News in 10
The 10 items below are the most significant elements of recent editions of Headline News Now—the AAOS thrice-weekly, online update of news of interest to orthopaedic surgeons. Check this page regularly for updates.
Updated on November 16, 2009.
1. Survey provides "snapshot of U.S. physicians.”
According to the 2008 Health Tracking Physician Survey, about three out of four physicians accepted all or most new Medicare patients, but fewer than six in 10 physicians provided charity care in 2008. The survey also found that physician demographics may be changing, with more women entering the field. Allthough three out of four physicians are men, women account for more than 40 percent of physicians younger than age 40. Other findings include the following:
- Nearly one-third of physicians worked in solo or two-physician practices, 15 percent worked in groups of three to five physicians, and 19 percent worked in practices of six to 50 physicians.
- More than 80 percent of physicians surveyed worked full time, more than half (53 percent) were 40 to 55 years old, and almost four in 10 have practiced medicine for more than 20 years.
- A slight majority of physicians (56 percent) were either full- or part-owners of their practices, while 44 percent were employees or independent contractors.
- In 2008, 44 percent of physicians reported receiving some form of performance-adjusted salary—for example, an adjustment based on their own productivity. Roughly a quarter indicated payment by fixed salary, and 20 percent received a share of practice revenue.
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2. Trauma care: Surgeon experience doesn't affect mortality, but timing of surgery might.
According to a study published in the August issue of Archives of Surgery, surgeon experience does not affect overal mortality rates as much as the overall system of care. The retrospective cohort study at an academic level 1 trauma center found that patients treated by novice surgeons vs experienced trauma surgeons demonstrated no difference in mortality (odds ratio, 1.33; 95% confidence interval, 0.82-2.15).
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Read an interview with the senior author...
In related news, a review article published in the September issue of the Journal of the AAOS finds that a damage-control approach may be more advisable for a subset of patients with multiple injuries. According to an analysis of several trauma registries in Germany, patients with life-threatening injuries who were in surgery for 6 or more hours did not do as well as those who were in surgery for less than 3 hours. The authors recommend performing stabilization procedures, such as using an external fixator, first, and delaying more invasive and time-consuming surgeries for a few days.
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A study in the September issue of The Journal of Bone and Joint Surgery also addresses the timing of surgery. Of 203 patients with either a femoral or tibial shaft fracture who were treated with intramedullary nailing, those who had surgery performed between 4 p.m. and 6 a.m. experienced more unplanned reoperations than those who had surgery performed between 6 a.m. and 4 p.m. Healing times were similar for both groups.
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3. Osteopenia diagnosis stirs disagreement in some medical circles.
An article in the New York Times examines the controversy surrounding a diagnosis of osteopenia (defined as below-normal bone mass, but not yet osteoporosis) and FRAX®—a tool designed by the World Health Organization (WHO) to evaluate fracture risk. Some physicians argue that, because WHO defines normal bone mass as that of an average 30-year-old woman, and bone naturally deteriorates with age, anyone much older than 30 is likely to qualify for a diagnosis of osteopenia. Furthermore, the algorithms used to determine fracture risk using FRAX® are kept secret, leaving physicians with no way to validate its conclusions. Compounding the issue is the fact that little agreement exists among medical personnel as to when treatment for bone loss should begin. Some studies suggest that taking current bone-loss drugs to treat osteopenia provides little or no benefits.
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4. Better clinical outcomes after carpal tunnel surgery.
For patients with carpal tunnel syndrome without denervation, surgical treatment may provide a modestly better clinical outcome than non-surgical treatment, according to a study published in the September 26 issue of the journal The Lancet. The authors conducted a parallel-group randomized controlled trial of 116 patients from eight academic and private practice institutions. Overall, 57 patients were assigned to carpal tunnel surgery, while 59 were assigned a well-defined, non-surgical treatment, including hand therapy and ultrasound. At 12 month follow-up, 101 patients (87 percent) were analyzed (49 of 57 in the surgery group and 52 of 59 in the non-surgery group. Patients in the surgery group displayed a significant 12-month adjusted advantage for surgery in function (Carpal Tunnel Syndrome Assessment Questionnaire [CTSAQ] function score: Δ -0.40, 95 percent confidence interval, 0.11—0.70, p=0.0081) and symptoms (CTSAQ symptom score: 0.34, 0.02—0.65, p=0.0357). There were no clinically important adverse events and no surgical complications.
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5. Physicians offer their perspectives on healthcare reform.
Two articles published in the New England Journal of Medicine offer varying perspectives on the issue of healthcare reform. In "Doctors as the Key to Health Care Reform," the author argues that the fee-for-service model incentivizes to maximize the elective services they provide, and that this incentive, combined with the introduction of new and expensive technology, is a major factor drive up healthcare costs. The author proposes a system based on tax-supported, universal insurance, with medical care provided by a national network of community-based, private, not-for-profit, multi-specialty, physician-managed group practices that would pay staff physicians a salary for providing cost-effective care within the limits of a publicly determined budget.
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In "21st-Century Health Care—the Case for Integrated Delivery Systems," the author argues that the United States must make healthcare coverage available to all citizens, and suggests that the current fee-for-service physician payment system should be replaced with a prospective payment system, and multispecialty integration of physicians combined with hospitals to form new “accountable” systems of care.
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6. Wrist fracture patients often go unchecked, untreated for osteoporosis.
A Korean study published in the October 1 issue of the Journal of Bone & Joint Surgery—American (JBJS-A) finds that patients with wrist fractures are less likely to be evaluated and managed for osteoporosis than those with hip or spine fractures. The authors reviewed a Korean database of 31,540 hip fractures, 58,291 spine fractures, and 61,234 wrist fractures in female patients older than age 50 during 2007, and found that 7,095 patients with hip fractures (22.5 percent), 16,779 patients with spine fractures (28.8 percent), and 5,348 patients with wrist fractures (8.7 percent) underwent diagnostic bone density scans. Researchers also found that 7,060 hip fracture patients (22.4 percent), 17,551 spine fracture patients (30.1 percent), and 4,594 wrist fracture patients (7.5 percent) were managed with at least one medication approved for the treatment of osteoporosis.
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7. ACL injuries on the rise; readmission increases with age and other factors.
In a review of 70,547 anterior cruciate ligament (ACL) reconstructions performed between 1997 and 2006 in New York State, a research team found that the number of ACL reconstructions performed in a year increased from 6,178 in 1997 to 7,507 in 2006. The team found that readmission within 90 days occurred at a 2.3 percent rate, and subsequent surgery on either knee within 1 year occurred at a 6.5 percent rate. Patients older than 40 years of age, with a preexisting comorbidity, who were male, or who were operated on by a lower-volume surgeon were at increased risk for readmission within 90 days. Predictors of subsequent knee surgery included being female, having concomitant knee surgery, and being operated on by a lower-volume surgeon. Predictors of a subsequent anterior cruciate ligament reconstruction included being younger than 40 years old, concomitant meniscectomy or other knee surgery, and surgery in a lower-volume hospital. The study was published in the October 1 issue of JBJS-A.
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8. Study finds discrepancies in AAOS conflict of interest reporting.
An article in this week’s New England Journal of Medicine finds that many physicians fail to disclose all potential conflicts of interest in conjunction with meeting presentations. The study compared the self-disclosure reported by physician presenters, committee members, and board members at the 2008 AAOS Annual Meeting (as recorded in the final program) with reports of payments that five hip and knee implant manufacturers were required to make under settlements with the Department of Justice. Of 344 payments noted by the implant manufacturers, physicians disclosed 245 (71.2 percent). Payments directly related to the topic of their presentation were reported at a higher rate (79.3 percent) than payments that were indirectly (50 percent) or not related (50.8 percent) to the topic. The most common reason for nondisclosure was that the payment was unrelated.
In response to the study, AAOS President Joseph D. Zuckerman, MD, noted, "The AAOS has, and will continue, to take steps to ensure that the presentation of information at our Annual Meetings is free from commercial bias and that our members disclose any conflicts of interest. In addition, our education committees will continue to manage such conflicts so that presentations are fair and balanced, without marketing overtones. All authors must disclose ALL potential conflicts of interest--whether related to the topic or not, and the process for reporting potential conflicts has been simplified and made electronic, allowing for year-round updates and reporting. We will continue to evaluate and improve the disclosure process and our member education efforts."
Read the complete study...
Read the AAOS Mandatory Disclosure Policy…
9. FDA requests further data on spinal fusion devices.
The U.S. Food and Drug Administration (FDA) has ordered manufacturers of 16 dynamic stabilization systems (DSSs) or spinal fusion components to conduct postmarket surveillance studies addressing the following issues:
- The fusion rate for DSSs compared to traditional stabilization systems
- The incidence rate, severity, and time course of adverse events for DSSs compared to traditional systems
- The type, incidence rate, and time course of subsequent surgical procedures for DSSs compared to traditional systems
- The cause of failure for DSSs based on analysis of systems that have been removed from patients
The agency states that currently not enough clinical data is available to determine whether DSSs provide enough spinal stability to allow for complete spinal fusion, because the system components may loosen, bend, or break over time. If fusion does not occur, a patient’s condition could worsen and possibly require additional surgical procedures. FDA will review clinical data gathered from the studies and consider whether labeling changes or additional preclinical and clinical testing requirements may be necessary for the devices.
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10. Canadian hip fracture rates dropping.
A Canadian study published in the August 26 issue of the Journal of the American Medical Association finds that rates of hip fracture have steadily declined over a 21-year period. Based on nationwide hospitalization data, researchers determined that, from 1985 through 2005, age-adjusted hip fracture rates decreased by 31.8 percent in women (from 118.6 to 80.9 fractures per 100,000 person-years) and by 25.0 percent in men (from 68.2 to 51.1 fractures per 100,000 person-years (p<0.001). A similar trend has been noted in the United States, despite growing numbers of elderly people. The reasons for the decline in hip fracture rates are unknown, although better nutrition, healthier living habits, fall prevention programs, and treatments to slow the development of osteoporosis may be contributing factors.
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