When Medicare’s Comprehensive Care for Joint Replacement (CJR) program was implemented in 2016, the health care community—especially orthopaedic surgeons— had 2 major concerns. First, would the program actually demonstrate the ability to decrease the costs of total joint replacements while maintaining the same, or improved, outcomes? Second, would CJR promote the unintended consequence of participating hospitals and surgeons ”cherry picking” lower-risk patients and steering clear of higher-risk (and presumably higher cost) patients? Both of these questions were at the heart of the study by Barnett et al. in a recent issue of the New England Journal of Medicine.
The authors evaluated hip and knee replacements at 75 metropolitan centers that were mandated to participate in the CJR program and compared the costs, complication rates, and patient demographics to similar procedures at 121 control centers that did not participate in CJR. The authors found significantly greater decreases in institutional spending per joint-replacement episode in institutions participating in the CJR compared to those that did not. Most of these savings appeared to come from CJR-participating institutions sending fewer patients to post-acute care facilities after surgery. Furthermore, the authors did not find differences between centers participating in the CJR and control centers in terms of composite complication rate or the percentage of procedures that were performed on high-risk patients.
While this 2-year evaluation does not provide the level of detail necessary to make far-reaching conclusions, it does address two of the biggest concerns related to CJR implementation from a health-systems perspective. There may be individual CJR-participating centers that are not saving Medicare money or that are cherry picking lower-risk patients, but overall the program appears to be doing what it set out to do—successfully motivating participating hospitals and healthcare facilities to look critically at what they can do to decrease the costs of a joint-replacement episode while simultaneously maintaining a high level of patient care. The Trump administration shifted CJR to a partly voluntary model in March 2018, and I hope policymakers consider these findings if further changes to the CJR model are planned.
Chad A. Krueger, 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.
According to data published in the New England Journal of Medicine in 2011, nearly 15 percent of orthopaedic surgeons are likely to face a medical liability claim each year, and the cumulative likelihood of an orthopaedic surgeon facing such a claim by the age of 45 is 88 percent. In addition to statistics like this that suggest a flawed system, the tort-based medical malpractice system has not proven to deter substandard care or improve patient safety–and neither has the tort-reform approach to improving the existing liability environment.
Alternatives to tort reform may provide a ray of hope. A recent JAMA article summarized what it calls “a welcome influx of creative initiatives that transcend traditional reforms.” The Mello et al. article evaluates nontraditional approaches that were or are being tested during demonstration projects supported by the Agency for Healthcare Research and Quality (ARHQ). The article devotes much of its space to the so-called communication-and-resolution approach pioneered by the Lexington, Kentucky VA hospital and the University of Michigan Health System. The worth-reading article also covers mandatory presuit notification and apology laws, judge-directed negotiation programs, clinical guideline-based safe-harbor laws, and administrative compensation systems.
In a recent AAOS Now article citing possible barriers to widespread implementation of these and other no-fault approaches to medical liability reform, David Sohn, MD, JD, identifies the trial lawyer lobby as probably the biggest political hurdle that needs to be overcome.
When physical therapy or anti-inflammatory medication fails, one popular treatment for leg pain caused by spinal stenosis is a steroid injection. However, according to a recently published , that treatment may be less effective than previously thought. The study found that patients with painful lumbar stenosis who received a combined lidocaine-glucocorticoid injection had about the same pain levels and degree of disability six weeks later than similar patients who were injected with lidocaine alone.
While these findings question the presumed efficacy of adding a glucocorticoid to lidocaine for epidural injection, they do not necessarily mean that all epidural injections for spinal stenosis are ineffective.
NEJM abstract: http://www.nejm.org/doi/full/10.1056/NEJMoa1313265
Some pediatricians have been hesitant to prescribe fluoroquinolone antibiotics such as levofloxacin for children because animal studies have found a risk of cartilage injury. A 5-year follow-up safety study of levofloxacin published recently in Pediatrics compared the safety of levofloxacin with a comparator antibiotic in more than 200 children. The number of musculoskeletal adverse events that were “possibly” related to the drugs was very low and essentially the same in both groups. This led the researchers to conclude that “the risks of cartilage injury with levofloxacin appear to be uncommon, are clinically undetectable during 5 years, or are reversible.” In a NEJM Journal Watch commentary on the study, Deborah Lehman, MD said these findings provide at most “a lack of endorsement of the fluoroquinolone-associated musculoskeletal problems seen in preclinical studies.” She adds that the study was limited by the fact that only half of the patients completed the planned 5-year follow up.