Archive | June 2014

Maximizing Your Non-Physician Practitioners

Physician assistants and nurse practitioners (often referred to as nonphysician practitioners, or NPPs) can be instrumental in helping physician practices speed reimbursements, increase patient satisfaction, and reduce paperwork burdens for doctors. An article on ORTHOPRENEUR, a digital journal, suggests that practices employ the following tips to ensure optimal utilization of these valuable professionals:

  • Create accurate job descriptions.
  • Research your payer mix and reimbursement rules.
  • Coordinate a pre-employment shadowing day before making a formal offer to an NPP.
  • Include professional memberships and CME allowance in the offer.
  • Market your new NPP just as you would a new physician.
  • Provide one-on-one training with physicians during the NPP’s orientation.
  • Create patient scheduling policies and protocols for your staff; train the staff on the type of appointments for which NPPs will be utilized.
  • Train your NPP on billing and documentation, including coding.

Update on Stem Cell Trials for Spinal Cord Injuries

About 12,000 new cases of spinal cord injury occur each year. The average annual cost for patients living with spinal cord injury is more than $70,000.

Armin Curt, MD, principal investigator in the StemCells trial for spinal cord injury patients, gave an update on the Phase I/II trials at the recent annual meeting of the American Spine Injury Association. All patients in the study have chronic spinal cord injuries and were treated with human central nervous system stem cells and short-term immunosuppressive drugs.

Dr. Curt reported that post–transplant gains in sensory function that were first reported in two patients have now appeared in two additional patients. The initial group of spinal cord injury patients participating in the trial had no mobility or sensory perception below the point of injury. Those in the second group were paralyzed but retained sensory perception below the point of injury. Two of the three patients in this second group, treated four to 24 months post injury, had significant sensory gains.

Researchers also noted that no one in the trial has experienced any adverse medical anomalies, such as segment deterioration, unexpected or unknown pain conditions, or loss of overall functional capacity.

Management Companies Big Players in Practice Acquisitions

Physician practice management companies have re-emerged as big players in physician practice acquisition. In 2011, more than half of the purchasers of physician practices were hospitals and health systems. In 2013, that percentage dropped to just 14% according to PwC US. Overall, the total value of US health services merger and acquisition (M&A) activity reached $12.3 billion during the first quarter of 2014, which is 152% higher than the same period in 2013. According to Brett Hickman, partner with PwC’s Health Industries Group, “Several indicators that we track point to robust M&A activity for the rest of the year… Combined with positive signs we’re seeing in the other health services sectors, we’re optimistic that there will be heightened deal activity in 2014.”

The slow-down in acquisitions by hospitals and health systems and the ramp up in activity by physician practice management companies is expected to continue as specialty groups try to cope with reimbursement changes and high regulatory costs that increase the challenge of running a profitable practice.

RA Progression Rate Predicts Need for Future Surgery

UK epidemiologists presenting at the annual meeting of the British Society for Rheumatology recently reported that X-ray evidence of rapid rheumatoid arthritis (RA) progression during the first 12 months of the disease can help predict the need for later surgery of hand, foot, hip, and knee joints. Lewis Carpenter and colleagues analyzed data from the Early Rheumatoid Arthritis Study and found that a change in the Larsen radiographic score of four units during the first 12 months of RA was associated with an 80% increased risk of subsequent surgery on joints of the hand and foot, and a 50% increase in the risk of later hip or knee surgery. (The 0 to 5 Larsen score includes both joint-erosion and joint-space narrowing components.) Carpenter told MedPage Today that these findings help “build the case for early treatment in rheumatoid arthritis” and support the argument that a “therapeutic window of opportunity” exists with RA.

Orthopaedic Job Seekers Motivated by Geography

According to a recent survey by JBJS among nearly 100 orthopaedic job seekers, the number-one challenge orthopaedists face each day is finding a balance between work and personal life. The second greatest challenge is the abundance of administrative hassles, such as dealing with insurers, liability issues, and reimbursement. Survey respondents said that when searching for a new job, location is the most important factor followed by job security and career advancement. Responses revealed a strong consensus that a teaching/academic hospital is the preferred type of facility in which to work. The two most compelling drivers that prompt job seekers to find a new job are desire for a better work environment and finding a better community for themselves and their families.

Editor’s Choice—June 2, 2014

The May 21, 2014 Orthopaedic Forum article, “Public perception regarding anterior cruciate ligament reconstruction” by Matava et al. is a timely reminder of how important physician-patient communication and patient education are.

In this study, 210 individuals (all but 7% of whom had a high school education and 50% of whom had a college degree) completed a predominantly multiple-choice questionnaire on their knowledge of anterior cruciate ligament (ACL) injury and its ramifications. Given the extensive media coverage of ACL injury in high-profile athletes, I think virtually everyone has heard the term “ACL.” But this study points out how superficial or incorrect patient knowledge is about ACL injury, even in this well-educated study cohort.

I urge you to read the article to see all the interesting findings, but here are a few of the most intriguing ones:

  • 51% of factual questions were answered correctly.
  • There was no correlation between education level and correct responses, but those with a higher activity level had a higher score on the survey.
  • 16 participants with prior ACL injury had no more correct responses than those with no knee injury.
  • 34% knew that the ACL was attached to bone at each end.
  • 70% did not know that the risk for ACL injury is different between men and women.
  • 48% thought that a complete ACL tear could heal without surgery.
  • 33% thought ACL repair was needed to be able to walk.
  • 32% thought ACL reconstruction surgery involved repairing the torn ligament.

While this article focused only on patient knowledge of ACL injury, the implications probably extend to essentially all orthopaedic surgical procedures. The push for us to use more shared decision making in deciding whether or not a surgical procedure is done requires that the patient has adequate information to make an informed decision. Unfortunately, the dearth of knowledge about a common knee injury among the general public highlighted in this article is so dramatic that it seems unlikely that the individuals surveyed could participate realistically in shared decision making about ACL surgery.

With orthopaedic procedures accounting for about 40% of CPT codes, it would be a huge challenge for orthopaedic practices to provide evidence-based education on all conditions prior to or during a discussion of possible surgical treatment. However, this article points out the need for much-improved patient education. Each orthopaedic practice will handle this differently, but perhaps when surgery is recommended, the physician extenders in an orthopaedic practice could suggest reliable websites through which patients can obtain information. The patients could then return with a list of questions that arose from their reading to be addressed during the final discussion related to surgical treatment.

However patient information is provided, this article points out the need for ongoing attention to filling the knowledge gap to realistically allow patients to be true participants in deciding which course of treatment is best.

JBJS Reviews Editor Echoes Call for Improved Osteoporosis Prevention and Treatment

In last month’s Editor’s Choice, JBJS Editor in Chief Vern Tolo. MD, called for more concerted efforts among orthopaedists to link care of fragility fractures to evaluation and treatment of osteoporosis. Now, JBJS Reviews Editor in Chief Thomas Einhorn, MD, echoes Dr. Tolo’s message in reference to the May 2 JBJS Reviews article on managing patients with osteoporotic distal radial fractures:

According to Dr. Einhorn, “This must-read article provides a concise summary of how to advance the diagnosis and treatment of osteoporosis and fragility fractures. The authors explain the latest evidence about the ‘three main pillars’ of treatment of distal radial fractures in people with osteoporosis: primary prevention, acute management, and reduction of risk of future fractures. The strides made among US orthopaedists to recognize and manage osteoporosis with programs such as the American Orthopaedic Association’s ‘Own the Bone’ initiative have been commendable. However, on a global scale, our specialty is woefully behind in taking an aggressive approach toward prevention and treatment of osteoporosis.”

In-Development App Would Enable Remote Gait Analysis via Smartphone

The accelerometer chip inside almost every smartphone, which helps the device know up from down, could help orthopaedic surgeons remotely analyze the gaits of their patients after joint-replacement surgery. So says Canadian orthopaedist Michael Dunbar, MD, an oft-published JBJS author.

Accelerometers can detect motion in three directions. Dr. Dunbar told Orthopedics This Week that he’s working on an app whereby patients, at the time of postsurgical check-ups, would strap the phone onto their back or hip and go for a walk in their own environs. The app would transmit the accelerometer-captured information to the doctor for gait analysis; the physician would then contact the patient by phone for further discussion about postsurgical progress.

Compared to the traditional follow-up X-ray–which, as Dr. Dunbar noted, “is just a [two-dimensional] picture of the patient lying down and has nothing to do with the patients’ walking”–the accelerometer-enabled remote gait analysis should be more accurate and less expensive and time-consuming.

Age-Related Differences in Physician Lifestyles

A recent study by the AMA Insurance Agency of 125,000 practicing physicians spanning across a broad spectrum of specialties found many significant differences in work/life profiles by age.

For example, almost 75% of physicians under the age 40 have student loan debt, with almost half owing $150,000 to $200,000. Eighty-three percent of all physicians are still paying off their loans. Nearly one out of four of physicians under 40 plans on changing employers in the next 5 years, while 44% of those 60 to 69 plan on retiring during that same timeframe. Retirement savings is a top concern of all physicians regardless of age. Half of the doctors surveyed said they are behind in their retirement plans with only 6% indicating they are where they think they should be.

Despite the fact that nearly 25% of the physicians surveyed work 60 to more than 80 hours a week, they are still very physically active outside of their profession. The top activities include running/jogging, bicycling, aerobics, and camping/hiking.

Pig-Bladder Cells Create Scaffold for Muscle Growth in People

In a pre-clinical trial among five men with 50% to 90% of leg-muscle loss due to injury, researchers found that implanted cells from pig bladders formed a biologically active scaffold that recruited native stem cells to help rebuild skeletal muscle. The authors of the study, in Science Translational Medicine, said the peptides released as the pig cells degraded mobilized the patients’ own stem cells to the site of injury. Three of the five patients showed marked improvement in standing, walking, and stair climbing. All five had undergone unsuccessful prior surgeries and physical therapy (PT). Speaking of PT, all five patients received a specialized 12- to 16-week course of PT prior to the implantation and postoperative PT that lasted from 5 to 23 weeks. The authors also stressed that the implanted scaffold works only in a scar tissue-free area adjacent to healthy tissue that has nerve and blood supplies.