Published 9/1/2007

Second Look

In case you missed these news items the first time around, AAOS Now gives you a second chance to review them. Links to all items are available online at www.aaos.org/now.

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VTE more likely after discharge
A study published in the Archives of Internal Medicine found that patients may be at greater risk of developing venous thromboembolism (VTE) during the 3 months following hospitalization than during hospitalization itself.

Researchers reviewed the medical records of residents in the Worcester, Mass., metropolitan area from 1999, 2001, and 2003 to find VTE diagnoses. In all, 1,897 patients were found to have confirmed episodes of VTE. VTE developed in 73.1 percent of those patients in the outpatient setting, and 59.9 percent of that group had undergone surgery or hospitalization during the preceding three months.

Among patients with hospital encounters, 67 percent experienced VTE within 1 month. Among 516 patients with a recent hospitalization in whom VTE subsequently developed, less than half (42.8 percent) had received anticoagulant prophylaxis for VTE during that visit.

One-third of inpatients at risk of VTE, PE
According to a study published online in the American Journal of Hematology, more than 12 million of 38 million hospital patients discharged in the United States during 2003 were at risk of VTE based on criteria defined by the American College of Chest Physicians (ACCP).

Researchers applied the ACCP standards to the 2003 Nationwide Inpatient Sample—the largest all-payor inpatient care database in the United States. Of patients that met the study’s inclusion criteria, 15 percent were at moderate risk, 24 percent were at high risk, and 17 percent were at extreme risk of VTE, based on a combination of age, other medical conditions, type of surgery, and prior history. VTE can lead to pulmonary embolism (PE), which evidence implicates in up to 10 percent of sudden in-hospital deaths.

The AAOS recently adopted clinical practice guidelines on the prevention of symptomatic PE in patients undergoing total hip arthroplasty and total knee arthroplasty. The guidelines summary can be found at: http://www.aaos.org/PE.pdf.

Acupuncture doesn’t help OA knee
A study published in the British Medical Journal found no additional improvement in pain scores when acupuncture was added to a course of advice and exercise for osteoarthritis (OA) of the knee. Researchers examined 352 adults (94 percent follow-up) aged 50 or older who had a clinical diagnosis of knee OA. Participants were evaluated for a change in scores on the Western Ontario and McMaster Universities OA index pain subscale. At 6 months after baseline, reductions in pain (expressed as mean [standard deviation]) were 2.28 (3.8) for patients who received advice and exercise, 2.32 (3.6) for those who received advice and exercise plus true acupuncture, and 2.53 (4.2) for those treated with advice and exercise plus nonpenetrating acupuncture.

Osteoporosis treatment may be cost-effective for older men
A study in the Journal of the American Medical Association (Aug. 8, 2007) finds that bone densitometry followed by oral bisphosphonate therapy may be cost-effective for older men.

At 60 years of age, more than one in four white men will experience an osteoporotic fracture; older men who have hip fractures have a higher mortality than women with hip fractures. Using a computer model and data drawn from several different studies, researchers found that “universal bone densitometry followed by oral bisphosphonate therapy among those found to have osteoporosis for all men aged 70 years or older regardless of fracture history or other fracture risk factors” would not be cost-effective, but that applying this treatment to men aged 65 years or older with a prior clinical fracture and for men aged 80 years or older without a prior fracture could be cost-effective, assuming a societal willingness to pay $50,000 per quality-adjusted life year (QALY) gained.

The costs per QALY gained for the densitometry and treatment compared to no intervention decreased with age and were substantially lower for men with a self-reported history of clinical fracture after age 50.

Joint Commission reviewing wrong-site surgery guidelines
The Joint Commission is reviewing the adequacy of its wrong-site surgery guidelines in the wake of two cases of wrong-site surgery at the same hospital this year. Both surgeries involved neurosurgeons.

A preliminary investigation suggested that hospital staff may not have followed all recommended safeguards, which include verification of the correct patient and body part, marking the body part to be operated on, and taking a “time out” in the operating room to double-check the surgical site before starting the procedure.

Shock wave therapy useful for stress fractures
A study in the American Journal of Sports Medicine found that extracorporeal shock wave therapy (ESWT) is an effective way to treat resistant stress fractures in athletes. Researchers examined 62 patients between the ages of 13 and 22 who were treated with ESWT at a single hospital from 1997 through 2003. On average, fracture symptoms began 1 year prior to undergoing ESWT. Each patient underwent one session of ESWT, and successful bone union was achieved in all cases roughly 3 months after ESWT.

CMS seeks data on financial relationships between hospitals and physicians
AIS Health.com reports that the Centers for Medicare and Medicaid Services (CMS) is preparing to contact an estimated 500 specialty and acute care hospitals to gather information on physician investment, ownership, and compensation relationships. Completion of the Disclosure of Financial Relationships Report (DFRR) is mandatory, and hospitals that do not respond within 45 days will face a $10,000/day civil penalty.

The DFRR was developed when only 140 out of 452 hospitals responded to an earlier, voluntary survey, raising suspicions of improper relationships under the Stark physician self-referral law. Based on the data collected from these 500 facilities, CMS will determine whether to collect the same data from all Medicare-participating hospitals on an annual basis. At least one legal expert has opined that some of the questions on the DFRR do not ask for information in a manner consistent with the “real world,” which may cause problems even for providers that have legitimate relationships.

Orthopaedic hospitals have lower complication rate
A study conducted by researchers at the University of Iowa finds that patients in orthopaedic specialty hospitals have a lower risk of complications compared to those treated in general hospitals, even after accounting for the fact that the specialty hospitals tend to avoid patients with conditions such as obesity, heart failure, and diabetes.

Researchers examined the records of Medicare beneficiaries age 65 and older (mean age 75) who received either total hip (51,788 cases) or total knee (99,765 cases) replacement surgery from 1999 through 2003. The patients were treated either at one of 38 specialty orthopedic hospitals or one of 517 general hospitals in the same markets. Overall, orthopaedic specialty hospitals had a 40 percent lower risk of complications after surgery.

Problems with resident duty hours
Survey results published in the Archives of Internal Medicine showed that many key clinical faculty believe resident duty-hour limitations have had a negative effect on patient care, as well as on resident education and professionalism.

Of 111 respondents at 39 internal medicine residency programs across the United States, 73 percent stated that they think that residents’ accountability to patients worsened after institution of duty restrictions, and 57 percent thought that residents’ ability to place patient needs above self-interest dropped.

Respondents also noted decreased satisfaction with teaching (56 percent), ability to develop relationships with residents (40 percent), and overall career satisfaction (31 percent). However, 50 percent of respondents felt that residents’ well-being had improved.

A separate study, published in the Annals of Internal Medicine, examined patient outcomes following the institution of limits on resident work hours. Although death rates for high-risk patients in teaching hospitals dropped somewhat, the study also found that surgical outcomes remained essentially unchanged.

According to the study, patient deaths in teaching hospitals dropped by one in 400 after regulations restricting residents to 80 hours per week or 30 hours per shift went into effect. Researchers state that more study needs to be done to understand why patient outcomes stayed the same and point out that the subjects of the study were limited to high-risk patients.

EMRs may have positive effect in liability cases
A survey conducted by the for-profit Medical Records Institute (Boston) finds that electronic medical records (EMR) systems may have advantages in the area of medical liability. The Internet-based survey drew responses from 115 practices in 27 specialties and 36 states from March 21 to June 30, 2007. About 20 percent of respondents stated that they had faced a medical liability suit in which documentation was based on the EMR, and of those, 55 percent stated that the EMR was helpful in the case. Further, 45 percent opined that EMRs would make them less vulnerable in liability cases, and nearly 20 percent responded that their insurer offers a discount for having an EMR system.

GAO report finds physician payment localities out of sync with actual costs
A report released by the U.S. Government Accountability Office (GAO) examined the 89 physician payment localities currently used by CMS to adjust physician reimbursement based on practice costs. The study found that more than half of the localities had counties within them with a payment difference of 5 percent or more between GAO’s measure of physicians’ costs and Medicare’s geographic adjustment for an area.

To address this disparity, GAO offered the following recommendations: CMS should examine and revise the payment localities using an approach that is uniformly applied to all states and based on the most current data, and it should update the payment localities on a periodic basis. CMS has responded that it will consider the first recommendation, but the agency plans to continue its current approach of updating localities when interested parties raise concerns.