Workers Comp Patients ARE Different
See a workers compensation patient on your schedule today? Do you form preliminary opinions about that person and his or her surgical recovery? Konrad I. Gruson, M.D., assistant professor of Orthopaedic Surgery at Albert Einstein College of Medicine, wanted to know. He shared his findings with OTW. “My partner Dr. Tony Wanich and I see a significant number of workers compensation patients who can’t return to work because of their injuries, in these cases it is recommendable to use workers comp attorney utah to defend your worker rights…typically, these involve the rotator cuff and labrum. Because there can be a negative connotation attached to these patients, we decided to look back into the literature and see if there was actually evidence for these suppositions. Thus, we embarked on a comprehensive review of the outcomes for surgical treatment of upper extremity injuries in workers compensation patients.”
“The most surprising finding was that these patients who have injuries to their upper extremity seem to—at baseline—have a worse perception of their injuries than their non workers compensation counterparts. We think that this is because this population is more likely to contain blue collar patients who routinely do strenuous physical work. There are also several studies indicating that these patients have more financial constraint and more marital discord, so perhaps this inclines them to see themselves as worse off than non workers compensation patients. Then there is the most cynical take on things, which is that these patients seek financial gain from remaining out of work and eventually going on permanent disability. This means that they would have an incentive to report a worsening level of pain to begin with…and to report less of a positive outcome in the long term.”
“When I begin treating a workers compensation patient I let them know that their clinical improvement is likely to take longer than a non workers compensation patient. Not only are they starting out at a worse subjective position than a non workers compensation patient, but they seemingly never achieve the same final clinical outcome as their non workers compensation counterpart…and it takes longer for them to reach a plateau. That being said, in the properly indicated workers compensation patient undergoing upper extremity surgery, reasonably good outcomes can be expected. The message is to treat workers compensation patients as a distinct population…no treating them with a cookie cutter approach.”
ACL Injuries in Kids: What Works, What Doesn’t
Let’s cut through the fog on ACL injuries in children. The journals are full of information on what approaches should be used. Dr. Jeremy Frank, a pediatric and adolescent sports medicine specialist and Assistant Director of [U18] Sports Medicine at Joe DiMaggio Children’s Hospital in Hollywood, Florida, recently clarified the problem in his lead article in the Journal of the American Academy of Orthopaedic Surgeons. He told OTW, “We are seeing a tremendous increase in ACL injuries in young people whose growth plates are open. With a plethora of studies and educated opinion in the orthopedic literature regarding appropriate treatment, my goal was to synthesize this large volume of data. What we concluded was that one must base their decision on whether or not to reconstruct the ACL not only on the patient’s chronological age but take into account their physiologic (stage of puberty) and skeletal age (bone age based on standard wrist x-rays) as well. Once this assessment is complete, you can then accurately decide what kind of operation is appropriate for each individual patient.”
“What does not work is applying adult principles to kids whose growth plates are still open. If you handle young patients in an adult manner you can injure their growth plate, and likely cause leg length discrepancy. Pediatricians routinely say, ‘Kids are not little adults.’ Pediatric orthopedists and pediatric sports medicine doctors say, ‘A child athlete is not an adult athlete.’”
Pyrocarbon: Better Wear Characteristics
Wear characteristics…it’s a drumbeat. While pyrocarbon implants have been around for a while, they are relatively new in the realm of orthopedic surgery. Joseph Abboud, M.D., an orthopedic surgeon at the Rothman Institute in Philadelphia, is helping to change that. Dr. Abboud commented to OTW, “We are currently involved in an IDE [investigational device exemption] trial being conducted by Integra LifeSciences looking at the use of pyrocarbon radial head replacements in comparison to a standard chrome cobalt radial head replacements for radial head arthritis or fractures.”
“Pyrocarbon’s potentially improved wear characteristics may offer improved longevity and outcomes in shoulder and elbow surgery compared to standard metal heads. One of our biggest concerns in total shoulder arthroplasty is polyethylene wear and glenoid failure. In previously conducted bench top research pyrocarbon has shown favorable wear characteristics on polyethylene as compared to a standard metal head. In addition, one of the most difficult aspects of shoulder arthroplasty is implanting a glenoid component. That is why some surgeons often opt to implant a hemiarthroplasty over a total shoulder arthroplasty despite studies showing inferior midterm results for hemiarthroplasties.”
“Interestingly, animal retrieval studies conducted with pyrocarbon joint implants have demonstrated that pyrocarbon implants cause minimal cartilaginous wear to the contra lateral side of the joint. The logical thought then would be that pyrocarbon hemiarthroplasties may end up providing better pain relief then metal hemiarthroplasties due to their potential for the decreased rate of progression of glenoid arthrosis. Early European and Australian data looking at this very issue has been promising. If these findings bear out in vivo then we may have a solution for a couple of challenging surgical problems in shoulder surgery. With that in mind there is great enthusiasm for a potential shoulder replacement IDE looking at pyrocarbon hemiarthroplasties in 2014.”
The $$ Is There for Meaningful Use, Is Security?
What’s that big thing coming down the pike? Opportunity or headache? Probably both. We are now approaching Stage 2 of CMS [Centers for Medicare and Medicaid Services] Meaningful Use and things could only get more challenging. Herb Alexander, M.D., President of the Society of Medical Consultants to the Armed Forces, has been delivering lectures on this topic for the last few years. He told OTW, “There are three significant changes required in Stage 2 for orthopedic surgeons. The first is the ability of the certified electronic health record (EHR) to send secure communications via email. We must work this out because private practitioners will have to do it. Next year, 2014, is ‘the magic year’ for us because in order to continue receiving the incentives being offered by the government, we have to comply with the program. Also coming down the pike for Stage 2 is that your EHR must be able to provide an electronic portal for patients to view their health records. Note that this will be mandatory for individual practitioners as well. The third is CPOE, or computerized physician order entry. These are but 3 of the 17 Core and 6 Menu items required for Stage 2. If you started meaningful use in 2011 then you received the maximum reimbursement from Medicare of $44, 000 over five years per doctor. If you wait until this year to qualify the maximum drops down to $39, 000; if you start in 2014 then the maximum is only $24, 000. Those of us waiting until 2015 get nothing but a 1% penalty; those of us delaying until 2016 will be hit with a 2% penalty.”
“My primary concerns with Stage 2 are related to security. How can we be certain that private information on the EHR patient portal sites is protected. What is to prevent someone who designs a patient electronic access portal from divulging a method to gain access to patient information? What will prevent a “hacker” from breaching security? All we need is one patient’s information to be leaked and the system will come under intense scrutiny.”
I continue to be amazed that physicians go to the expense and jump through the hoops to become compliant with this electronic record joke. It is unlikely you will ever achieve meaningful use and receive the money promised. In the meantime, you will most likely spend or lose more money on lost productivity, hiring personell to make it work, and compliance consultants such as Dr. H A. All of these steps are taken to see more Medicare and Medicaid patients.