OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.
I want to expand on my previous posts (Tips to Excel Under MIPS and Why EHR Data & Analytics Matter) and focus on another differentiating factor when it comes to electronic health record (EHR) systems and your success with Medicare’s Merit-based Incentive Payment System (MIPS).
The ability to interact with specialized health registries is another functionality your EHR system should have. Active engagement with a clinical data registry falls under the Advancing Care Information (ACI) component of MIPS. In general, having EHR-enabled access to such specialized health registries can make MIPS compliance easier and help you earn bonus points, which translates into increased practice income.
Some examples of orthopaedic-specific registries could include the following:
- Medial Meniscus Tear, Acute Registry
- Plantar Fasciitis Registry
- Low Back Pain
- Herniated Disc, Cervical Registry
In addition to having the ability to interact with orthopaedic-specific registries in order to participate in ACI and improve your MIPS score, registry engagement through your EHR system will help to improve population health by collecting and reporting on data about musculoskeletal treatment effectiveness and disease trends. Public health reporting can be very complicated and time-consuming, but having an EHR system that automatically and seamlessly collects and transmits the data to the registry, without manual intervention, is a robust advantage.
Finally, access to registry data will help your practice with the Improvement Activities component of MIPS, which, during the so-called transition year of 2017, is weighted at 15% of the total MIPS score.
Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.
Access the most relevant peer-reviewed orthopaedic content, including unlimited CME, by purchasing a 1-year JBJS JOPA CME membership—for the limited-time special rate of $99.
Your JBJS JOPA CME membership includes the following essential ingredients for your professional development and education:
- New JBJS Reviews CME every week
- Full access to JBJS Reviews and JBJS Journal of Orthopaedics for Physician Assistants (JOPA)
- Monthly Image Quizzes
- Annual PA Salary Survey
- Physical Exam and Injection Video Library
With more than 50 AMA PRA Category 1 CreditsTM available annually* with your membership, you can complete all your CME for under $100.
To obtain the special $99 rate, click here and enter code WHQ834AA at checkout.
*The Journal of Bone and Joint Surgery Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. JBJS designates each JBJS Reviews journal-based activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Among the estimated 250,000 surgical rotator cuff repairs performed annually in the US, a growing percentage are being done on younger patients to prevent tear propagation and tissue degeneration. But how durable are the outcomes of those procedures?
In the August 16, 2017 issue of The Journal, Collin et al. report the 10-plus-year results of surgical repair of isolated supraspinatus tears. In this rather large cohort (288 patients with an average age of 57 years evaluated clinically, with 210 of those also evaluated with MRI), complications were not uncommon at 10.4%. On a more positive note, the average Constant score improved from about 52 before surgery to 78 at 10 years after surgery. The 10-year Constant scores correlated with MRI-determined repair integrity but were inversely associated with preoperative fatty infiltration of the supraspinatus.
These findings imply that careful patient selection based on both clinical factors and imaging studies is critically important in identifying patients with the best chance for good, long-term functional results. The presence of a cuff tear, particularly a large chronic one, is not always a surgical indication for repair. For example, Collin et al. found that the rate of retears was significantly higher in patients >65 years old than in those who were younger.
As is frequently the case in orthopaedics, we need additional prospective research with long-term functional and anatomic repair outcomes to better understand which patients are most likely to benefit from early repair of an isolated supraspinatus tear.
Marc Swiontkowski, MD
Analgesia after total knee arthroplasty (TKA) is a multimodal affair these days. Main goals include maintaining adequate patient comfort while limiting opiate use and permitting early mobilization.
In the August 2, 2017 issue of JBJS, Sogbein et al. report on a blinded randomized study comparing the performance of two types of analgesia often used in multimodal TKA pain-management protocols: preoperative motor-sparing knee blocks and intraoperative periarticular infiltrations.
Prior to surgery, the 35 patients in the motor-sparing block group received a midthigh adductor canal block under ultrasound guidance, combined with posterior pericapsular and lateral femoral cutaneous injections. The 35 patients in the periarticular infiltration group received study-labeled local anesthetics intraoperatively, just prior to component implantation.
Defining the “end of analgesia” as the point at which patient-reported pain at rest or activity rated ≥6 on the numerical rating scale and rescue analgesia was administered, the authors found that the duration of analgesia was significantly longer for the motor-sparing-block group compared with the periarticular-infiltration group. The infiltration group had significantly higher scores for pain at rest for the first 2 postoperative hours and for pain with knee movement at 2 and 4 hours. There were no between-group differences in time to mobilization, length of hospital stay, opiate consumption, or functional recovery.
The use of prescription painkillers in the US increased four-fold between 1997 and 2010, and postoperative overdoses doubled over a similar time period. In the August 2, 2017 edition of The Journal of Bone & Joint Surgery, Schoenfeld et al. estimated the proportion of nearly 10,000 initially opioid-naïve TRICARE patients who used opioids up to 1 year after discharge for one of four common spinal surgical procedures (discectomy, decompression, lumbar posterolateral arthrodesis, or lumbar interbody arthrodesis).
Eighty-four percent of the patients filled at least 1 opioid prescription upon hospital discharge. At 30 days following discharge, 8% continued opioid use; at 3 months, 1% continued use; and at 6 months, 0.1%. Only 2 patients (0.02%) in this cohort continued prescription opioid use at 1 year following surgery.
In an adjusted analysis, the authors found that an age of 25 to 34 years, lower socioeconomic status, and a diagnosis of depression were significantly associated with an increased likelihood of continuing opioid use. Those patient-related factors notwithstanding, the authors claim that the outcomes in their study “directly contravene the narrative that patients who undergo spine surgery, once started on prescription opioids following surgery, are at high risk of sustained opioid use.”
However, in his commentary on this study, Robert J. Barth, PhD, cautions that the exclusion criteria restricted even this large sample to about 19% of representative spine surgery candidates, making the findings not widely generalizable. Having said that, the commentator adds that the study supports findings of prior research that persistent postoperative opioid use is more related to “addressable patient-level predictors” than postsurgical pain. He also notes that the findings are “supportive of guidelines that call for surgical-discharge prescriptions of opioids to be limited to ≤2 weeks.”
Demographic reality dictates that orthopaedic surgeons will be under ever-increasing pressure to serve aging patients. This explosion in the need for diagnostic and treatment services calls for engaged and informed patients to work with physicians in a shared decision-making process.
In the August 2, 2017 issue of The Journal, Sepucha et al. document the positive impact that patient decision aids—succinct presentations of treatment options and their attendant risks and benefits—have in shared decision making for hip, knee, and spinal complaints. In this prospective cohort study focused on routine orthopaedic care, the authors show that decision aids lead to higher knowledge scores among patients, greater patient involvement in shared decision making, lower surgical rates, and better patient-experience ratings.
The quality of available decision aids is generally excellent, and they are typically more evidence-based than information patients can locate on the Internet. In this time when orthopaedic surgeons are evaluating higher volumes of patients, these tools can inform patients before or after they interact with their orthopaedist. In addition to providing everyday-language explanations of clinical benefits and risks, these aids help individual patients align their health-care decisions with their personal values, needs, and lifestyles. I hope that these tools will find increasing use over the next 5 to 10 years in the orthopaedic practice environment.
Marc Swiontkowski, MD
The new second-quarter 2017 JBJS Quarterly CME Exam—based on articles published in April, May, and June 2017—is now available.
This course contains 100 assessment questions on topics including Shoulder, Infection, Knee, Pediatrics, Trauma, Hip, General Interest, Sports Medicine, Hand & Wrist, Basic Science, Oncology, Foot & Ankle, Elbow, and Spine.
Selected articles included in the CME Q2 Examination:
- Formal Physical Therapy After Total Hip Arthroplasty Is Not Required. A Randomized Controlled Trial
- Management of ACL Injuries in Children and Adolescents
- Modular Fluted Tapered Stems in Aseptic Revision Total Hip Arthroplasty
- The Clinical Outcome of Computer-Navigated Compared with Conventional Knee Arthroplasty in the Same Patients.
This activity is approved for 10 AMA PRA Category 1 Credits™ and by ABOS for 10 scored and recorded SAE credits
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of August 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Clinical Prediction Models for Patients With Nontraumatic Knee Pain in Primary Care: A Systematic Review and Internal Validation Study.”
This systematic review yielded two new prognostic models for function and recovery in patients with nontraumatic knee pain. A longer duration of complaints predicted poorer function.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, David Teague, MD, co-author of the July 5, 2017 Specialty Update on orthopaedic trauma, selected the five most clinically compelling findings from among the 34 studies summarized in the Specialty Update.
A randomized, sham-controlled clinical trial1 failed to demonstrate improved functional recovery or accelerated radiographic healing with the addition of low-intensity pulsed ultrasound (LIPUS) to the postoperative regimen of fresh tibial fractures.
Two studies support early weight-bearing (WB) after certain operatively managed lower extremity injuries, an allowance that may substantially improve a patient’s early independence. One randomized study2demonstrated that immediate WB after locked intramedullary fixation of tibial fractures is not inferior in union time, complication rates, or early function score when compared with a 6-week period of non-WB. The second randomized trial3 found early WB after select ankle fracture fixation (no syndesmosis or posterior malleolar fixation included) resulted in no increase in complications, fewer elective implant removals, and improved 6-week function, relative to late weight-bearing.
The addition of posterior fixation to anterior fixation for patients with anteroposterior compression type-2 injuries (symphysis disruption, unilateral anterior sacroiliac joint widening) improved radiographic results and led to fewer anterior plate failures.
Less femoral neck shortening occurred with cephalomedullary nail fixation devices (2 mm) than with a side plate and lag screw construct (1 cm) when treating OTA/AO 31-A2 intertrochanteric fractures (unstable, 3 or more parts) in patients ≥55 years of age, although functional outcomes were similar for the two groups.
- Busse JW, Bhandari M, Einhorn TA, Schemitsch E, Heckman JD, Tornetta P 3rd, Leung KS, Heels-Ansdell D, Makosso-Kallyth S, Della Rocca GJ, Jones CB, Guyatt GH; TRUST Investigators writing group. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ. 2016 ;355:i5351.
- Gross SC, Galos DK, Taormina DP, Crespo A, Egol KA, Tejwani NC. Can tibial shaft fractures bear weight after intramedullary nailing? A randomized controlled trial. J Orthop Trauma. 2016 ;30(7):370–5.
- Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ. Early weightbearing and range of motion versus non-weightbearing and immobilization after open reduction and internal fixation of unstable ankle fractures: a randomized controlled trial. J Orthop Trauma. 2016 ;30(7):345–52.
Recurrence rates after surgical treatment for hallux valgus (bunion) range from 4% to 25%. Findings from a study by Park and Lee in the July 19, 2017 edition of The Journal of Bone & Joint Surgery suggest that non-weight-bearing radiographs taken immediately after surgery can provide a good estimate of the risk of recurrence.
The study analyzed proximal chevron osteotomies performed on 117 feet. At an average follow-up of two years, the hallux valgus recurrence rate was 17%. (Recurrence was defined as a hallux valgus angle [HVA] of ≥20°.)
Bunions were 28 times more likely to recur when the postoperative HVA was ≥8° than when the HVA was <8°. The HVA continued to widen over time in patients with recurrent bunions, but stabilized at six months in those without recurrence. An immediate postoperative sesamoid position of grade 4 or greater was also significantly associated with recurrence.
If future studies confirm their results, the authors believe that such data could be used “to suggest intraoperative guidelines for satisfactory correction of radiographic parameters,” and thus help surgeons minimize the risk of hallux valgus recurrence. Commentator Jakup Midjord, MD concurs, noting that non-weight-bearing radiographs can be “closely related to intraoperative radiographs, so we can modify correction as needed in the operating room.”