Should We Be Worried About the Trend to Risk Adjust Patients?
In five years will we have a system where sicker patients are having trouble finding surgeons? Perhaps, says Thomas Vail, M.D., professor and chairman of the Department of Orthopaedic Surgery at the University of California, San Francisco (UCSF). He tells OTW, “These days we are seeing much more emphasis on quality, value, and outcomes in healthcare, which is generally a very positive development. The caution is that there is relatively little public understanding of risk adjustment and how that plays into defining quality. It’s important because if we just talk about outcome without risk adjustment, we can potentially end up in a situation where people with various risk factors have different access to care. For example, if the impression is that an individual has a higher than average risk of a complication, longer length of stay, lesser functional outcome, or higher cost associated with a needed procedure, there may be reluctance on the part of the payer or provider to cover the cost or provide the procedure.”
“A positive by-product of risk assessment is that it takes into account individual patient factors when determining the expected outcome. Not only does risk assessment give a patient more accurate information about what their individual risks might be, but also provides a better framework for understanding how well a provider is doing in meeting the needs of their specific patient population. It is important for CMS [Centers for Medicare and Medicaid Services] and orthopedic surgeons to get a handle on this for the sake of a more informed public that can participate in a shared medical decision. If not, in short order we could see a situation where some of the neediest patients have barriers to access because of circumstances that they cannot control or understand. We have to compare apples to apples…and we must be specific. For example, what is the risk involved in XYZ total knee surgery done by THIS surgeon at THIS hospital?”
Regulatory Overview Hurting Availability of Juvenile Implants!
What to do if an off-the-shelf implant doesn’t fit your 14-year-old patient? Will there be a custom implant if needed? Mark P. Figgie, M.D., chief of the Surgical Arthritis Service at Hospital for Special Surgery, is working to ensure that there will be. He tells OTW, “My colleagues and I undertook a multicenter study with the idea that our work would help assure continued access to appropriately sized implants for younger patients. The better the implant fits, the better it should function, and the longer it should last. When you’re operating on a 12-year-old you want the implant to be right so that they can have it for a long time.”
“Over the years we found that juvenile idiopathic arthritis (JIA) patients present unique problems because their bones grow abnormally since the growth plates are affected. With the complex bone structure, anatomical variations, and deformities, off the shelf implants often don’t fit in these cases. In many instances we have designed custom implants. At this point, however we are finding that the FDA has gone through a reevaluation and has changed definition of custom made implants, essentially making them more restrictive. I understand that there are good reasons for this as custom implants don’t undergo the same testing and evaluation as off the shelf implants. We are taking existing designs, modifying them, and doing calculations to ensure the strength is appropriate. It involves a lot of work and time at a significant cost, and now we are finding that many of the manufacturers that used to make custom implants are now shutting down these departments.”
“In the old days there was little regulation, and it was almost as if you could jot down a design on the back of a napkin and have it made. In today’s environment, however, we having more difficulty getting things that are medically appropriate made for our patients. So we have reviewed and analyzed the cases of JIA patients from five centers to determine what worked, what failed, and to try and come up with standard ‘custom’ designs. Our goal is to determine the range of sizes and shapes for the JIA patients and design implants that are intraoperatively customizable, then maybe one of the manufacturers could develop these as standard products.”
“At this point we are still analyzing data; thus far we have seen that the implants are not lasting as long as they need to. We are measuring X-rays and looking at failure mechanisms. You typically see a normal relation of width to depth of the femur and the tibia; in these JIA patients, that relationship is abnormal. They often have trumpet shaped femurs and tibias and to make things last longer we want the best bone coverage to better distribute the stresses across the maximum surface area. Currently, if you are forced to fit the implant from front to back and it’s not wide enough then you are losing out on bone coverage. Once we settle these issues, our next step will be to look at what to do as far as design work. Within a year we should be sitting down at the drawing table to figure out the designs we want to start with. By that time we will have a tremendous X-ray database that will be invaluable in this work.”
Finally! A “Go-To” Source of Information Re: Smoking and Nonunions
Puzzled at the lack of one “go-to” source for information on smoking and fractures, a team of orthopedic surgeons decided to fill this void in the literature. Mara L. Schenker, M.D., administrative chief resident at Penn Orthopaedics of the University of Pennsylvania, led the team. She tells OTW, “I became interested in this topic because this was a problem that we encountered every single day on the orthopedic trauma service—a fracture patient who smokes. When we looked at the literature initially to help guide us in counseling these patients, there was no single source that provided a good summary of the literature available, so we decided to do a meta-analysis on the topic. Our primary finding was that smoking leads to increased risk of long bone nonunion, specifically tibia fracture and open fracture nonunion. In addition, there was a trend towards longer healing times for the long bones, tibia fractures, and open fractures that did heal.”
“I was surprised that there was not a confirmed higher risk of soft tissue complications after open fractures or long bone fracture surgery. This could be for many reasons, perhaps the large variability in how infections were defined in each of the different studies that we included. We will need to look more closely at this. The first place to start is to figure out a universal definition of infection (superficial infection and deep infection). From there, it would need to be applied in a focused and rigorously designed study to look at the effects of smoking on post-operative and open fracture-related infections.”
Asked how her work will it change the daily practice of the “average” orthopedic surgeon, Dr. Schenker said, “This provides a single source of information by which all orthopedic surgeons and primary care practitioners alike can use to counsel their patients to stop smoking when they have a fracture. Orthopedic surgeons can tell their patients, ‘It has been shown that smoking can lead to a higher risk of your fracture not healing. This may be as good of an opportunity as any for you to quit smoking. And this may have an impact on other smoking-related diseases that are outside of the realm of orthopedics.’ A fracture is something that a patient can see and feel NOW, but the possibility of lung cancer and other smoking-related diseases are not as tangible in the immediate-term, and stopping smoking now may have a real impact on that risk as well.”
Michael J. Yaszemski, M.D. Honored With Tipton Award
The American Academy of Orthopaedic Surgeons (AAOS) and the Orthopaedic Research and Education Foundation has bestowed the William W. Tipton, Jr. M.D. Leadership Award upon Dr. Michael Yaszemski of Mayo Clinic. Dr. Yaszemski served as chair of the department of spine surgery for 10 years; he is also with the musculoskeletal oncology division at the Mayo Clinic.
Dr. Yaszemski directs the Polymeric Biomaterials and Tissue Engineering laboratory at the Mayo Clinic, and has been chair of the AAOS Device Forum since 2006. He is currently in his 33rd year of service in the U.S. Air Force Reserve, having attained the rank of Brigadier General, and serves as the reserve military advisor to the President of the Uniformed Services University of the Health Sciences. During his tenure at the Mayo Clinic he has supervised 140 Ph.D. students, post-doctoral fellows, residents, clinical fellows, visiting scientists and clinicians. He has been on the AAOS Leadership Fellows Program since its inception a decade ago.
