Doctor-Led Models Superior!
A certain in-the-know health policy expert is predicting a pendulum shift—back towards orthopedic surgeons having more say in the care of their patients. Chad Mather, M.D. is an attending orthopedic surgeon at Duke University. Dr. Mather, an AAOS (American Academy of Orthopaedic Surgeons) Washington Health Policy Fellow, tells OTW, “Right now, orthopedic surgeons are mobilizing toward adapting to different payment models, much of which requires more integrated care for episodic payments. What we’re starting to see is that physician-led models deliver more cost efficient and convenient care. My health policy colleagues and I were just in Washington, D.C. discussing how to protect access to in-office ancillary services, and we are convinced from examining the evidence that doctor-led initiatives will soon emerge as the most successful models of care. In episodic payment models, reimbursement could go to the orthopedic surgeon, the hospital, or a primary care doctor. We believe that the orthopedic surgeon is the best equipped provider to manage the pathway of care. For example, the facility where a procedure is performed a major driver of the cost of care. Orthopedic surgeons can get patients to the least expensive facility that is safe for them.
“It’s early, but one reason we know that this is imminent is because market conditions favor physician led models—most hospital-based services cost significantly more than office-based services. Perhaps the most important piece of this is that orthopedic surgeons are in a unique position of knowing more about both primary and specialty musculoskeletal care than any other provider. The musculoskeletal system is widely known to be underrepresented in medical school—as opposed to the cardiopulmonay system, for example—yet one out of every five presenting complaints to primary care physicians in this country is musculoskeletal. Primary care doctors are just not as well equipped to manage orthopedic issues as they are equipped to handle, for example, cardiology or GI problems. I think it will become increasingly clear to payers as they scrutinize different care models that orthopedic surgeons are best equipped to deliver high value musculoskeletal care.”
Dump the Chainsaw in Spine Surgery
Why use a chainsaw, says Izzy Lieberman, when you can use precision technology? Isador Lieberman, M.D. is an orthopedic surgeon with the Texas Back Institute. He tells OTW, “I’ve been emphasizing more and more lately about the importance of pre-operative planning for spinal surgery. This is an evolving process; surgeons have always done this to a certain extent, using X-rays and CT scans to estimate what we think we should do in the OR. That was the state of the art for the last 25 years. Now we have at our disposal technology to help us measure and apply implants within 1 millimeter tolerances; we are beyond using a chainsaw. At this juncture in our field, the placement of instruments and implants is so much more critical. We are fortunate to have much improved imaging and software to help us plan operations, determine the degree of correction for sagittal or coronal balance, and figure out the size and placement of the implant. Then we take this information to the operating room and combine it with navigation and robotics to facilitate the pre-operative plan. Why not take advantage of these tools? Why not go into the OR as prepared as possible?”
“If a contractor was going to redo your kitchen and he looked around and said, ‘Yeah, we’ll move this about six inches, ’ and wanted to proceed without a blueprint, would you let him remodel your kitchen? Probably not. It’s the same thing with a pilot. If you heard that the pilot didn’t do a preflight plan you wouldn’t get on the plane with him. We need to be able to say, ‘I’m going to cut from point A to point B, take out a 20 degree wedge here, decompress L1-2, etc.’ With robotics and navigation we have that capability.”
“I often hear, ‘But does this really save time in the OR?’ ‘Absolutely!’ is my response. Recently I did a complex revision and spent 35 minutes developing my pre-operative plan. I booked the case on the basis of experience with other such cases…I allotted seven hours and ended up finishing in four hours. When I finish a case early I can be more efficient with hospital resources, be cost effective, and minimize the patient’s operative risk. And from a systems viewpoint, OR efficiency is being scrutinized more, so it is increasingly important to plan your time.”
“With a pre-operative plan my team works like an orchestra. The anesthesiologist knows at what point to expect hemodynamic issues, the scrub tech knows exactly what size screws need to be ready, the circulating nurse knows exactly what equipment I need and has everything ready to go (i.e., nobody is running around mid-surgery looking for xyz gizmo). And if your plan doesn’t go as expected, you call the audible, which is also pre-operatively planned. All surgeons must know how to get into trouble and how to get out of trouble. With a pre-operative plan you have thought about it even before you set foot in the operating room. I suspect that this kind of pre-operative planning and precision will ultimately be required by the FDA and licensing boards, very similar to the pre-operative time out.”
Local Beats General – Like a Drum
Know about neuraxial anesthesia? You should! A full 95% of anesthesiologists and surgeons at Hospital for Special Surgery (HSS) are using it for joint replacements. Stavros Memtsoudis, M.D., Ph.D. is director of Critical Care Services at HSS in New York; he has just published his work in the Anesthesiology. He tells OTW, “While the majority of joint replacements in the U.S. are performed under general anesthesia, we at HSS have found that using neuraxial anesthesia—as opposed to general anesthesia—decreases the risk of blood transfusions, decreases length of stay, as well as a host of organ related complications.”
So why isn’t everyone using it? “There are a multitude of things that come into play, namely, patient, institutional, and surgeon preferences. And unless you work in a place where a lot of knee and hip arthroplasty is done, then most likely everyone is accustomed to general anesthesia. Then there is the issue of anticoagulation; neuraxial techniques that are used for postoperative pain control, such as epidurals, are considered contraindicated with potent anticoagulants. I just spoke with physicians in Canada who are reviewing an enormous amount of national data and trying to come up with best practices for hip and knee arthroplasty. They are using our paper to guide them and hope to increase their rate of utilization of neuraxial anesthesia—which now stands higher than in our study in U.S. hospitals but may be as low as 50%.”
“This type of anesthesia requires a certain level of expertise and is quite involved as the patient has no feeling below the waist but often requires sedation especially for longer surgeries. The process requires a team approach and mutual understanding of the roles of every individual to make neuraxial anesthesia successful. I encourage my colleagues to look at the outcomes beyond the OR. From our end, we have seen a dramatic decrease in complications and mortality rates, as well as even better implant performance. We just may find that insurers will start paying close attention to the type of anesthesia used. Interestingly, one of the first people to contact me was someone from a risk management journal. The reporter asked how these findings may affect medical litigation issues; my answer was that it will be no different than with competing medications or interventions that are used to treat a specific condition. The patients must be informed of risks, benefits and alternatives and complications may occur irrespective of the intervention.”
Capture the Fracture
One fracture is bad enough, but two or three is, well, common in some places. The International Osteoporosis Foundation (IOF) is attacking this gap in fracture care with a new program—Capture the Fracture. Carey Kyer, science project manager for the IOF tells OTW, “Capture the Fracture will reduce secondary fractures by promoting the development of Fracture Liaison Services (FLS) worldwide. We are setting international standards for FLS, and have developed a Best Practice Framework (BPF), a set of 13 standards outlining the essential and aspirational components of a successful FLS. We are making the BPF a ‘living’ document by putting it into action through our program: ‘Capture the Fracture Best Practice Recognition.’ Via this program, FLS submit their system to Capture the Fracture, we assess it using the BPF and award the FLS a gold, silver or bronze achievement level in accordance with the BPF.”
“The FLS is recognized on our web-based map which allows FLS the opportunity to showcase their achievements, lets policy makers/healthcare systems to see a visual representation of FLS services and service gaps worldwide, and serves as a resource. Among other things the Web site includes audits and surveys from around the world, implementation guides and toolkits, and future plans for a mentorship and grant program for developing systems.”
As for measuring the program’s success, Kyer stated, “Initially, we will track the uptake of our program and awareness of the campaign through map growth, i.e., tracking the number of FLS appearing on our map. We started with 10 and have grown to 32 since our launch in March. Success will also be measured by Web site hits/clicks, growth of FLS by country, and citations of Capture the Fracture in publications. Orthopedic surgeons can get involved by endorsing the program, joining the coalition of partners, submitting the FLS at their hospital to be recognized on the Capture the Fracture map, and using the BPF to implement an FLS at their hospital.”
