Guarantee a Surgical Outcome? Really? // New Shoulder Study Tackles Instability // and More

New Shoulder Study Tackles Instability

Shoulder instability doesn’t just get operated out of existence, unfortunately. Indeed, there remains a gray area surrounding this condition. Matthew T. Provencher, M.D., M.C., U.S.N.R. is the chief of Sports Surgery at Massachusetts General Hospital and associate professor of Surgery at Harvard University. He tells OTW, “Orthopedic surgeons continue to be cautious of patients with bone loss and who present with risk factors for recurrence. We are still defining what those variables mean and how much each contributes to the overall picture when evaluating a patient with shoulder instability. To this end, we are conducting long term prospective studies on the outcomes of several different types of treatment. At present, in addition to focusing on characterizing glenoid and humeral head bone loss in recurrent anterior shoulder instability, we are also examining patient demographics, risk factors for developing recurrent instability, as well as variables associated with successful treatment outcomes.”

“Variables taken into account include history and examination findings of the instability condition, high fidelity radiographic imaging and risk assessment based on activity. We want to know what makes it likely that the shoulder will have recurrent injury and how can we best determine treatment based upon desired activity. Rugby, for example, has a higher reinjury rate than most other sports. Currently, we are in the data analysis phase, and are fortunate to be able to use our large database of shoulder instability information from the Naval Medical Center in San Diego. Our preliminary findings are that if you are young, recurrence is not necessarily related to your sport or your being a contact athlete…this is very different than what we previously thought. And we can have reasonable confidence in these findings; we have a high number of enrolled patients—approximately 350 participants—and because of that we can ask more directed questions.”

“Ideally, we would be like to be able to say to someone, ‘Here are the major risk factors for your likelihood of recurrence after an instability event. If someone has these factors—patient factors, radiographic findings, or the type of surgery proposed—then we will better predict how patients will do the first time. One thing is for sure…revisions after an initial stabilization procedure are a huge challenge, so we should really be looking at how to optimally treat this condition and be able to get it right the first time.”

Guaranteeing the Outcome? Really? Harvard Takes a Stab.

“Prove your worth” is the increasingly louder refrain from the government and insurers. It gets down to value, says Jon J.P. Warner, M.D., chief of the Massachusetts General Shoulder Service and director of the Boston Shoulder Institute Fellowship. He tells OTW, “‘Value’ means many different things to different parties. With the advent of healthcare reform and social transformations which is occurring in care delivery, it’s becoming ever more important to consider value. To try and get further clarification on value, and how to measure and implement it, I am fortunate to be working with a group from Harvard Business School. Leading things on the Harvard side is Professor Michael Porter, known for his work on ‘Value Based Healthcare.’”

“Value, which is outcome divided by cost, is really interpreted differently by many parties. The patient receives value if they get a solution to their problem (i.e., the pain is gone, etc.). To the surgeon, value has a more economic meaning…the more volume of surgery they do the more value they get. This is because the government and insurers have reduced payments to such an extent that doctors may be naturally inclined to increase their volume to offset lower payments. This is paradoxical, of course, because then the value for the patient is negatively affected (less time spent with the doctor).”

“In my practice I do many revision reconstructions of failed surgeries; we see numerous failures and try to understand the reasons for this. Unfortunately, it’s often the volume problem, i.e., volume is rewarded, not outcome. Looking specifically at a hospital episode for rotator cuff repair, there is a cost attributed to the hospital for the anesthesia, labs, etc. This is the majority of the cost of care. Then you have the surgeon’s fee, which accounts for 5-10% of care. The growth of costs for hospitals is greater than that for doctors. The hospital basically allocates costs, which may result in higher charges for some things to make up for other cost areas. This therefore reduces value overall. Insurance companies want to limit their payments in order to stay solvent; this can lead to increased demand to offset lower payments (increasing volume and resulting in less value for patients).”

“We are working on creating a single bundled payment for rotator cuff surgery. Our model is such that the payor gives one dollar amount over the entire episode of care, say one year which includes the surgical procedure. It is critical that the costs for such an episode are calculated accurately and we are using a sophisticated accounting method which allows us to calculate the actual costs according to time and activity spent on patient care. Moreover, as we have data on the success of such surgery we are able to then offer a guarantee on the outcome for one year. In the case of a failure then the cost of additional care would be covered.”

“It is important, we believe, that the physician experts drive this process in collaboration with the hospital, as physicians are the only ones who clearly know the necessary care steps and can thus avoid unnecessary treatments and diagnostic studies.”

“This is, fundamentally, an effort to align incentives. Hospitals may be resistant because they can’t allocate costs and make large profits on some surgical cases in order to cross subsidize other care which loses money; surgeons may or may not like this approach because it incentivizes outcomes but imposes risk.”

“Healthcare reform has always been predicated on the management of cost, not value. This has not seemed to change with Obamacare. This means that if one surgeon delivers a service and has a bad outcome and another delivers a service and has a good outcome, then the insurance company or the government (in the case of Medicare) pays the same for both. This system incentivizes process without connecting it to outcome to value; we need to incentivize outcome.”

“Our goal for 2014 is to provide an example of value-based shoulder care in order to incentivize others to follow this approach. We are completing the first half of the accounting study at Brigham and Women’s Hospital, and the second half at Massachusetts General. Upon completion, we will propose a single bundled payment for rotator cuff repair with a one year guarantee on results, which will be less expensive than the way we do it now. It will provide a margin to both the hospital and physician and will incentivize outcome. Patients will derive value as they will have a guarantee on their outcome with the assurance that the physician and the hospital share some risk with the patient. This approach will allow for better value as outcome will go up and cost will go down.”

Laminectomy Out, Decompression In?

Spine surgeons in Florida are shaking up the conventional thinking when it comes to treating spinal stenosis in adults. Antonio Castellvi, M.D. is a spine surgeon with the Florida Orthopaedic Institute. He tells OTW, “Using cadavers we looked at data on the volume of the neural canal and the neural foramina pre and post op. Then we performed surgery on 50 patients and found that we were able to resolve symptoms of claudication with improvement in canal volumes. We followed these patients out two years and saw no significant degradation of those improvements. This was surprising, of course, because the gold standard is laminectomy…and yet I was enlarging the canal by 20-30% and still getting good clinical outcomes. We have followed some patients up to four years and no one had to go back to the OR for a laminectomy.”

“Using indirect decompression on the neural structures can be effective, although I suspect it will take a while to gain popularity. The procedure is done with an anterior cage that distracts the disc space; it can be done laterally or with a straight ALIF.”

2, 000 Patient Study Spots Solution to Female Stress Fractures

Women have three times the risk for stress fractures than men. And when it comes to lower extremity stress fracture risk, how you move may be an important risk factor according to some researchers. Kenneth L. Cameron, Ph.D., M.P.H., ATC, is Director of Orthopaedic Research at Keller Army Hospital in West Point, New York. He told OTW, “We studied nearly 2, 000 military cadets and found that injury prevention programs may indeed help prevent stress fractures in athletes and military personnel. While other studies have indicated that lower extremity movement patterns and strength are associated with stress fractures and overuse injuries, our study is one of the first to identify dynamic knee rotation and frontal plane angles as important prospective risk factors for lower extremity stress fractures.”

“In this study, which we recently presented at the American Orthopaedic Society for Sports Medicine, we found that the incidence rate for stress fracture injuries among females was nearly three times greater than among males. Specific lower extremity movement patterns appear to be predictive of subsequent lower extremity stress fracture injury and athletes with more internal knee rotation and knee valgus, and limited hip and knee flexion, are at greatest risk.”

“Going forward it will be important to see if movement retraining interventions to increase knee flexion and extension strength, increase knee and hip flexion motion, and limit knee abduction (valgus) and internal rotation can reduce the risk of lower extremity stress fracture in athletic and military training populations. It will also be important to refine field assessments for high risk movement patterns that can be used to screen and identify those at greatest risk to lower extremity stress fracture.”