In May, more than 300 orthopaedic surgeons attended the National Orthopaedic Leadership Conference in Washington, DC. During the conference, attendees took time to recognize the success of the AAOS Project Value initiative, which was started by former AAOS president John R. Tongue, MD. The initiative’s project team set out to quantify the social and economic benefits of musculoskeletal health care.
Four studies have been published as a result of this effort, three of which were published in JBJS:
- “The Direct and Indirect Costs to Society of Treatment for End-Stage Knee Arthritis,” JBJS, August 21, 2013. This article estimated that TKA has already generated lifetime societal savings to the U.S. economy of $12 billion.
- “Societal and Economic Impact of Anterior Cruciate Ligament Tears,” JBJS, October 2, 2013. Analysis found estimated annual savings from ACL reconstruction of $10 billion.
- “The Societal and Economic Value of Rotator Cuff Repair,” JBJS, November 20, 2013. Estimated lifetime savings to the U.S. economy were calculated to be $3.44 billion.
- “How Does Accounting for Worker Productivity Affect the Measured Cost-Effectiveness of Lumbar Discectomy?” Clinical Orthopaedics and Related Research, December 2013.
AAOS also hosts a website to highlight the notion of value in orthopaedics: www.ANationInMotion.org/value.
Kaiser Health News and the Chicago Tribune recently collaborated on a story that led with the following observation: “When America’s joint surgeons were challenged to come up with a list of unnecessary procedures in their field, their selections shared one thing: none significantly impacted their incomes.”
The comment refers to the five items on the AAOS-approved Choosing Wisely list of orthopaedic-related procedures that physicians and patients should discuss and question (see the related OrthoBuzz item from Feb. 26, 2014).
Orthopaedists are not alone in this allegedly income-protecting tactic: “Some of the largest medical associations selected rare services or ones that are done by practitioners in other fields and will not affect their earnings,” the article stated.
For example, the Choosing Wisely list developed by the North American Spine Society (NASS) does not include spinal fusion, a controversial but lucrative procedure. “What we did when we made up the list was to start with more straightforward situations and hopefully expand that later,” said NASS board member F. Todd Wetzel in the article. That explanation makes some sense, considering that the evidence base for many tests and procedures—orthopaedic and otherwise—is equivocal.
Ultimately, the best decisions are made on a patient-by-patient basis, and the patient’s role in the Choosing Wisely campaign can’t be overemphasized. It’s about having a rational and respectful two-way conversation when a patient insists on having a certain test because his or her friend with the same symptoms had that test—or when a physician strongly recommends a certain procedure, the risks and benefits of which the patient doesn’t understand.
While it’s hard not to agree with Morden et al. in their NEJM Perspective piece (Feb. 13, 2014) that “more numerous and more courageous lists should be developed,” patient-education efforts must be ramped up because culling out low-value tests and procedures from the health care system should not and cannot solely be the responsibility of physicians.
Research reported at the 2014 AAOS Annual Meeting concluded that universal neuromuscular training for young athletes can be an effective and inexpensive way to avoid ACL sprains and tears. The research also found that screening tools, such as isokinetic tests to identify neuromuscular deficits, may reduce ACL injuries among high-risk athletes.
The modeling study evaluated a hypothetical cohort of 10,000 student athletes ages 14 to 22. Universal training reduced the incidence of ACL injury by 63%, while the screening program for at-risk athletes reduced the incidence rate by 40%. The study concluded that universal training would save an average of $275 per player per season when compared to estimated ACL reconstruction costs.
“Use of both preventative measures and screening tools sounds appealing, but often there are significant financial, administrative and social hurdles that have to be overcome before they can be implemented on a widespread level,” cautioned lead study author Eric F. Swart, MD, an orthopaedic resident at Columbia University Medical Center in New York.
For more information, read here: http://m.prnewswire.com/news-releases/universal-neuromuscular-training-reduces-acl-injury-risk-in-young-athletes-250280401.html
By a vote of 64 to 35, the US Senate approved a one-year “patch” of the current SGR-based Medicare payment formula, rather than entirely replacing the flawed system. President Obama signed the bill, which provides a 0.5% increase in physician Medicare reimbursements for the rest of 2014.
It’s the 17th such temporary stopgap Congress has passed over the last 11 years, and it came despite staunch opposition to another short-term “doc fix” by many physician groups, including the AMA and the AAOS. When the House passed the same measure a week earlier, AAOS president Frederick Azar, MD, said he was “profoundly disappointed.”
There was a last-ditch but unsuccessful effort by Senate Finance Committee chairman Ron Wyden (D-Oregon) to get his colleagues to vote on a permanent repeal of the SGR formula. Had Congress not acted at all, a 24% cut in Medicare reimbursements would have taken effect April 1, 2014. Previous patch votes have been accompanied by congressional promises to use the reprieve to hammer out a bipartisan deal to pay for a permanent SGR repeal. That has never happened, and few are optimistic that it will happen this year.
As physicians are swallowing the bitter pill of another SGR patch, some are relieved with another stipulation in the bill: a one-year delay in the implementation of the ICD-10 code set until at least Oct. 1, 2015. The AMA recently estimated that implementing the new, more complex code set could cost small practices up to $225,000, and last July the AAOS supported a bill to stop the transition to ICD-10 so physicians could develop an appropriate alternative. Another provision in the new bill gives the secretary of Health and Human Services permission to address “misvalued codes” used in the Medicare physician fee schedule.
According to Thomas Barber, MD, chair of the AAOS Council on Advocacy, “The delay in ICD-10 implementation may provide temporary relief for some, but the importance of a permanent SGR policy together with the harmful misvalued codes provision in this patch greatly outweigh any benefits.”
Read a summary of the bill’s provisions here: http://www.massmed.org/Advocacy/Key-Issues/Medicare/Summary–Protecting-Medicare-Access-Act-of-2014/#.UzrNkqJ0lyI
Orrin Franko, MD is a fifth-year orthopaedic surgery resident at University of California, San Diego. He has an interest in researching and promoting the orthopaedic uses of social media and mobile apps. In addition to multiple publications on these subjects, Dr. Franko is the founder and creator of TopOrthoApps.com, a website that reviews mobile apps for orthopaedic surgeons. We appreciate his willingness to answer a few questions for OrthoBuzz.
JBJS: Looking back on this year’s AAOS Annual Meeting in New Orleans, what were some of the highlights for you?
Dr. Franko: I was impressed by the combination of traditional posters, digital videos, and presentations. With regard to mobile technology, I was pleasantly surprised to see such a dramatic increase from just two years ago. This year I saw four posters that developed or validated a smartphone or tablet app for clinical use and patient care, something that I have never seen before. On the exhibit floor, iPads are now a ubiquitous platform for displaying education about products, and many new products integrate wireless capabilities and iPad functionality directly into their use.
JBJS: You presented several times in the Electronic Skills Pavilion at AAOS. Tell us a bit about the sessions and the audience response.
Dr. Franko: The Electronic Skills Pavilion provides a unique presentation opportunity for surgeons to give 45-minute talks on a variety of technology-related topics such as social media, practice websites, search engine optimization, and digital photography and videography. This year, I gave three talks on using mobile apps (iPad and iPhone) for education, patient information, and practice enhancement. The talks were very well attended, which suggests to me that surgeons are eager to learn how to use technology to improve their practice and efficiency.
JBJS: How have you seen the attitudes of orthopaedic surgeons toward mobile technology and apps change over the past 3 years?
Dr. Franko: The past 3 years have shown a clear up-trend in the prevalence and use of apps in hospitals and clinics among both residents and surgeons. This is reflected not only in my personal experience, but also in various studies that have assessed mobile-device usage among all physicians and specifically among orthopaedic surgeons. Using a phone in the hospital is no longer a distraction; it’s a critical educational device.
JBJS: What would you say to orthopaedists who are concerned about HIPAA compliance when using apps?
Dr. Franko: HIPAA will always be a “hot topic” with regard to mobile and wireless devices. This stems from a combination of fear about new technologies that are not well understood, and from the learning curve associated with the introduction of any new technology. First, I would remind everyone that historical medical documentation and care utilized paper charts, standard phone lines, fax machines, and text pagers—none of which are encrypted or HIPAA-compliant. In contrast, mobile devices, text messages, phone calls, and email are much more easily encrypted and protected from data breaches.
Admittedly, these systems are not perfect and never will be. However, if appropriate steps are taken to reduce risks, most hospitals permit the use of all these devices. Generally speaking, surgeons should be aware of patient information that is stored directly on their device versus “in the cloud” (on a remote server at another location). And, if information is stored in the cloud, this should be encrypted at a minimum. I equate the current status of mobile technology for patient care to the off-label use of FDA-approved medical devices: as long as surgeons are aware of how these new technologies work and take measures to protect their patients while working within the restrictions of their hospitals, they should be able to safely implement information technologies that benefit their patients.
JBJS: How do you think JBJS can best address the needs of orthopaedic residents?
Dr. Franko: I think JBJS is taking important steps to address residents’ needs to obtain reliable, peer-reviewed orthopaedic information. As a result of Google, the current generation of residents is accustomed to free, unlimited, and contextually searchable information without delay. This is in stark contrast to searching for archived journal articles on library shelves. By providing fully searchable article titles and full text with the ability to download PDFs for offline viewing, JBJS allows residents to find the information they need when it’s needed. Whether this is provided via a traditional website or via a mobile app is a decision of the journal, but mobile apps have proven to be efficient and reliable tools for journal reading.
(Editor’s note: The recent launch of JBJS Reviews included a free app for use with iOS and Android devices.)
JBJS: What trends in orthopaedics are you most intrigued by?
Dr. Franko: I am most intrigued by the ability to engage patients in the mobile sphere and help them to be participants in their own care. The increase in medical knowledge is true not only for residents and surgeons, but also for patients. Our patients have the ability to learn more about their diseases and potential treatment options than ever before, and they present to our clinics and hospitals with sophisticated questions and expectations about their care. I would like to see technology bridge the gaps between physicians and patients with regard to education and outcomes, while also potentially collecting useful data that can help guide further treatment.
JBJS: Looking ahead to the next 20 years, what three significant advances or changes in orthopaedics do you foresee?
Dr. Franko: While I cannot predict the future, I am hopeful that we will see technology enhance three specific areas of orthopaedic surgery. First, I expect to see drastic changes in resident education that utilize a combination of new technologies to disseminate orthopaedic information. That will include interactive digital journal club discussions, video and web-cast surgical techniques, online board-preparation courses, and curriculum changes that accommodate new work-hour restrictions. Second, I anticipate that medical record digitization will no longer be a burden and will rather demonstrate its potential benefits by improving clinical efficiency, patient safety, and enhancing outcomes research. Third, I am interested in watching the transition to universal healthcare and its impact on healthcare economics and ultimately patient outcomes. This will, in turn, greatly influence practice models and surgeon compensation for my generation of surgeons. That, in turn, will affect the way medical advances are developed and introduced into the field.
JBJS: What is your favorite thing about your profession?
Dr. Franko: The patients. Every day I have the opportunity to help people who are deeply motivated to improve and return to activity, which motivates me to help them in any way possible. My second favorite aspect of my profession is having such diverse and open-minded colleagues who are both exceptional clinicians as well as researchers. As a result, there has been great interest in studying the utility of new technology for the benefit of patient care.
The Choosing Wisely campaign seeks to bring more awareness to tests and procedures that should be discussed between physicians and patients. The campaign was spearheaded by the ABIM Foundation, and the American Academy of Orthopaedic Surgeons (AAOS) partnered with the campaign to develop a list of the five things physicians and patients should question.
- Avoid performing routine post-operative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.
- Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.
- Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.
- Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.
- Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief.
The list was developed after review of approved clinical practice guidelines and included input from specialty society leaders.
Here are a few excerpts from the JBJS conversation with Dr. Jo Hannafin, President of AOSSM (American Orthopaedic Society for Sports Medicine).
JBJS: You were recently elected the first woman president of AOSSM – what significance do you see in that fact?
Dr. Jo Hannafin: My election to the AOSSM presidency reflects the breadth of membership in the AOSSM and the slowly changing face of orthopaedic surgery. Our goal as educators and surgeons is to bring the best and brightest medical students into our field and this includes men, women and individuals with diverse racial and ethnic backgrounds.
JBJS: What are your key goals for your presidency?
Dr. Jo Hannafin: My goals as president are to increase engagement of the membership in the AOSSM via volunteerism (committee involvement), attendance at specialty day and the annual meeting, and by providing continued opportunities for community education by our members via the STOP Sports Injury program started by Dr. James Andrews.
JBJS: How do you think JBJS can best address the needs of the members of AOSSM and other sub-specialty organizations?
Dr. Jo Hannafin: JBJS can address the needs of orthopaedic surgeons by partnering in webinar programs and by continuing to publish high quality manuscripts in subspecialty areas.
JBJS: What trends in orthopaedics/sports medicine are you most intrigued by?
Dr. Jo Hannafin: The identification of biomarkers with early association with trauma or sports injury has the potential to modify the development of post-traumatic arthrosis. This idea is particularly compelling in sports injuries such as the acute ACL. The frequency of this injury continues to increase, and we are seeing younger athletes sustaining this injury. The continued attention to the development and validation of injury prevention programs provides opportunity for risk modification.
The use of biologic therapy in sports medicine, such as stem cell transplantation and PRP, may have the potential to treat sports injuries, but the clinical use of these treatments needs to be carefully studied and validated.
JBJS: What at are your expectations of changes to come as a result of the Affordable Care Act (ACA)?
Dr. Jo Hannafin: The ACA is an extraordinarily complex document and quite honestly, with a few exceptions, I don’t think we know what it will bring. The ACA will provide health insurance to a large number of previously uninsured or uninsurable people (those with pre-existing conditions). The volume of patients seeking care will increase, and that has the potential to stress the existing system. Reimbursement for orthopaedic care will likely be modified and requires the careful attention of our members, hospital systems, specialty organizations, and the AAOS.
JBJS: Looking ahead to the next 20 years or so, what do you think might be three significant advances or changes in orthopaedics?
Dr. Jo Hannafin: I anticipate that scientists will be able to identify biomarkers associated with acute injury and physicians/surgeons will have the capacity to modify the response to catabolic agents, thus preventing the development of post-traumatic arthrosis. The field of biomechanical engineering will provide surgeons with improved scaffolds which when combined with biologic therapies will permit restoration of bone, cartilage, and ligaments. The field of total joint arthroplasty will benefit from continued interaction with scientists to optimize interface mechanics and prolong the lifetime of arthroplasty implants.
JBJS: You recently participated in a webinar co-sponsored by JBJS and JOSPT. Do you see benefits from greater teamwork among different types of health-care providers? If so, what are the most important benefits? What barriers remain to greater collaboration?
Dr. Jo Hannafin: Teamwork and interaction between providers of musculoskeletal care will continue to grow and will be necessary as the volume of patients treated increases. We need to define the scientific benefits of conservative and surgical treatments for musculoskeletal conditions, and this will require interactions between scientists, physicians, surgeons, and physical therapists. The questions posed during the adhesive capsulitis webinar reflected input from both surgeons and physical therapists and helped each group to understand the issues associated with treatment. The ultimate benefit of this interaction is improved patient care, which is important to all of us. The biggest barrier is time!
JBJS: You have recently overcome some serious health issues. It’s great to hear that you are doing well. Has this experience changed the way you approach your patients?
Dr. Jo Hannafin: The last two years of my life have been marked by highs and lows. My election to the presidency of the AOSSM, and the associated opportunities, has been personally and professionally fulfilling. In April 2012 I was diagnosed with early multiple myeloma, which was treated at Dana Farber Cancer Institute with chemotherapy followed by an autologous stem cell transplant. The experience was the most difficult challenge that I have faced but I received incredible support from family, friends, patients and AOSSM colleagues from across the country. I am happy to report that my health is excellent and I have been back to a normal schedule for almost one year. The experience reinforced the need for careful and thoughtful communication with our patients.
JBJS: What is your favorite thing about your profession?
Dr. Jo Hannafin: As a sports medicine specialist, I love taking care of athletes and active people of all ages. While many sports related injuries do not require surgery, it is especially gratifying as a surgeon to restore function via repair and reconstruction of injured structures, permitting return to sports or fitness activities.
JBJS: Thank you, Dr. Hannafin for sharing this time with us. We look forward to speaking with you again in the near future.