Many surgeons realize that to improve value, we must improve the quality of care while decreasing its cost. Clinical Practice Guidelines (CPGs) developed by the AAOS and other medical societies are designed to help improve the quality of care and safety for patients, while also reducing inappropriate care and decreasing cost. Unfortunately, the evidence used for the development of CPGs is often of mixed quality. It is therefore crucial that studies evaluate patient outcomes when clinicians do and do not adhere to CPGs, so we can ensure that the guidelines are achieving their objective of improving care.
In the October 16, 2019 issue of The Journal of Bone and Joint Surgery, Giladi et al. hypothesize that adhering to Recommendation 3 of the AAOS CPG regarding radiographic indications for operative management of distal radial fractures would yield improved patient outcomes and cost benefits. Recommendation 3 of the CPG suggests that fractures with post-reduction radial shortening of >3 mm, dorsal tilt of >10°, or intra-articular displacement or step-off of >2 mm should be operatively treated. The authors retrospectively reviewed 266 patients, 145 of whom were treated operatively and 121 of whom were treated nonoperatively. Based on the guideline recommendation, only 6 patients were determined to have undergone inappropriate operative fixation, but 68 patients in the nonoperative cohort received inappropriate treatment; many of those had higher-grade fractures that, per the guideline, should have been surgically treated.
Using QuickDASH outcome scores at 4 time points up to 1 year and 1-year direct cost data, the authors compared the appropriately treated operative cohort to both the appropriate and inappropriate nonoperative groups. They also compared the appropriate and inappropriate nonoperative groups to each other. QuickDASH outcomes for appropriate nonoperative treatment were better than those for inappropriate nonoperative treatment at 1 year. In addition, inappropriate nonoperative treatment cost 60% more than appropriate nonoperative treatment. Although this cost comparison did not reach statistical significance, (p=0.23), it does suggest a cost savings with adherence to the CPGs. Appropriately treated operative patients reported less disability than the inappropriately nonoperative group.
As we continue to work at increasing health-care value, it is critical that we review CPGs in action, as Giladi et al. have done in this study. A potential next step would be to investigate whether the modest improvements in QuickDASH scores noted between appropriate operative treatment and inappropriate nonoperative treatment justify the 6-fold higher cost of operative treatment.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
A “Clinical Therapeutics” article in the March 12, 2015 New England Journal of Medicine focuses on viscosupplementation for knee osteoarthritis (OA). In presenting a case vignette and making a therapeutic recommendation, Australian author David Hunter, MB, PhD, invokes the old, 2008 AAOS clinical practice guideline (CPG), which, according to Dr. Hunter, “determined that the evidence was inconclusive and a recommendation could not be made for or against the use of intraarticular hyaluronate.” However, the AAOS updated CPGs for knee OA in 2013, and the guideline for viscosupplementation changed substantially. It now reads: “We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee,” and that recommendation receives a “Strong” rating, based on evidence from more recent research studies.
In the end, the patient in the case vignette—a 67-year-old woman with knee pain, radiographic signs of knee OA, and a BMI of 32—was advised not to use hyaluronate injections and instead was encouraged to lose weight and undertake a muscle-strengthening exercise program.