During its December 2017 meeting, the AAOS Board of Directors approved the release of two quality-focused products that will provide orthopaedic surgeons with additional evidence-based resources for clinical decision making.
Taking measure: Carpal tunnel syndrome
The new performance measures for carpal tunnel syndrome are the first set of performance measures that are based on a previously published AAOS Clinical Practice Guideline (CPG). The measures, to be submitted to the U.S. Centers for Medicare & Medicaid Services (CMS) for consideration, also stand out as the first such complement to provide evidence-based practice advisories for orthopaedic hand surgery.
The measures were developed as a collaborative project between the Academy and the American Society for Surgery of the Hand (ASSH), with funding from a grant from the Board of Specialty
Societies (BOS) and the ASSH. Although AAOS and ASSH are listed as the measure’s codevelopers, the Academy will assume responsibility as their steward for future updates. With the recent approval from the AAOS Board, the performance measures will be submitted to CMS and the National Quality Forum for consideration for use in quality reporting.
The performance measures for carpal tunnel syndrome consist of the following three advisories, expressed in terms of “discouraging” a modality or treatment approach, for management of the condition. These advisories discourage:
- the use of MRI for diagnosis of carpal tunnel syndrome
- the use of adjunctive surgical procedures during carpal tunnel release
- the routine use of occupational and/or physical therapy after carpal tunnel release
Because the use of performance measures to guide practice decisions, as well as reimbursement by Medicare and other payers, is just now evolving in earnest, practitioners are still familiarizing themselves with measures that affect their practice areas and implications for patient care.
Robin Kamal, MD, chair of the Carpal Tunnel Quality Measures Work Group, acknowledged that many physicians are apprehensive about being told how to practice medicine, possibly in contradiction to their best judgment and experience and to the best interest of the patient.
He said that when the set of performance, or quality, measures was put up for public comment, “About 90 percent of the comments had to do with fear of not being able to do certain things when it is clinically necessary. If we remember that we always have room for improvement, then these quality measures make sense. The purpose is not to limit surgeons or prevent them from doing things based on the patient’s pathology, values, or preferences, but to limit doing things based on surgeons’ preferences or routines that aren’t supported by evidence.”
The measures chosen, he said, were selected to encompass “topics that are supported by evidence and those that most surgeons adhere to.” One of the main objectives behind this performance measure, he said, was to “provide surgeons with meaningful measures to report, as opposed to measures that do not relate to their practice or patients.”
One hurdle to the embrace of performance measures, Dr. Kamal said, is the belief that they are “are black and white or binary—you can or can’t do something.” Instead, he explained, “They are made so you can do what is best for the patient and deliver patient-centered care. Some orthopaedic surgeons are fearful that performance measures mean they can’t utilize services or complete procedures when they’re needed for a patient. These measures are designed so that they allow for some variation in care based on patient disease, comorbidities, and preferences.”
In practical terms, CMS and the government will use performance measures to assess how well providers are adhering to best practices and evidence-based medicine. The three measures in the AAOS/ASSH set demonstrate high, but not universal, compliance among surgeons.
“There is no real absolute for adherence,” Dr. Kamal said. “Some of our measures had relatively high levels of adherence, but there is always room for improvement.”
Dr. Kamal said he encourages his fellow surgeons to regard performance measures as adjuncts to high-quality care. “As long as we remind ourselves that quality measures are a way to improve our ability to deliver evidence-based care centered around patients, it’s just another way that helps us to do our jobs better while being good stewards of limited resources,” he said.
The Hip OA AUC: A tool for evidence-based decision making
AUCs are an online tool that provides clinicians with algorithms on how to optimally treat an orthopaedic injury or condition, including hypothetical scenarios and possible treatments, ranked for appropriateness based on the latest research and clinical expertise and experience. The physician enters the patient scenario into the tool, which signals whether certain treatment modalities fit into the category of Appropriate, May Be Appropriate, or Rarely Appropriate.
The new Appropriate Use Criteria (AUC) release offers guidance on management of osteoarthritis (OA) of the hip and reflects the CPG on Management of Osteoarthritis of the Hip, which offers strong recommendations for the following:
- the use of presurgical treatment modalities to ease pain and improve mobility, including corticosteroid injections, physical therapy and non-narcotic medication (specifically, nonsteroidal anti-inflammatory drugs or acetaminophen, or, in appropriate situations, tramadol) for pain
- both anterior and posterior approaches for total hip arthroplasty (THA)
The AUC reinforces the CPGs admonition against management of chronic arthritis pain with opioid medications. Robert H. Quinn, MD, the AAOS section leader on the Committee of Evidence-Based Quality and Value, explained, “We drew a firm stand that basically no patient with arthritis pain, excluding surgery-related pain, should be getting opioids”—with some specific exceptions allowed for tramadol.
Dr. Quinn said the work group for the AUC devoted considerable discussion to—and encountered some differences of opinion over—the issue of modifiable risk factors, notably obesity, diabetes, mental health disorders, and smoking.
“There was perhaps some misunderstanding about modifiable risk factors,” he said. “If you have them present, the question is, has the patient made an attempt to address them? What do you do with the morbidly obese patient who has made a tremendous effort to lose weight and is now still technically obese but has hit the limit in the ability to lose more weight and may be disabled?”
The AUC steers a flexible course for such a patient. “If you plug in the different factors and you include modifiable risk factors, you will come up with some scenarios in which surgery may be appropriate,” Dr. Quinn said (Fig. 1). “For those patients who have tried to modify their risk factors and have made a substantial improvement but also understand the added risks versus benefits in proceeding when those factors are not completely eliminated, it may make sense in those situations to go ahead with surgery. This was controversial, with some no votes. Some thought hip replacement surgery should never be appropriate in the presence of modifiable risk factors. The most important message is that in the one-on-one discussion, the surgeon and patient weigh the risks and benefits and come to a conclusion about surgery.”
Overall, Dr. Quinn said, “The most important thing in any decision is the relationship between the experienced surgeon and the well-informed patient. These AUCs are not meant to be proscriptive. They are meant to be helpful. In the end, it’s one surgeon and one patient, and the aim is that both are using the best evidence to reach a treatment plan or decision.”
The AUC on OA of the Hip may be found at http://www.orthoguidelines.org/oahipauc
Terry Stanton is the senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org.