Offsite Consultations Using Smartphones is Reliable
Researchers from Israel decided to look at the trend of taking video clips of computed tomography (CT) scans and sending them as instant messages (IM).
Their work, which appears in the February 2017 edition of The Spine Journal, compared the reliability of two methods of diagnosing, classifying, and treating thoracolumbar spine fractures. The first was the capture of video clips from a picture archiving and communication system (PACS) transmitted by a smartphone-based IM application to another smartphone. The second method involved viewing the images directly on the PACS.
The authors wrote, “Intraobserver agreement for determining fracture level was near perfect. Intraobserver agreement for AO classification, proposed treatment, neural canal penetration, and Denis classification were substantial. Intraobserver agreement for loss of vertebral height and kyphosis were moderate.”
Ido Stahl, M.D. is with the Division of Orthopedic Surgery at Rambam Healthcare Campus in Haifa. He told OTW, “Over the past decade smartphones have become an integral part of every aspect of our life including our professional practice. Using messaging applications to transfer x-ray images and CT scans to the on-call physician has become the norm allowing us to obtain their expert opinion anytime anywhere, but we realized there is very little published material to prove the efficacy of our routine. Our work has shown that using smartphone-based instant messaging application is reliable, accessible and inexpensive means of communication making smartphones a powerful tool for doctors in the emergency department (ED), primary care clinics or remote medical centers, enabling timely and appropriate treatment.”
“Using smartphones as a means of off-site consultation is reliable and can be used in the emergency setting for decision-making. This method could prove to be critical in the expeditious treatment of injuries requiring surgery or, conversely, reduce waiting time in the ED and unnecessary interfacility transfers for injuries which can be treated conservatively. We should always keep in mind that imaging studies do not replace the physical examination and are no replacement for thorough clinical evaluation of the patient.”
“We are currently performing several other research studies regarding the transfer of images and movies over smartphone applications. In addition, a study involving decision-making in pediatric orthopedic trauma over smartphones has recently been accepted to the Journal of Pediatric Emergency Care.”
Risk-Adjusted Outcomes in Medicare TJR Procedures
Research performed at MPA Healthcare Solutions in Chicago, and published in the January 2017 edition of The Journal of Bone and Joint Surgery, involved the pursuit of objective ways to define risk-adjusted outcomes for elective lower-extremity total joint replacement (TJR). The scientists examined 253,978 patients who underwent total hip replacement and 672,515 patients who underwent total knee replacement.
Donald E. Fry, M.D. is executive vice president for Clinical Outcomes Management at MPA Healthcare Solutions, adjunct professor of Surgery at Northwestern University, and professor emeritus of Surgery at the University of New Mexico School of Medicine.
Dr. Fry told OTW, “We are seeking objective methods to define risk-adjusted outcomes of surgical care. By developing these objective metrics, hospitals and clinicians can more specifically focus on areas where care can be redesigned to improve results. Importantly, composite measurement of outcomes becomes very important in Bundled Payment initiatives, such as the Comprehensive Care for Joint Replacement by CMS [Centers for Medicare and Medicaid Services]. By comparing hospital performance, providers can have a clear idea of the opportunities for improvement. Reducing adverse outcomes rates becomes a key for better performance with prospective payments models.”
“Most adverse outcomes for joint replacement patients (and other surgical procedures that we have studied as well) occur following discharge from the hospital. There are more 90-day post-discharge deaths and more 90-day readmissions than there are inpatient complications of care. Because more adverse outcomes of care occur after discharge, it would be our contention that hospitals and orthopedic surgeons may not know what their overall outcomes of care happen to be. Up to 40% of readmissions and emergency department visits occur at hospitals other than where the index procedure was performed. Hospitals and orthopedic surgeons need to participate jointly in efforts to know what the post-discharge outcomes are for their patients, and to design coordinated efforts to reduce these events.”
“Better risk adjustment tools are needed. Our research has been with administrative data. The addition of more clinical information (e.g., laboratory data) will be of great value. The addition of socioeconomic data will enhance the risk adjustment for hospital readmissions. While the shortcomings of administrative data are understood, all should appreciate that administrative data give the results of care for patients after discharge that may not be available to the hospital or the clinician from clinical registries. The development of hybrid databases that combine clinical, administrative, and socioeconomic data gives the best opportunity to refine predictive modeling. With better predictive modeling, the opportunities for care improvement are enhanced. In addition, our research has been only in Medicare patients. Further research is necessary with all-payer databases that include documentation of outcomes that occur in the post-discharge period.”
The CHOP Experience: Dedicated Orthopaedic Trauma OR Improves Efficiency
Researchers from The Children’s Hospital of Philadelphia (CHOP), a level-I pediatric trauma center, wanted to weigh in with data on the use of dedicated orthopedic trauma operating rooms (ORs). Do they improve patient flow? Do they save money? They undertook a retrospective analysis of two 3-year intervals before and after implementation of a weekday, unbooked OR reserved for orthopedic trauma cases. A total of 719 cases occurred before the implementation of the dedicated OR, and 750 cases were performed after the implementation.
Wudbhav N. Sankar, M.D. is director of the Young Adult Hip Preservation Program at CHOP. He commented to OTW, “We had a fundamental shift in the way we handled pediatric trauma a few years ago. We felt that our new system of a dedicated trauma room really improved patient care and patient satisfaction in terms of the way we handled pediatric trauma. We performed the study to determine whether this was indeed the case and to validate our anecdotal feelings about the change.”
Dr. Sankar continued, “I think the biggest take home message from the study is that much like in adult centers, the use of a dedicated trauma room turns out to be very effective and efficient for treating pediatric trauma. Our study demonstrates that systematic improvements in the way that urgent cases are handled to make a big difference in both surgeon and patient satisfaction and lead to a more efficient system.”
“I think more work needs to be done on the cost-effectiveness of a dedicated trauma room. We did a relatively preliminary cost analysis but certainly there are more complex factors at play including the opportunity cost of an unused operating room. Calculating the cost of care and the cost of delays in care is quite involved and further work is necessary to really understand this issue.”
