Rothman Institute Expanding Into New York!
The prestigious Rothman Group has just signed an agreement with Northwell Health, New York State’s largest health care provider, to develop centers of excellence for orthopedic care in the New York Metropolitan area.
With experts in every orthopedic sub-specialty and 25 locations in the Philadelphia region, Rothman Institute has it covered. On the other hand, there is always room for growth.
“We’re excited about the affiliation with the Rothman Institute,” said Nicholas Sgaglione, M.D., chair of orthopedics at Northwell Health, in the April 20, 2017 news release. “The affiliation will bring together two nimble, forward-thinking organizations that emphasize high-quality care. We also look forward to working with the Rothman Institute to co-brand various marketing initiatives, the ongoing recruitment of top-level physicians, joint research, and tracking and measuring patient outcomes.”
Alexander R. Vaccaro, M.D., Ph.D., M.B.A. president of Rothman Institute, Richard H. Rothman Professor and chairman of the Department of Orthopaedics, and professor of neurosurgery at Thomas Jefferson University and Hospitals said to OTW, “We set out to bring a new model of care to the New York area…one that provides high quality, affordable service delivered by in-network physicians. A joint venture with Northwell Health was a natural fit because we share that vision of healthcare.”
In-network is the key, says Dr. Vaccaro. “If patients must go out of network then their out of pocket expenses are high. Our goal is to provide the entire market with an opportunity to have access to the best doctors. We are selecting physicians with established practices, excellent reputations, and who are steeped in an academic background. In addition, our model includes a good clinical algorithm that helps avoid unnecessary, wasteful care.”
“Our New York-based physicians will function where they are now, in Northwell Health facilities, and in our future centers of excellence. At the present time, we are completing the required paperwork and New York licensing; we anticipate being operational in 6-12 months.”
As for how warm the New York welcome has been, Dr. Vaccaro notes, “Let’s just say that not everyone is thrilled that we are embarking on this project. It’s disruptive to that market, which is largely out of network. Patients will benefit, however, as they will have our superbly talented clinicians who are performing cutting-edge research.”
Dr. Vaccaro’s final word? “Being out of network helps no one.”
PROMs: Useful Despite Controversy
Are Patient Reported Outcome Measures (PROMs) too complex as they are currently written, as has been suggested by several studies. Researchers at the University of Alabama at Birmingham were not convinced.
Their study, “Readability of Orthopaedic Patient-reported Outcome Measures: Is There a Fundamental Failure to Communicate?” was published online April 3, 2017 in Clinical Orthopaedics and Related Research.
The researchers analyzed 86 independent, orthopedic and general wellness PROMs, as well as four relevant short forms, and 11 adults, physical health question banks from the PROMIS (Patient-Reported Outcomes Measurement Information System), were included for analysis.
Brent A. Ponce, M.D. associate professor in the Division of Orthopaedic Surgery at the University of Alabama at Birmingham, told OTW, “Reports, including some we have published, have identified that patient education materials are frequently written at several reading grade levels above the American Medical Association (AMA) and National Institutes of Health (NIH) recommendations of 6th and 8th grade, respectively.”
“Recently, an article suggested this was also true for PROMs, catching our attention, as PROMs are being increasingly stressed in clinical practice. We wondered, ‘If PROMs are not readable to most patients, then how accurate and useful are the results reported in the literature?’ This led us to research the process of how many commonly used PROMs are validated.”
“Surprisingly, many PROMs have not been validated, and for those that have been validated, readability is often not a criterion used. Now, it is vital to understand that readability does not equate to comprehension, but the issue of PROMs being written at unreadable levels was a bit of a ‘does the emperor have no clothing’ moment—we place immense value upon surveys which may not accurately evaluate what we intend to measure.”
“The weakness of the recent reports commenting on the poor readability of PROMs is that they were limited in their scope of PROMs used and relied upon a single readability measure. Admittedly, there is no gold-standard readability formula for use with patient-directed medical literature, and all available algorithms were originally developed for use in education, business, and the military.”
“However, there are nearly 20 English-text, readability measures available, and each algorithm stresses different aspects of document formulation—sentence length vs. complex words vs. paragraph length, etc. Therefore, we sought to find a ‘true’ readability by taking the median grade level from 19 independent readability algorithms assessing each PROM.”
“The most important finding from our article is encouraging. That is, we identified that 74% (64/86) and 94% (81/86) of the PROMs analyzed met AMA and NIH reading level recommendations, respectively. This suggests that there is not an urgent need to revamp PROMs to make them more readable. Until this point, there was near-unanimous agreement in the literature that patient health materials, including PROMs, were written at levels too difficult to comprehend for the average patient.”
“This thought process has led to drastic revisions of patient-directed materials, and a growing concern regarding the continued utility and validity of PROMs in clinical practice and research. However, the findings of our study cast doubt upon this assumption, and increase confidence in using PROMs as an integral aspect to objectively quantify subjective surgical outcomes in daily orthopaedic practice and research. PROMs are a vital tool in orthopaedics, and we should not fear using them due to their previously perceived low readability levels.”
“The most surprising aspect of this article was not necessarily the high readability of most PROMs, but instead how easily the PROMs written at higher-than-recommended reading levels corrected with a few simple, previously published steps. In fact, many PROMs achieved recommended reading levels following only the removal of technical terms (for example, using ‘adapt’ instead of ‘compensate,’ or ‘expect’ instead of ‘anticipate’).”
“This gives us hope moving forward; though the edited PROMs may still require re-validation, they are capable of adjustment into a more easily readable format. In short, we were happy to see that there is no need to ‘throw the baby out with the bathwater’ and completely redevelop entire PROMs, but instead minor syntax changes may be sufficient.”
“In short, we would like orthopaedic surgeons to be confident that they are receiving reliable data when using PROMs for clinical and research endeavors. PROMs are a critical tool for assessing surgical outcomes, and they should be used without fear of invalidated results due to PROM reading level.”
“Additionally, we would like surgeons to use PROMs which best fit their patient population’s reading level. For example, illiteracy rates in many parts of our country can be quite high. In these areas, even though many PROMs meet both AMA and NIH recommendations, surgeons should consider preferentially using PROMs written at the appropriate reading level for their specific patient population.”
Pregnant Orthopedic Patients: Teamwork Is Imperative
A new literature review by Tejwani of New York University’s (NYU) Langone Medical Center describes how complex caring for orthopedic patients who are pregnant can be. The author describes how changes the mother’s body undergoes during pregnancy need to be considered when planning care for mother and fetus alike. The article, “Treatment of Pregnant Patients With Orthopaedic Trauma,” was published in the May 2017 edition of the Journal of the American Academy of Orthopaedic Surgeons.
Lead author Nirmal Tejwani, M.D., an orthopedic trauma surgeon with New York University Langone Orthopedics, told OTW, “We had a couple of patients with fractures who were pregnant and needed surgery. While discussing the risks of surgery with the patients we realized that there was not much in the way of orthopedic literature or guidance. This prompted us to review the available literature and come up with recommendations in the treatment of pregnant patients with fractures.”
According to an NYU May 1, 2017 news release, “Although the causes of orthopaedic traumas vary, pregnant women and their unborn babies are most vulnerable to injuries in motor vehicle crashes. Among those injured as drivers or passengers, up to 64% were not wearing seat belts at the time of the collision, which can cause harm to the mother and fetus.”
“The most preventable factor is wearing a seat belt. Pregnant women typically don’t wear seat belts because they feel this harms the fetus; however, they should be counseled on the importance of seat belt use in preventing maternal and fetal harm,” says Dr. Tejwani.
Pregnant patients with orthopedic trauma when compared with non-trauma patients:
- Have a greater likelihood to deliver prematurely–more than three weeks before a baby is due–in gestation weeks 24 to 33 (17% versus 3%) and 37 weeks (31% versus 3%).
- Have the greatest likelihood to deliver prematurely if they previously fractured their pelvis.
- Have a 15% higher rate of delivery by cesarean section (C-section).
- Are more likely to undergo C-sections if they previously fractured their pelvis.
- More frequently delivered their babies on admission (34% versus 13%).
Dr. Tejwani commented to OTW, “The physiology of the mother changes in pregnancy and different stages of pregnancy demand knowledge and attention of the obstetrics team along with awareness by the orthopedic surgeon as to whether surgery can proceed safely.”
“Orthopedic surgeons should be aware of the changing maternal physiology, the need for a multi-disciplinary team, and be quick to refer these patients to hospitals which have these various specialties available at all times.”
