Karl M. Koenig

Shared Decision-making in Orthopaedic Surgery

BackgroundThe process of clinical decision-making and the patient-physician relationship continue to evolve. Increasing patient involvement in clinical decision-making is embodied in the concept of “shared decision-making” (SDM), in which the patient and physician share responsibility in the clinical decision-making process. Various patients’ decision aid tools have been developed to enhance this process.Questions/purposesWe therefore (1) describe decision-making models; (2) discuss the different types of patients’ decision aids available to practice SDM; and (3) describe the practice and early impact of SDM on clinical orthopaedic surgery.MethodsWe performed a search of the literature using PubMed/MEDLINE and Cochrane Library. We identified studies related to shared decision-making and the use of patients’ decision aids in orthopaedics. The search resulted in 113 titles, of which 21 were included with seven studies on patients’ decision aid use specifically in orthopaedics.ResultsAlthough limited studies suggest the use of patients’ decision aids may enhance decision-making, conclusions about the use of these aids in orthopaedic clinical practice cannot be made and further research examining the best type, timing, and content of patients’ decision aids that will lead to maximum patient involvement and knowledge gains with minimal clinical workflow interruption are needed.ConclusionIn clinical practice today, patients are increasingly involved in clinical decision-making. Further research on SDM in orthopaedic surgery examining the feasibility and impact on practice, on patients’ willingness and ability to actively participate in shared decision-making, and the timing and type of patients’ decision aids appropriate for use is still needed.

Trends in Utilization and Outcomes of Hip Arthroscopy in the United States Between 2005 and 2013

BACKGROUND The utilization of hip arthroscopy continues to increase in the United States. The purpose of this study was to examine trends in hip arthroscopy procedures and outcomes. METHODS We performed a retrospective cohort study using Optum Labs Data Warehouse administrative claims data. The cohort comprised 10,042 privately insured enrollees aged 18-64 years who underwent a hip arthroscopy procedure between 2005 and 2013. Utilization trends were examined using age-specific, sex-specific, and calendar-year-specific hip arthroscopy rates. Outcomes were examined using the survival analysis methods and included subsequent hip arthroscopy and total hip arthroplasty (THA). RESULTS Hip arthroscopy rates increased significantly over time from 3.6 per 100,000 in 2005 to 16.7 per 100,000 in 2013. The overall 2-year cumulative incidence of subsequent hip arthroscopy and THA was 11% and 10%, respectively. In the subset of patients in whom laterality of the subsequent procedure could be determined, about half of the subsequent hip arthroscopy procedures (46%) and almost all of the THA procedures (94%) were on the same side. Decreasing age was significantly associated with the risk of subsequent arthroscopy (P < .01), whereas increasing age was significantly associated with the subsequent risk of THA (P < .01). The 5-year cumulative incidence of THA reached as high as 35% among individuals aged 55-64 years. CONCLUSION The utilization of hip arthroscopy procedures increased dramatically over the last decade in the 18-64-year-old privately insured population, with the largest increase in younger age-groups. Future studies are warranted to understand the determinants of the large increase in utilization of hip arthroscopy and outcomes.

Advanced Age and Comorbidity Increase the Risk for Adverse Events After Revision Total Hip Arthroplasty

With the institution of quality-assurance parameters in health care, physicians must accurately measure and report the true baseline rates of adverse events (AEs) after complex surgical interventions. To better quantify the risk of AEs for revision total hip arthroplasty (THA), we divided a cohort of 306 patients (322 procedures) into age groups: group I (<65 years, n = 138), group II (65-79 years, n = 119), and group III (≥80 years, n = 65). Ninety-day rates of major AE were 9%, 19%, and 34% in the groups, respectively. Group III had an increased chance of experiencing major AE compared with groups I and II. Age and Charlson Comorbidity Index independently predicted major complications, whereas body mass index, sex, and type of revision did not.

Developing a pathway for high-value, patient-centered total joint arthroplasty.

BackgroundTotal joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed.Questions/purposesThe purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA.MethodsWe used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9).ResultsThe care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level.ConclusionsWe developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation.Level of EvidenceLevel V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Is Early Internal Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures?

BACKGROUND In the treatment of distal radial fractures, physicians often advocate internal fixation over cast treatment for potentially unstable fracture patterns, citing the difficulties of successful nonoperative treatment and a decrease in patient tolerance for functional deficiencies. This study was performed to evaluate whether early internal fixation or nonoperative treatment would be preferred for displaced, potentially unstable distal radial fractures that initially had an adequate reduction. METHODS A decision analytic model was created to compare early internal fixation with use of a volar plate and nonoperative management of a displaced, potentially unstable distal radial fracture with an acceptable closed reduction. To identify the optimal treatment, quality-adjusted life expectancy was estimated for each management approach. Data from the literature were used to estimate rates of treatment complications (e.g., fracture redisplacement with nonoperative treatment) and of treatment outcomes. Mean health-state utilities for treatment outcomes of painless malunion, functional deficit, and painful malunion were derived by surveying fifty-one adult volunteers with use of the time trade-off method. Sensitivity analysis was used to determine which model parameters would change the treatment decision over a plausible range of values. RESULTS Early internal fixation with volar plating was the preferred strategy in most scenarios over the ranges of parameters available, but the margins were small. The older patient (mean age, 57.8 years) who sustains a distal radial fracture can expect 0.08 more quality-adjusted life years (29.2 days) with internal fixation compared with nonoperative treatment. Sensitivity analysis revealed no single factor that changed the preferred option within the reported ranges in the base case. However, the group of patients sixty-five years or older, who had lower disutility for painful malunion, derived a very small benefit from operative treatment (0.01 quality-adjusted life year or 3.7 days) and would prefer cast treatment in some scenarios. CONCLUSIONS Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature. This long-term gain in quality-adjusted life years outweighed the short-term risks of surgical complications, making early internal fixation the preferred treatment in most cases. However, the difference was quite small. Patients, especially those over sixty-four years old, who have lower disutility for the malunion and painful malunion outcome states may prefer nonoperative treatment.

Predictors of Facility Discharge, Range of Motion, and Patient-Reported Physical Function Improvement After Primary Total Knee Arthroplasty: A Prospective Cohort Analysis

BACKGROUND Patients are discharged to home or inpatient settings after primary unilateral total knee arthroplasty (TKA). Few studies have compared patient outcomes following these 2 rehabilitation models for TKA patients. We identified predictors of inpatient discharge, 3-month postoperative range of motion (ROM), and 3-month postoperative patient-reported physical function improvement (Veterans RAND 12-Item Physical Component Score [PCS]) between these discharge settings. METHODS We studied prospectively collected cohort data for 738 TKAs between April 2011 and April 2013 at a high-volume tertiary academic medical center in a rural setting. All patients followed a standardized care pathway that involved prospective data collection as part of routine clinical care. Adjusting variables included age, sex, preoperative PCS, surgeon, modified Charlson Comorbidity Index, preoperative body mass index, laterality, and preoperative ROM; the 3-month models also included length of stay and discharge disposition as adjusters. RESULTS Significant adjusted predictors of inpatient discharge included older age, female sex, surgeon, comorbidity, lower PCS, and body mass index greater than 40. Only lower preoperative ROM predicted postoperative ROM. Inpatient discharge and higher preoperative PCS predicted lower PCS improvement. Home-based rehabilitation was associated with greater 3-month PCS improvement and showed no difference with 3-month ROM. CONCLUSION Discharge to home-based rehabilitation after TKA, rather than inpatient facility, is associated with higher physical function at 3 months postsurgery and shows no difference with 3-month ROM. Total knee arthroplasty inpatient discharge should be based on patient care requirements rather than perceived benefit of improved ROM and physical function.

The Use of Hyaluronic Acid and Corticosteroid Injections Among Medicare Patients With Knee Osteoarthritis

INTRODUCTION Hyaluronic acid (HA) and corticosteroid (CS) injections are frequently used in the management of osteoarthritis (OA) of the knee, despite a lack of strong evidence supporting their efficacy in the literature. The purpose of this study is to evaluate trends in HA and CS usage in Medicare patients over the past 15 years. METHODS The Medicare 5% national sample database was used to identify 581,022 patients (representing an estimated 11.6 million) with a diagnosis of knee OA between 1999 and 2013. RESULTS The percentage of newly diagnosed knee OA patients who received any injection trended from 39% in 1999 to 47% in 2006 and then declined to 37.5% in 2013. However, the mean number of injections per newly diagnosed OA patient nearly doubled from 0.27 to 0.45 for CS and from 0.18 to 0.36 for HA. Among those having both HA and CS injections, 69% had CS as first-line treatment, whereas 31% had HA first. CONCLUSION The percentage of newly diagnosed knee OA patients receiving injections peaked in 2007 and then decreased steadily through 2013, as did the proportion of patients receiving HA injections as first-line therapy. However, the number of injections per patient has increased significantly over the past 15 years in both groups.

Nonelective Primary Total Hip Arthroplasty: The Effect of Discharge Destination on Postdischarge Outcomes

BACKGROUND Medicare has enacted a mandatory bundled payment program for primary total joint arthroplasty that includes nonelective primary total hip arthroplasty (THA). Efficient postacute care management has been identified as an opportunity to improve value for patients. We aimed to identify risk factors for and compare rates of complications by discharge destination and then use those factors to risk-stratify non-elective THA patients. METHODS Patients who underwent nonelective primary THA from 2011 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database and categorized into those discharged to skilled nursing facility or inpatient rehabilitation facility vs home self-managed/home health (HHH). Bivariate and multivariate analyses of risk factors for postdischarge adverse events were performed using patient characteristics and intraoperative variables. RESULTS In bivariate analysis, skilled nursing facility or inpatient rehabilitation facility patients compared with HHH patients, had lower rates of postdischarge severe adverse events (SAEs; 49% vs 58%; P < .001) and unplanned 30-day readmissions (71% vs 83%; P < .001). HHH discharged patients with 1 or more of risk factors had a 1.85-6.18 times odds of complications within the first 14 days. CONCLUSION The most important risk factors for predicting postdischarge SAE and readmission are predischarge SAE, dependent functional status, body mass index >40 kg/m2, smoking, diabetes, chronic steroid use, and American Society of Anesthesiologists class 3/4. Nonelective THA patients without these risk factors may be safely discharged to home after THA. Orthopedic surgeons and their nonelective THA patients must agree on the most appropriate discharge destination through a shared decision-making process that takes into account these significant risk factors and other psychosocial factors.

Value-based Healthcare: Part 1—Designing and Implementing Integrated Practice Units for the Management of Musculoskeletal Disease

P atients, payers, providers, and policymakers have expressed a need for care delivery models designed around patient-centered value, and are actively pursuing payment structures to encourage this approach in musculoskeletal care. When analyzed with respect to value (defined as health benefits that accrue to patients per healthcare dollar spent), most current models of practice fall short due to: (1) An inability to measure outcomes that truly matter to patients, (2) limited transparency around the clinical and financial outcomes that are measured, and (3) a lack of care coordination across providers involved in the patient’s musculoskeletal care cycle [4]. While bundled payment initiatives such as Medicare’s Comprehensive Care for Joint Replacement (CJR) are concrete steps toward addressing these challenges, their scope is limited, as they are designed around procedures rather than conditions. These payment initiatives do not address the underlying misalignment in incentives that encourages greater emphasis on more resource intensive care, rather than improved health. It has been noted [5] that there is a need for more-comprehensive bundled payments covering conditions, as well as delivery models that enable providers to succeed in that environment. A few institutions (such as MD Anderson Cancer Center and The Dell Medical School at the University of Texas at Austin) have started to trial co-located, multidisciplinary teams of clinical and nonclinical providers (eg, case managers, social workers) to treat conditions over the full care cycle. We call these teams Integrated Practice Units (IPUs). In Part 2 of this column, which will be published in next month’s issue of Clinical Orthopaedics and Related Research, we will take an inside look at an IPU team A Note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the first of a two-part series on Integrated Practice Units (IPUs), a novel, patientcentered, value-based, multidisciplinary care model piloted at a small number of institutions. Part 1 will cover how to design and implement an IPU. Look for Part 2 of this series in next month’s CORR, which will cover obstacles to implementing this new approach, as well as concrete examples of tools, clinical flows, and organizational approaches to surmount them. Value-based Healthcare explores strategies to enhance the value of musculoskeletal care by improving health outcomes and reducing the overall cost of care delivery. We welcome reader feedback on all of our columns and articles; please send your comments to eic@clinorthop.org. The authors certify that they, or any members of their immediate families, have no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons.

Health Utility of Early Hemiarthroplasty vs Delayed Total Hip Arthroplasty for Displaced Femoral Neck Fracture in Elderly Patients: A Markov Model

BACKGROUND Treatment for femoral neck fracture among patients aged 65 years or older varies, with many surgeons preferring hemiarthroplasty (HA) over total hip arthroplasty (THA). There is evidence that THA may lead to better functional outcomes, although it also carries greater risk of mortality and dislocation rates. METHODS We created a Markov decision model to examine the expected health utility for older patients with femoral neck fracture treated with early HA (performed within 48 hours) vs delayed THA (performed after 48 hours). Model inputs were derived from the literature. Health utilities were derived from previously fit patients aged more than 60 years. Sensitivity analyses on mortality and dislocation rates were conducted to examine the effect of uncertainty in the model parameters. RESULTS In the base case, the average cumulative utility over 2 years was 0.895 for HA and 0.994 for THA. In sensitivity analyses, THA was preferred over HA until THA 30-day and 1-year mortality rates were increased to 1.3× the base case rates. THA was preferred over HA until the health utility for HA reached 98% that of THA. THA remained the preferred strategy when increasing the cumulative incidence of dislocation among THA patients from a base case of 4.4% up to 26.1%. CONCLUSION We found that delayed THA provides greater health utility than early HA for older patients with femoral neck fracture, despite the increased 30-day and 1-year mortality associated with delayed surgery. Future studies should examine the cost-effectiveness of THA for femoral neck fracture.