. In the first stage, the theological or fictive, men try to give explanations in terms of supernatural beings. At the second stage, the metaphysical or abstract, theological explanation has given way to explanation in terms of abstract entities such as Absolute Motion or Absolute Justice. In the third stage, the scientific or positive, metaphysical explanations have given way to scientific explanations, that is to explanations which do not refer to any unobservable entities but instead simply correlate observable phenomena with each other. This is a picture of intellectual history in which philosophy takes the place of theology and then science takes the place of philosophy.