In a recent OrthoBuzz post, I commented on the apparent benefits to patients when Scottish hip-fracture guidelines were followed. Now, in a “closer-to-home” study in the May 16, 2018 issue of JBJS, Bedard et al. examine the effects of AAOS clinical practice guidelines (CPGs) on the use of injections for knee osteoarthritis (OA). The authors used an insurance database housing more than 1 million knee OA patients to evaluate the change in rates of corticosteroid and hyaluronic acid injections from 2007 to 2015. This date range includes the periods before and after the publication of the AAOS CPGs for knee arthritis (both the first edition, published in early 2009, and the second edition, published in late 2013).
The authors found that the rate of hyaluronic acid injections by orthopaedic surgeons decreased significantly after both publications of the guidelines and that the utilization of corticosteroid injections appears to have plateaued since the most recently published guidelines. Still, almost 40% of all of the patients in the cohort received a corticosteroid injection, with 13% having received a hyaluronic acid injection. In absolute numbers, those percentages represent more than half a million injections, despite the facts that the evidence supporting either injection for the treatment of knee OA is weak at best and that almost half of the patients receiving one of these injections ended up getting a total knee replacement within a year.
While the changes in practice revealed by Bedard et al. may seem relatively small, they are a step in the right direction toward value-based care. CPGs are easy to pick apart, but they are developed carefully and for a good reason—to provide us with evidence-based recommendations for excellent patient care. It is gratifying to see that such guidelines are having a positive impact in our field.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
It is easy, perhaps even fun (in a cynical way), to discredit clinical guidelines and suggested care pathways for certain orthopaedic diseases. They are often nuanced, may require a significant change to our practice that we find impractical, and may seem to offer little benefit over current practices. Why change when our patients do just fine with how we have always treated them? Well, as Farrow et al. clearly demonstrate in the May 2, 2018 edition of JBJS, we should follow these guidelines and patient care pathways in hip fracture patients ≥50 years old because patients have better outcomes when we do.
The authors found that increased adherence to the Scottish Standards of Care for Hip Fracture Patients (SSCHFP), implemented in Scotland in 2014, led to a >3-fold decrease in patient mortality at 1 month and a 2-fold decrease in mortality at 4 months. High levels of adherence to the SSCHFP also led to shorter hospital stays and decreased odds of discharging patients to high-care settings, such as a skilled nursing facility. This cohort study of data collected from >1,000 patients saw only 8% of the initial population lost to follow-up.
Just as importantly, when the authors ran a multiple regression analysis, they found that no single SSCHFP practice or patient variable was as important as following the total SSCHFP protocol. The authors thus conclude that “the impact of the standards as a whole is greater than the sum of the parts and highlights the importance of a multidisciplinary team approach…” In other words, following the protocol helped improve patient outcomes. Period.
Studies like this by Farrow et al. are important and impactful. Practice guidelines and care criteria are developed with careful attention to the evidence base, but we are just starting to see published data on their effect on outcomes. This makes them difficult to accept because we DO have data (at least anecdotal data) supporting our current practices. It is easier to stick to our known current methods than to adopt new ones, however subtle, that require change and have little accompanying outcomes data. Implementing practice guidelines will always be challenging, but having data such as these showing the power of their effect should help make adoption easier.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Click here to read a press release about this study from the University of Aberdeen.
From the perspective of a geriatric patient with a hip fracture, having a preoperative echocardiogram may not seem like a big deal, especially since it’s a noninvasive test. However, as Adair et al. reveal in an April 19, 2017 JBJS study, following clinical guidelines established by the American College of Cardiology (ACC) and the American Heart Association (AHA) could have prevented “cardiac echoes” from being done in 34% of 100 elderly hip fracture patients without missing any disease. Such unnecessary testing not only adds cost to the health care system, but can also delay surgical treatment for an operation that evidence suggests is best performed within 24 to 48 hours.
A single reviewer blinded to the later results of the tests assessed whether the ACC/AHA guidelines were followed in each case of an ordered echo; when ≥1 of the criteria were met, the echo was considered ordered in accordance with the guidelines. The rate of adherence to the guidelines was 66% over the 3.5-year study period. No important heart disease was found in any of the 34 patients who underwent an echocardiogram that had not been indicated by the guideline criteria, and 14 of the 66 patients (21%) for whom an echo was indicated by the criteria were found to have heart conditions serious enough to modify anesthesia or medical management.
The most common documented reasons for ordering an echo outside the guideline criteria were dementia that prevented evaluation of preoperative cardiac condition and generic “evaluation of cardiac function,” even though those patients had no history, physical exam findings, or work-ups that suggested heart disease.
Adair et al. conclude that these findings “suggest that integration of [clinical practice guidelines] into a perioperative protocol has the potential to improve the efficiency of preoperative evaluation, reduce resource utilization, and reduce the time to surgery without sacrificing patient safety.”
Over the last 10 years, the AAOS has invested a great deal of effort and resources into developing Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria. One rationale for these efforts was to follow the lead of our cardiovascular brethren, who have disseminated the highest level of evidence available to their community to help ensure that clinical decision making, in collaboration with the patient and family, is supported by the most solid science.
The paper published in the October 21, 2015 edition of JBJS by Oetgen et al. provides us with an evaluation of the impact of CPGs in managing femoral shaft fractures in children. The authors performed detailed chart reviews on 361 patients treated for a pediatric diaphyseal femoral fracture between 2007 and 2012. They analyzed each patient record to determine whether age-specific CPGs—which were published for this condition in 2009—were followed.
The results are somewhat discouraging. Oetgen et al. identified little if any impact of the CPG on clinical practice. Is that because surgeons are unaware of these tools? Or do they feel they know better than the literature synthesis at their disposal? Without more research, we will not know the answer to that question, but I suspect that recognition of the utility of CPGs will take a decade at least. I have the impression that younger surgeons are more accepting of the concepts of meta-analysis and levels of evidence as they influence clinical decision making—and as they were utilized to develop CPGs. Waiting longer to make judgments about the impact of CPGs seems appropriate.
There is another factor also. These documents are guidelines, not restrictive formulas. Oetgen et al. emphasize that point in their introduction. Physicians everywhere wish to retain the privilege of making the best educated decision for each patient and family; this fact is partly responsible for the pushback that AAOS leadership received when starting down the CPG path. Additionally, during decision making for children with femoral shaft fractures, parental preferences will play a very strong role, regardless of the guidelines. This reality may ultimately limit efforts to accurately measure the clinical impact of CPGs by analyzing administrative databases.
So let’s give these guidelines a little more time to mature, and let’s give our orthopaedic community more time to become familiar with the utility of these documents. And, above all, let’s not turn guidelines into “cookbook” patterns of clinical decision making. Inputs from the treating physician, patient, and family should always be preeminent.
Marc Swiontkowski, MD