The March 16, 2016 JBJS includes a careful incidence, treatment, and outcome analysis by Pearson et al. of CMS data regarding C2 cervical-spine fractures that occurred in the Medicare population from 2000 to 2011. The study’s methodological quality comes as no surprise, as the group hails from Dartmouth, the home of the renowned Dartmouth Atlas of Health Care, which has posed many vexing clinical and cost questions for the orthopaedic community.
Pearson et al. found that while the incidence of C2 fractures in the elderly increased 135% from 2000 to 2011, the rate of surgical treatment for this injury remained essentially unchanged. I find that static rate of surgical treatment troubling, because, after controlling for potential confounders, the authors found that surgical treatment was associated with a nearly 50% decrease in 30-day mortality and a 37% decrease in one-year mortality, relative to nonoperative approaches.
I believe that our apparent reluctance to perform surgery in these cases is due to the underlying belief that upper C-spine fixation/fusion in the elderly presents a prohibitively high risk. I question that general proposition because we think quite the opposite nowadays when managing hip fractures and many other metaphyseal fractures with high complication profiles in older people. Certainly, the major risks with upper C-spine surgery are potentially fatal neurologic and vascular injuries, but this well-done analysis demonstrates that the mortality outcomes are markedly better with surgery. In addition, JBJS recently published a paper by Joestl et al. on the outcomes of C2 fusions in geriatric patients with a dens fracture nonunion, which confirmed good outcomes and a favorable risk profile (see related OrthoBuzz post).
I think it is time for the orthopaedic, neurological-spine, and rehabilitation communities to seriously reconsider our approach to elders with C2 fractures. As Pearson et al. conclude, until an RCT is performed on this question (if ever), “surgeons and patients should use the available data in a shared decision-making model to choose the treatment consistent with an individual patient’s values.”
Marc Swiontkowski, MD
Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in elderly people, and one form of it —ossification of the posterior longitudinal ligament, or OPLL—occurs quite frequently in younger patients. The March 2, 2016 JBJS features a prospective, multicenter Level II study by Nakashima et al. demonstrating that surgical decompression for OPLL yields functional and quality-of-life improvements comparable to those seen with surgical decompression in patients with other forms of DCM, such as spondylosis and disc herniation.
The authors measured function and quality-of-life before and two years after surgical decompression in more than 400 patients, 28% of whom had OPLL and the remainder of whom had other forms of DCM. With most two-year outcomes being comparable between the two groups, the authors found only two notable differences:
- A higher risk of perioperative complications in the OPLL group, although there were no between-group differences in the rate of neurological complications.
- Lower social functioning scores on the SF-36 among the OPLL patients.
The authors conclude that the comparable surgical outcomes “support the inclusion of both OPLL and other forms of degenerative myelopathy under the single umbrella of DCM.”
OrthoBuzz occasionally receives posts from guest bloggers. This “guest post” comes from Richard S. Yoon, MD and Alexander McLawhorn, MD, MBA.
Starting on April 1, 2016, Medicare will implement its Comprehensive Care for Joint Replacement (CJR) model in about 800 hospitals in 67 metropolitan areas around the United States. Finalized in November 2015, the CJR initiative is intended to enhance value for patients undergoing lower extremity joint replacement (LEJR) by motivating institutions to achieve quality improvement via cost control. (For a complete discussion of “value” in orthopaedics, see “Measuring Value in Orthopaedic Surgery” in JBJS Reviews.)
Medicare hopes CJR will promote standardized, coordinated care that takes each LEJR patient seamlessly through an “episode of care” that maximizes outcomes at a reduced cost. Episodes are triggered by hospital admission and are limited to admissions resulting in a discharge paid under MS-DRG 469 or 470. For CJR purposes, episodes last for 90 days following discharge.
Initially, episode target prices will be based on historical hospital-specific reimbursements, but over time, the target prices will increasingly reflect regional averages. If a hospital’s average LEJR episode cost is below the target price, it can receive a “bonus” from CMS. If its average cost is above the target price, it will owe CMS the difference. CMS has designed a gradual rollout plan to mitigate downside risk in the first year and provide current and future participants adequate time to implement evidence-based, cost-effective care and other quality programs in their institutions.
Richard Iorio, MD, chief of adult reconstruction at NYU-Langone Medical Center’s Department of Orthopaedic Surgery, says, “There will be definite winners and losers in CJR. Once geographic pricing becomes the dominant metric for target prices, there will be intense price competition in geographic areas and potential access problems for high risk patients.” At the moment, CJR stratifies risk based only on MS-DRG code and whether a patient has a hip fracture. Unless a more robust risk stratification method is implemented, “cherry-picking” patients may become a significant issue. (See related OrthoBuzz post “Tool for Pre-TJA Risk Stratification.”)
If you are an orthopaedic surgeon who performs LEJR, ask your department head or health system about CJR, because strategies that minimize cost and maximize quality may vary from hospital to hospital. Alignment of hospitals and surgeons is probably the most critical success factor with CJR. To that end, gainsharing— a key component of well-functioning hospital-surgeon partnerships within any bundled-payment environment —for individual orthopaedic surgeons is specifically allowed within the CJR final rule.
Click here for more information, including FAQs and a list of participating areas.
Richard S Yoon, MD is executive chief resident at the NYU Hospital for Joint Diseases.
Alexander McLawhorn, MD, MBA is an arthroplasty fellow at the Hospital for Special Surgery.
Ample research has revealed that a patient’s psychological status influences the outcomes of many medical interventions. While orthopaedists treating patients with multiple-system orthopaedic trauma might not think first of the patient’s mental health, they should definitely take it into account, according to a prognostic study by Weinberg et al. in the March 2, 2016 Journal of Bone & Joint Surgery.
The study found that depression was an independent predictor of increased complications among 130 polytrauma patients who had preexisting psychiatric disorders. The authors also found that, relative to patients managed by a general trauma surgery service, those managed by an orthopaedic surgery service were less likely to receive their home psychiatric medications while hospitalized and were less likely to receive instructions for mental-health follow-up upon discharge. The findings prompt the authors to encourage “awareness of [psychiatric] comorbidities during the treatment of orthopaedic conditions, the involvement of mental health-care providers in care, and the arrangement for meaningful mental health follow-up at the time of discharge.”
In her commentary on the Weinberg et al. study, Margaret McQueen, MD not only concurs with the authors’ admonitions, but adds that “we should control for psychiatric distress in our outcome measures to define the effect of surgical treatment more accurately.”
Whether and when to surgically treat injuries to the anterior cruciate ligament (ACL) remain difficult questions for patients, doctors, and physical therapists to answer.
On Wednesday, March 30, 2016 at 12:30 pm EDT, a complimentary webinar, hosted jointly by JBJS and the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), will arm orthopaedists and physical therapists with up-to-date information to help ensure the best possible clinical decisions for patients with ACL injuries.
Hege Grindem, PT PhD, will present the JBJS paper, “Nonsurgical or Surgical Treatment of ACL Injuries,” and Vincent Eggerding, MD, will present the JOSPT systematic review, “Factors Related to the Need for Surgical Reconstruction After ACL Rupture.”
Moderated by JBJS Deputy Editor Robert Marx, MD, the webinar will include additional perspectives on these clinical questions from three ACL
experts, Daniel Whelan, MD, Lynn Snyder-Mackler, PT, ScD, and Lars Engebretsen, MD.
In the March 2, 2016 edition of JBJS, Rongen et al. air some dirty laundry regarding the orthopaedic community’s registering and reporting on randomized controlled trials (RCTs). According to the authors, only 25% of 362 RCTs published in the top-ten orthopaedic journals between January 2010 and December 2014 were reported as having been registered. Furthermore, of those 25%, only 47% were registered before the end of the trial, and only 38% of those 25% were registered before the enrollment of the first patient, as specified by the International Committee of Medical Journal Editors (ICMJE).
Additionally disheartening is the finding that among the 26 trial reports that the authors deemed eligible for evaluation of consistency between the registered outcome measure(s) and outcomes reported in the published article, 14 (54%) were found to have one or more outcome-measure discrepancies.
Let us re-commit collectively to meeting the timely registration standards required by federal payors such as the NIH and encouraged by the ICMJE. Doing so will ultimately improve the care of patients who have the conditions we study. In general, orthopaedic surgeons are leaders among the surgical specialties when it comes to initiatives that improve patient care. But adequate trial registration and prevention of selective outcome reporting are areas where we are behind the curve, and we need to fix that ASAP. As Rongen et al. emphasize, improvement will require the “full involvement of authors, editors, and reviewers.”
Marc Swiontkowski, MD
Increasingly, the care of patients with musculoskeletal problems is being provided by teams of providers with varied professional backgrounds and diverse types of experience.
On March 1, 2016, JBJS Reviews presented its inaugural “team approach” article, entitled “Treatment of Head and Neck Injuries in the Helmeted Athlete,” by Diduch et al.
The article summarizes updated recommendations for on-field and in-hospital injury evaluation, spine-boarding, and equipment removal. Throughout, the authors stress that initial and follow-up steps in the process are a team effort that may involve the athletic trainer, team physician, EMS provider, and emergency, orthopaedic, and primary-care physicians.
Insisting that team collaboration should begin prior to any athletic competition or event, the authors strongly recommend preseason training and pregame time-outs for all members of the sidelines medical team to clarify roles, responsibilities, and communication strategies.
Diduch et al. also discuss in detail the team approach to concussion evaluation and management, including team-based decisions about the need for and destination of emergency transport.