Tranexamic Acid in Hip, Knee Arthroplasty: Michigan Experience
When researchers from the University of Michigan Medical Center looked into it, they found that the use of tranexamic acid (TXA) in their state varied widely and that the data suggested that TXA had a significant effect on the risk of transfusion. Brian R. Hallstrom, M.D. is associate chair for Quality and Safety in the Department of Orthopaedic Surgery at the University of Michigan Medical Center. He commented to OTW, “One of our first quality improvement projects in the Michigan Arthroplasty Registry was reducing unnecessary blood transfusion.”
The team had plenty of cases to work with: 23, 236 primary total knee arthroplasty cases and 11, 489 primary total hip arthroplasty cases in the MARCQI (Michigan Arthroplasty Registry: Collaborative Quality Initiative).
Dr. Hallstrom, co-director of MARCQI, added, “The adoption of TXA into orthopaedic practices has been slow due to concerns among surgeons and anesthesiologists about the potential risks of the medication. We found the TXA group received significantly fewer blood transfusions. In addition, our large, statewide experience supports other smaller studies that have not shown an increase in blood clots or cardiovascular events. In fact, we found an association with fewer blood clots in knee replacement patients and fewer readmissions in hip replacement patients.”
“Published rates of transfusion after hip and knee replacement have historically been quite high. TXA offers one tool to help surgeons reduce the need for blood transfusion which will reduce risk to patients, stress on the blood supply and cost to the system.”
“The combination of multimodal pain control, rapid rehabilitation and reduced blood loss and swelling has really revolutionized the care of hip and knee replacement patients over the last few years. These and other factors will only serve to improve the quality and value of care for the many patients having these remarkable, life changing procedures as we move into the next era of health care.”
Great Results for Novel Osteoporosis Therapy
A new study utilizing data from the ACTIVE (Abaloparatide Comparator Trial in Vertebral Endpoints) trial has found that regardless of bone density, age, and previous history of fracture, abaloparatide-SC offers consistent protection against bone fractures in postmenopausal women.
Felicia Cosman, M.D. is an osteoporosis specialist and medical director of the Clinical Research Center at Helen Hayes Hospital, senior clinical director of the National Osteoporosis Foundation and professor of medicine at Columbia University.
Dr. Cosman commented to OTW, “Some patients with osteoporosis who might be candidates for abaloparatide treatment have prior fractures from osteoporosis whereas others have very low bone density without a fracture history. In this study we sought to determine whether abaloparatide would work similarly well in both groups of women. Furthermore, we believed it was important to show that abaloparatide could work in younger patients as well as the very old and to demonstrate that abaloparatide could reduce fractures in women who had either low spine and/or low hip BMD [bone mineral density].”
“Abaloparatide was so consistently effective in all subgroups. Abaloparatide’s effects on improving BMD as well as its effects to reduce risk of both vertebral and nonvertebral fractures were totally independent of whether a woman had had a prior fracture (of either the spine or any other bone), how low her BMD was at the start of the study or how old she was.”
“Orthopedic surgeons are in a unique position to reduce the toll of osteoporosis and its complications on individual patients as well as society. We know that the vast majority of patients with osteoporosis related fractures do not receive treatment for their underlying disease. We need orthopedists to reinforce the message to patients that fractures suffered in minor falls are to a large extent related to the strength of the underlying bone tissue. All patients who have major fractures during adulthood with trauma equal to a fall from standing height (or less) require evaluation and treatment for osteoporosis. The risk of a second fracture is particularly high in the first two years after the fracture. Abaloparatide produces a rapid reduction in the risk of subsequent fractures and is therefore particularly helpful in patients that orthopedists see regularly.”
“Many orthopedists will themselves be comfortable treating patients with abaloparatide. Others will be more comfortable referring these patients back to their internists or other specialists. Either way, if orthopedists stress how important the treatment of osteoporosis is (in addition to the treatment of the fracture itself), patients will be far more willing to take the medication necessary to reduce the disability, pain, loss of independence and even death associated with osteoporotic fractures.”
Patient Knowledge of Cost=Choosing Cheaper Facility?
In what is novel research, investigators from Harvard embarked on a study looking at the impact of price information and choice of facility. The study by Anna D. Sinaiko, Ph.D., M.P.P., of the Harvard T.H. Chan School of Public Health, Boston, and co-authors examined Aetna’s web-based price tool on choice of health care facility for eight services.
Dr. Sinaiko told OTW, “Giving patient’s information about the price for health care services at different providers is one strategy to engage patients in their health care decision-making and empower them to choose providers that are the best option for them. In addition, as patients face higher cost-sharing in their health plans, and pay larger amounts out-of-pocket for their care, price information is increasingly salient. We pursued this study to investigate whether patients who view price information in advance of having a health care service choose different providers, or pay lower prices, than patients who don’t view price information.”
“For two of the eight services we studied, imaging services (e.g., selected CT and MRI scans) and sleep studies, patients who viewed price information in advance of their procedure chose lower cost physicians than other patients. These patients also spent less overall for imaging services.”
“Patient use of transparency tools such as the one examined in our paper remains low, but the services that are most searched by patients are health care services that are ‘shoppable, ’ in that they are non-life threatening, non-emergent, and often elective. Several orthopedic procedures, such as joint replacement, fall into this category.”
“Moreover, the availability of transparency tools is increasing, and they may start to be combined with efforts to channel patients to lower-cost orthopedic providers, such as tiered networks or reference-based pricing, in order to increase the impact of those interventions.”
“In the short term, orthopedic surgeons may not see a lot of impact; although some orthopedic procedures are good candidates for shopping, relatively low proportions of patients are using price transparency tools. However, if these tools gain traction among patients, then orthopedic surgeons may begin to get questions from patients about prices or about their out-of-pocket costs before having procedures. Such questions provide an opportunity for physicians to help patients interpret price differences, to help them anticipate their costs, or to provide information about quality of care, all of which can improve patient decisions and the value that patients get from their health care.”
