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Football Team Formation / Source: Johntex 2005
Football Team Formation / Source: Johntex 2005

New Data Large Joint Cost Data on the Way // Amazing New Study uses MRI Alone to Predict NFL Return to Play // and More!

Elizabeth Hofheinz, M.P.H., M.Ed. • Mon, March 3rd, 2014

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New Large Joint Cost Data on the Way

What if you could have a friendly face ‘shadowing’ a patient through his or her entire cycle of care? Doing so, it turns out, will yield detailed metrics not only on outcomes, quality and patient experiences but also on the cost to deliver that care. Tony DiGioia, M.D. is the orthopedic surgeon at the University of Pittsburgh Medical Center (UPMC) who has developed this novel approach…a program that is now spreading nationwide. Dr. DiGioia tells OTW, “I am one of a number of physicians working with the Institute for Healthcare Improvement (IHI) and Harvard Business School in an effort to answer the value “equation” of health outcomes per dollar spent for knee and hip replacements. Over the last several years at UPMC, we have implemented the Patient and Family Centered Care Methodology and Practice (PFCC M/P)’ that is now being used around the country. More recently, we have been collaborating with Dr. Robert Kaplan from Harvard Business School, who developed ‘time-driven, activity-based cost’ (TDABC) accounting system. With the combined TDABC plus PFCC approach we can now also  determine the true cost of hip and knee surgery through a full cycle of care.”

Dr. DiGioia is Medical Director of the Bone and Joint Center, which is based at Magee-Women’s Hospital of UPMC. He says, “Shadowing is the link between TDABC and PFCC. With the ‘shadowing tool’, an unbiased observer follows the patient and family as they go through their care experience which provides real-time metrics. While for years we have captured information on outcomes and quality, we have never been able to measure the true cost to deliver these outcomes…now we can. Within this value framework, IHI with Harvard Business School have developed the first-ever Total Joint Learning Community in order to spread these approaches while coupling process improvement with financial performance; there are 31 centers from across the U.S. and even one in Brazil. Each center has made a 12 month commitment to apply TDABC while collecting outcomes metrics. The power of the Learning Community is that TDABC is being applied across the spectrum of organizations, from small community hospitals to large tertiary care academic centers and we can compare results. The cycle of care—we use 30 days before surgery until 90 days after—also coincides with the commonly used bundling time frame. So one secondary benefit for the 31 centers is that they are setting the stage to compete in the accountable care and bundling world.”

“At this point all the sites have developed their process maps, i.e,. the flow of care through the total joint care experience. With the patient as the focus we can collect all the metrics necessary for TDABC that includes personnel costs, consumables, space costs, and capital equipment. Dr. Kevin Bozic from the USCF Medical Center and I are the lead faculty members for IHI in the Learning Community. We have been able to help mentor the other sites since our programs have already applied TDABC for our patients needing joint replacement. One goal of this effort is to enhance efficiencies and process improvement along with clinical outcomes in order to finally answer the ‘value equation’ of outcomes divided by true costs. We will also begin to look at ways to improve outcomes while reducing costs. As an unintended but very positive and powerful consequence of these efforts at UPMC is that TDABC has generated a conversation between clinicians and the finance people. Given our future within the accountable care world of new payment models and care delivery systems, every facility must have that discussion.”

Oxysterols…Problem-Free Bone Formation?

From the petri dish to reality…California researchers are moving forward with the use of new biologics to study bone formation. Jeff Wang, M.D. is a Professor of Orthopedic Surgery and Neurosurgery at the Keck School of Medicine of the University of Southern California. He tells OTW, “We are using specific osteogenic small molecule oxysterols to get detailed information on bone formation. Farhad Parhami, Ph.D., M.B.A., Professor of Medicine at the David Geffen School of Medicine at UCLA and I have started putting spinal fusion models together and are finding solid bone formation with none of the complications that we see with BMP. There is no apparent inflammation that can lead to fluid collection and wound problems, and we don’t see any evidence of heterotopic bone formation.”

“Although oxysterols cause robust bone formation when used alone, we are now testing the effect of adding stem cells and bone marrow cells to the oxysterols to increase healing even more substantially. Furthermore, we have shown that if you add small doses of bone morphogenetic protein (BMP), there is a synergistic effect with oxysterols in vitro, and we are now testing whether this synergy also occurs to stimulate bone healing in vivo. At this point we are putting oxysterol into larger animals; if the results are positive and the FDA gives us the go-ahead, then we could move to testing them in humans in the near future.

Dr. Wang, who is Chief of the Orthopaedic spine service at the Keck Medical Center of USC and co-director of the USC Spine Center, tells OTW, “The most important thing to understand is that while we have learned a lot from BMPs, now there are new proteins that could be used for bone formation. Biologics is still the future…we know there are better ways to achieve bone healing.”

Osteogenic oxysterols have been licensed to MAX BioPharma Inc, a UCLA startup biotechnology company that is leading the therapeutic development of these new molecules.”

Amazing New Study Uses MRI Alone to Predict NFL Return to Play

Wouldn’t it be nice to tell, say, Mike Tomlin, when exactly his star player will be back on the field? It IS possible, says James P. Bradley, M.D., M.S., a sports medicine specialist with Burke & Bradley Orthopedics at the University of Pittsburgh Medical Center. Dr. Bradley, who is also head orthopedic surgeon for the Pittsburgh Steelers, told OTW, “My colleagues and I did a study on hamstring injuries in NFL players—the Eagles and the Steelers—and found that based on an MRI alone we could predict when a player would return to play. We started out with 31 MRI criteria and eventually broke it down to five: the number of muscles involved, the percentage of cross-sectional area involved, the location of the injury, any retraction or cyst formation, and the length of the injury on the T2 weighted MRI signal.”

“We reviewed 57 MRIs on 43 players, 5 of which were bilateral. Then we developed a radiographic scoring system that predicted when players would return to play. Based on the grading system alone if they had grade one injuries (mild) then they missed one game, grade two players missed two games, and grade three injured players missed six or seven games. We then divided them into three categories. MRI results that predicted a rapid return to sport (seven days or less) had less than 50% of the cross-sectional area involved, were in a proximal or mid muscle tendon junction, only involved a single muscle injury, had no circumferential edema and no retraction, and involved less than 5cm of the muscle. Those who returned to play between 7 and 16 days had multiple muscle injuries, involved greater than 50% of the cross-sectional area, involved the distal long head of the biceps and the short head of the biceps, and had circumferential edema. Those returning to play after 22 days had any retraction at any location, greater than 75% of the cross-sectional area involved, and had cyst formation.”

“That was our denominator; I compared this versus an injection of autologous condition plasma (ACP), a type of PRP, in 26 players. In the ACP group, we found less early pain, and early improvement in plank test, ROM, and strength in the last 15 degrees of flexion. A grade one injury gained three days of practice time, a grade two gained five days of practice time. There were no grade three injuries in this study group. In a typical season we have between two and four re-tears in the same area of the hamstring, which significantly increases time off the field. When we used ACP we had no re-tears; this is a very significant finding. We are collecting data now on more NFL players to see if these results continue to hold true.”

Michael Bosse, M.D. Honored by SOMOS

Michael Bosse, M.D., an orthopedic surgeon and director of Orthopedic Clinical Research at Carolinas HealthCare System’s Carolinas Medical Center, has received the prestigious Allgood Award from the Society of Military Orthopedic Surgeons, the highest level of recognition given by that organization. The award is named for Col. Brian Allgood, who served his country as an orthopedic surgeon and a champion for the wounded warrior. He was killed in combat in 2007 while serving in Iraq.

Dr. Bosse is currently co-principal investigator (PI) and clinical chair of the Major Extremity Trauma Research Consortium (METRC), involving Carolinas HealthCare System among 24 Level I trauma centers and 4 military hospitals in the U.S. METRC is dedicated to addressing many of the clinical problems facing returning wounded veterans.

Dr. Bosse is a retired U.S. Navy captain, and graduate of Annapolis and the University of Maryland School of Medicine. A few his many accomplishments include: serving aboard the hospital ship Comfort during Desert Storm; leading a group of orthopedic surgeons to Haiti aboard the Comfort in 2010 following the earthquake; serving as a leader of an important study of outcomes of limb salvage vs. amputation following severe traumatic injury; and a founding member of the Carolinas MED-1 mobile hospital team.

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