Orthopedics

Summary by Website Contributor Guy Guenthner

 

Orthopedic surgery practice includes high volume clinics, expensive, often elective surgical procedures, and outcomes based largely on patients’ functional status. In addition, orthopedic surgery serves a diverse patient population that spans all ages, ethnic backgrounds, and socioeconomic statuses. All of these characteristics represent opportunities for orthopedics to be substantially impacted when considering pay-for-performance models. Extensive research has therefore been conducted to identify specific concerns regarding the impact of P4P of orthopedic surgery.

Defining “value” in orthopedics and evaluating patient satisfaction are key areas of current research as summarized in Goldman (454). An extension of this research has investigated how best to measure patient outcomes (Freehill (456), Makhni (483), Lizzio (484)) and how to reduce risks that may impact orthopedic surgeons in a P4P system (Chotai (485), Edelstein (457), Regan (458), Bhattacharyya (460)). There have been concerns over how P4P may impact treatment decisions (Ihejirika (482)) and individual physicians, specifically in the orthopedic trauma setting (Morris (455)). However, there has also been promising research suggesting P4P models may lower the rate of post-operative complications for certain orthopedic patient populations (Tsai (461)).

 

Orthopedics Literature

(185) Bhattacharyya T, Mehta P, Freiberg AA. Hospital Characteristics Associated with Success in a Pay-for-Performance Program in Orthopedic Surgery. Journal of Bone and Joint Surgery. 2008: 90 1240-1243.

PMID: 18519316

Summary:

  • Analysis of hospital characteristics associated with success in the CMS/Premier Hospital Quality Incentive Demonstration for total hip and knee arthroplasty.
  • Top performing hospitals were located in the Midwest and were teaching hospitals. Meanwhile, the size of the hospital and revenue were not associated with top performance in hip and knee replacements.
  • Orthopedic specialization was the strongest predictor of top performance.

Significance to Literature:

Hospitals that are more capable of specializing will perform better on performance measures related to specialty fields.

 

 

(441) Kamal RN1; Hand Surgery Quality Consortium. Quality and Value in an Evolving Health Care Landscape. J Hand Surg Am. 2016 Jul;41(7):794-9. doi: 10.1016/j.jhsa.2016.05.016.

PMID: 27374791

Summary:

  • The focus on how to define and measure quality while providing cost-efficient care has recently been increasing in orthopedics with the implementation of patient-reported outcome measures to evaluate total joint arthroplasty by hip and knee surgeons
  • However, the author argues that hand surgery is unique within orthopedic subspecialties
    • Hand surgery is heterogeneous with general, orthopedic, and plastic surgeons all treating patients “from the shoulder to the fingertips”
    • A wide variety of procedures makes it difficult to come up with the clinically-relevant “cross-cutting” outcome measures payers ask for
    • There is strong influence of psychosocial factors  and coping strategies on patient-reported outcomes in hand surgery as symptoms and limitations may still persist
  • As hand surgeons prepare for value-based health care they should ask:
    • How do we balance adopting innovative payment models without affecting research efforts?
    • How do we leverage a value-based model to benefit all stakeholders?
    • How do we best use value-based incentives to motivate research and quality improvement without potentially devaluing the physician-patient relationship?

Significance to Literature:

“Appreciating the limitations to using patient-reported outcomes in hand surgery can ensure hand surgery is appropriately assessed in novel payment models”

 

 

(454) Goldman, A. H., & Kates, S. (2017). Pay-for-performance in orthopedics: How we got here and where we are going. Current Reviews in Musculoskeletal Medicine, 10(2), 212-217.

PMID: 28389971

Summary:

  • Review of 2013-2016 literature regarding how the P4P is shaping orthopedics
  • Identified “value” in orthopedics as a critical issue to be defined
  • Accurate risk calculators are needed for specific orthopedic procedures like Total Joint Arthroplasty
  • Patient satisfaction plays a large role in P4P rubrics, and satisfaction can be influenced by demographic factors out of the control of the treating physician

Significance to Literature:

As P4P is implemented in orthopedics, value of care, quality/risk stratification, and patient satisfaction are key areas of current research.

 

 

(455) Morris, B. J., Richards, J. E., Archer, K. R., Lasater, M., Rabalais, D., Sethi, M. K., et al. (2014). Improving patient satisfaction in the orthopaedic trauma population. Journal of Orthopaedic Trauma, 28(4), e80-4.

DOI: 24158181

Summary:

  • Orthopedic trauma patient satisfaction difficult to accurately assess given high acuity traumatic injuries inhibiting ability to form patient-physician rapport
  • Studied impact of providing patients with attending orthopedic trauma surgeon biosketch card including picture, brief synopsis of educational background, specialty, surgical interests, and research interests
  • Patients receiving biosketch card of his or her attending orthopedic surgeon showed significant improvements in patient satisfaction

Significance to Literature:

Attending physician biosketch cards can increase inpatient satisfaction in an orthopedic trauma patient population.

 

 

(456) Freehill, M. T., Mannava, S., & Safran, M. R. (2014). Outcomes evaluation of the athletic elbow. Sports Medicine and Arthroscopy Review, 22(3), e25-32.

PMID: 25077753

Summary:

  • Evaluating orthopedic surgery outcomes in high-level athletic populations is difficult using standard outcome metrics due to good overall health and high baseline function
  • Manuscript reviewed five most clinically relevant outcome measures for sports-related elbow outcomes
  • Kerlan-Jobe Orthopedic Clinic score is the only outcome tool validated for elbow injuries in the overhead athlete

Significance to Literature:

Both validating outcome measures for specific orthopedic interventions (e.g. elbow surgery) and considering elite athlete populations are relevant challenges for P4P models to be successful in orthopedics.

 

 

(457) Edelstein, A. I., Kwasny, M. J., Suleiman, L. I., Khakhkhar, R. H., Moore, M. A., Beal, M. D., et al. (2015). Can the American College of Surgeons risk calculator predict 30-day complications after knee and hip arthroplasty? The Journal of Arthroplasty, 30(9 Suppl), 5-10.

PMID: 26165953

Summary:

  • Risk stratification of total hip (THA) and knee (TKA) arthroplasty patients is essential for accurate P4P assessment
  • ACS-NSQIP universal risk calculator does not predict complications on an individual basis suggesting need for arthroplasty-specific risk calculator to better inform risk adjusted quality comparisons

Significance to Literature:

Current common orthopedic risk calculators are not sufficiently patient specific to be used for total joint arthroplasty risk adjustment in P4P.

 

 

(458) Regan, D. K., Manoli, A.,3rd, Hutzler, L., Konda, S. R., & Egol, K. A. (2015). Impact of diabetes mellitus on surgical quality measures after ankle fracture surgery: Implications for "value-based" compensation and "pay for performance". Journal of Orthopaedic Trauma, 29(12), e483-6.

PMID: 26595598

Summary:

  • Evaluated impact of diabetes mellitus (DM) and associated complications after open reduction internal fixation (ORIF) of an ankle fracture
  • Mean length of stay, in-hospital mortality rates, and total hospital costs were significantly greater for the DM cohort than non-DM cohort following ankle ORIF

Significance to Literature:

Testing the effect of co-morbidities on orthopedic outcome measures can provide risk-adjustment guidance for P4P.

 

 

(459) Shih, T., Nicholas, L. H., Thumma, J. R., Birkmeyer, J. D., & Dimick, J. B. (2014). Does pay-for-performance improve surgical outcomes? an evaluation of phase 2 of the premier hospital quality incentive demonstration. Annals of Surgery, 259(4), 677-681.

PMID: 24368657

Summary:

  • Manuscript evaluated whether 2006 changes in incentive design in P4P program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals
  • Examined discharge data for patients who underwent CABG, hip replacement, and knee replacement
  • Premier HQID did not improve surgical outcomes

Significance to Literature:

P4P models may not improve surgical outcomes.

 

 

(460) Bhattacharyya, T., Iorio, R., & Healy, W. L. (2002). Rate of and risk factors for acute inpatient mortality after orthopaedic surgery. The Journal of Bone and Joint Surgery.American Volume, 84-A(4), 562-572.

PMID: 11940616

Summary:

  • Orthopedic surgeons operate on a diverse patient population, many of which who have ongoing medical problems
  • Study obtained hospital records to identify rate of mortality and evaluate risk factors for mortality after orthopedic surgery
  • Mortality rate was highest in patients older than seventy and 50% of all deaths occurred after operative treatment of hip fractures

Significance to Literature:

Studies identifying mortality risk factors can help risk adjust P4P in orthopedic surgery.

 

 

(461) Tsai, Y. S., Kung, P. T., Ku, M. C., Wang, Y. H., & Tsai, W. C. (2018). Effects of pay for performance on risk incidence of infection and of revision after total knee arthroplasty in type 2 diabetic patients: A nationwide matched cohort study. PloS One, 13(11), e0206797.

PMID: 30388167

Summary:

  • Total knee arthoplasty (TKA) on the rise as worldwide population ages and diabetic patients are known to face greater risks of TKA postoperative infection or revision
  • Investigated if diabetic patient participation in P4P programs influences incidence rate of TKA postoperative infection or revision
  • Joining P4P lowered risk of postoperative infection and significantly lowered the risk of revision
  • Other factors impacting risk of postoperative infection or revision included being young and male, having multiple comorbidities, and receiving care at regional or public hospitals

Significance to Literature:

P4P may lower the rate of post-operative complications for certain orthopedic patient populations.

 

 

(482) Ihejirika, R. C., Sathiyakumar, V., Thakore, R. V., Jahangir, A. A., Obremskey, W. T., Mir, H. R., & Sethi, M. K. (2015). Healthcare reimbursement models and orthopaedic trauma: will there be change in patient management? A survey of orthopaedic surgeons. Journal of orthopaedic trauma, 29(2), e79-e84.

PMID: 24901735

Summary:

  • Researchers hypothesized changing payment models from fee-for-service to fixed payment models (including P4P) would impact treatment decisions and patient care in orthopedic trauma.
  • An electronic survey consisting of 3 orthopedic trauma clinical scenarios was distributed to orthopedic surgeons and each of the three cases was presented in three different healthcare settings
    • Our current healthcare setting
    • Setting in which 90-day reoperation or readmission would not be reimbursed
    • Setting in which capitated healthcare structure paid a fixed amount per patient
  • In each case, there was significant increase in respondents’ choice to transfer patients to tertiary care centers under capitated and penalization systems as compared to current model

Significance to Literature:

  • A healthcare system with readmission penalties or capitated reimbursement models may lead to an may significantly impact physician treatment decisions for complex orthopedic trauma patients.

 

 

(483) Makhni, E. C., Meadows, M., Hamamoto, J. T., Higgins, J. D., Romeo, A. A., & Verma, N. N. (2017). Patient Reported Outcomes Measurement Information System (PROMIS) in the upper extremity: the future of outcomes reporting?. Journal of shoulder and elbow surgery, 26(2), 352-357.

PMID: 28104094

Summary:

  • Patient reported outcomes (PROs) are integral to determine the impact of clinical care in P4P initiatives
  • Certain concerns exist regarding traditional PROs in patients with upper extremity disability and injury including lack of consensus regarding selection of PROs for given diagnoses, inconsistent administration techniques and administrative burdens
  • The NIH has created Patient Reported Outcomes Measurement Information System (PROMIS) to standardize and comprehensively measure outcomes across multiple disease states, including orthopedics.
  • PROMIS measures represent a potential improvement to current practice of measuring PROs.

Significance to Literature:

  • The creation of standardized protocols and systems to measure patient outcomes is an important step in eliminating specialty specific concerns regarding traditional patient reported outcomes.

 

 

(484) Lizzio, V. A., Blanchett, J., Borowsky, P., Meldau, J. E., Verma, N. N., Muh, S., ... & Makhni, E. C. (2019). Feasibility of PROMIS CAT Administration in the Ambulatory Sports Medicine Clinic With Respect to Cost and Patient Compliance: A Single-Surgeon Experience. Orthopaedic journal of sports medicine, 7(1), 2325967118821875.

PMID: 30733973

Summary:

  • Routine patient-reported outcomes (PROs) have recently been replaced by Patient-Reported Outcomes Measurement Information System (PROMIS) to reduce specialty specific concerns over PROs
  • Authors sought to investigate patient compliance with PROMIS in sports medicine clinic
  • Electronic collection resulted in a patient compliance of over 90%, although older patients were generally less compliant than younger patients
  • Compliance rate based on injury showed compliance was significant higher in for hip patients than for shoulder

Significance to Literature:

  • Implementation of patient outcome reporting measures will generally result in high compliance, but may be impacted by patient specific demographics.

 

(485) Chotai, S., Sivaganesan, A., Parker, S. L., Sielatycki, J. A., Archer, K. R., Nian, H., ... & Devin, C. J. (2018). Drivers of Variability in 90-day Cost for Primary Single-level Microdiscectomy. Neurosurgery, 83(6), 1153-1160.

PMID: 29850849

Summary:

  • P4P must account for variability in the cost of index surgeries during the global period
  • Study sought to analyze the drivers of variability in total 90-day cost associated with single-level microdiscectomy
  • Obesity, history of myocardial infarction, length of surgery and hospitalization, complications and readmissions, post discharge healthcare utilization, diagnostic imaging, and number of days of rehabilitation all impact cost of single level microdiscectomy

Significance to Literature:

  • Cost of surgery and the factors influence costs are important to identify in developing P4P models.