Fracture liaison services and similar coordinated, multidisciplinary fragility-fracture reduction programs for patients with osteoporosis work (see related OrthoBuzz posts), but until now, the data corroborating that have come from either academic medical centers or large integrated health care systems. The November 7, 2018 issue of The Journal of Bone and Joint Surgery presents solid evidence from a retrospective cohort study that a private orthopaedic practice-based osteoporosis management service (OP MS) also successfully reduces the risk of subsequent fragility fractures in older patients who have already sustained one.
Sietsema et al. collected fee-for-service Medicare data for Michigan residents who had any fracture from April 1, 2010 to September 30, 2014 (mean age of 75 years). From that data, they compared outcomes for patients who received nurse-practitioner-led OP MS care from a single-specialty private orthopaedic practice within 90 days of the first fracture to outcomes among a propensity-score-matched cohort of similar patients who did not receive OP MS care. There were >1,300 patients in each cohort, and both groups were followed for an average of 2 years. The private practice’s OP MS services incorporated the multidisciplinary protocols promulgated by the American Orthopaedic Association’s “Own the Bone” program.
The cohort exposed to OP MS had a longer median time to subsequent fracture (998 versus 743 days), a lower incidence rate of any subsequent fracture (300 versus 381 fractures per 1,000 person-years), and higher incidence rates of osteoporosis medication prescriptions filled (159 versus 90 per 1,000 person-years). Over the first 12 months of the follow-up period, total medical costs did not differ significantly between the 2 cohorts.
These findings are consistent with those reported from academic or integrated health-system settings. According to the authors, this preponderance of evidence “emphasize[s] the importance of coordinated care in reducing subsequent fractures, lengthening the time to their occurrence, and improving patient outcomes.” Sietsema et al. conclude further that “the U.S. Medicare population would benefit from widespread implementation of such models in collaboration with orthopaedic providers and payers.”
It is well established that obese patients who undergo total joint arthroplasty have increased risks of complications and infections. But what about folks who are not obese, but are just generally large? Do they also have increased post-arthroplasty complications, compared to their smaller counterparts? That is the question Christensen et al. explored in a registry-based study in the November 7, 2018 edition of JBJS.
In addition to BMI, the authors examined 3 other physical parameters—body surface area, body mass, and height—to determine whether these less-studied characteristics (all contributing to “bigness”) were associated with an increased rate of various adverse outcomes, including mechanical failure and infection, after primary total knee arthroplasty (TKA). They evaluated data from more than 22,000 TKAs performed at a single institution and found that the risk of any revision procedure or revision for a mechanical failure was directly associated with every 1 standard deviation increase in BMI (Hazard Ratio [HR], 1.19 and 1.15, respectively), body surface area (HR, 1.37 and 1.35, respectively), body mass (HR, 1.30 and 1.27, respectively), and height (HR, 1.22 and 1.23, respectively). In this study, 1 standard deviation was equivalent to 6.3 kg/m2 for BMI, 0.3 m2 for body surface area, 20 kg for body mass, and 10.5 cm for height.
These findings, while not all that surprising, are enlightening nonetheless. The study shows that increasing height has a greater negative impact on TKA outcomes than previously thought. While I spend a lot of time counseling patients with high BMIs about the increased risks of undergoing a TKA (and while such patients can take certain actions to lower their BMI prior to surgery), I do not spend nearly as much time counseling patients who are much taller than normal about their increased risks (and height is not a modifiable risk factor). Nor do I spend much time thinking about a patient’s overall body mass or body surface area in addition to their BMI. This study will remind me not to overlook these less commonly examined physical parameters when discussing TKA with patients in the future.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
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 November 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Does Health Care Utilization Before Hip Arthroscopy Predict Health Care Utilization After Surgery in the US Military Health System? An Investigation Into Health-Seeking Behavior.”
This observational cohort study found that patients who used more health care prior to hip arthroscopy also used more health care after surgery. The findings lead the authors to conclude that clinicians “should consider prior patterns of health care utilization…when determining care plans and prognosis.”
Experienced orthopaedic clinicians understand that anxious patients with high levels of pain are some of the most challenging to evaluate and treat. Both anxiety and pain siphon away the patient’s focus and concentration, complicating the surgeon’s job of relaying key diagnostic and treatment information—often leaving patients confused and dissatisfied. Moreover, such patients usually want a quick solution to their physical pain and mental angst, whether that be a prescription for medication or surgery. At the same time, despite controversy, variously defined levels of “patient satisfaction” are being used as a metric to evaluate quality and value throughout the US health-care system. This reinforces the need for orthopaedists to understand the complex interplay between biological and psychological elements of patient encounters.
In the November 7, 2018 issue of The Journal, Tyser et al. use validated instruments to clarify the relationship between a patient’s pre-existing function, pain, and anxiety and the satisfaction the patient received from a new or returning outpatient visit to a hand/upper extremity clinic. Not surprisingly, the authors found that higher levels of physical function prior to the clinic visit correlated with increased satisfaction after the visit, as measured by the widely used Press Ganey online satisfaction survey. They also noted that higher antecedent levels of anxiety and pain, as determined by two PROMIS instruments, correlated with decreased levels of patient satisfaction with the visit. The authors assessed patient satisfaction only with the clinic visit and the care provider, not with any subsequent treatment.
Most patients are likely to experience some level of pain or anxiety when they meet with an orthopaedic surgeon. To leave patients more content with these visits, we need to set appropriate expectations for the visit in advance of the interaction and develop real-time, in-clinic strategies that help patients cope with anxiety. Such “biopsychosocial” strategies may not by themselves dictate the ultimate treatment, but they may go a long way toward helping patients understand their options and feel satisfied with the care provided. Secondarily, such strategies may help improve the satisfaction scores that administrators, rightly or wrongly, are increasingly using to evaluate musculoskeletal practitioners.
Marc Swiontkowski, MD
On Wednesday, November 14, 2018 at 8:00 PM EST, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from five orthopaedists with an impressive track record of success in meeting this challenge head-on:
- Regis O’Keefe, MD, PhD, FAOA
- Mary O’Connor, MD, FAOA
- Julie Samora, MD, PhD, MPH
- Kristy Weber, MD, FAOA
- Lisa Lattanza, MD, FAOA
Recognizing the lack of diversity in the profession of orthopaedics as a critical issue, this webinar is one of many AOA initiatives supporting increased diversity within the profession.
Seats are limited, so REGISTER NOW.