Published 3/1/2008

Second Look

If you missed these news items the first time around, AAOS Now gives you a second chance to review them.

Headline News Now, the AAOS thrice-weekly, online update of news of interest to orthopaedic surgeons, brings you the latest on clinical, socioeconomic, and political issues, as well as important announcements from AAOS.

Study finds inappropriate transfers to trauma centers
study published in the Journal of the American College of Surgeons finds that many patients with minimal injuries are being transferred to trauma centers from community hospitals, despite the fact that community hospitals are capable of dealing with those injuries. Authors conducted a retrospective cohort study of trauma registry data on 9,064 patients. Of those, 6,875 patients (76 percent) arrived directly from the scene, and 2,189 patients (24 percent) were transferred. Overall, the transferred group was more severely injured, but most (64 percent) had sustained minor injuries, and 824 patients (39 percent) met secondary overtriage criteria, which was defined as patients transferred from another hospital emergency department to a trauma receiving unit who had an injury severity score less than 10, who did not require an operation, and who were discharged to home within 48 hours of admission. Researchers suggest that the trend may be a result of recent changes in the Emergency Medical and Active Labor Treatment Act (EMTALA), to no longer require community hospitals to provide emergency specialty coverage.

An article published in the November 2007 issue of AAOS Now examines the growing crisis in emergency care and takes a look at the impact of EMTALA.

Study: Many hospital inpatients at risk for VTE
study published in the Feb. 2 issue of the journal The Lancet finds that, worldwide, many hospitalized patients are at risk for venous thromboembolism (VTE), but few receive appropriate prophylaxis. Researchers reviewed hospital charts at 358 hospitals in 32 countries and assessed the risk of VTE for all hospital inpatients aged 40 years or older admitted to a medical ward, or those aged 18 years or older admitted to a surgical ward. A total of 68,183 patients were enrolled. Of those, 45 percent were categorized as surgical patients, with the remainder as medical patients. Using 2004 American College of Chest Physicians (ACCP) criteria, 35,329 patients (51.8 percent) were judged to be at risk for VTE. Of surgical patients at risk, 11,613 (58.5 percent) received ACCP-recommended VTE prophylaxis, although the percentage of patients in individual countries who received VTE prophylaxis ranged from a low of 0.2 percent to a high of 92.1 percent.

The AAOS has developed clinical guidelines on the prevention of symptomatic pulmonary embolism in patients undergoing total hip or total knee arthroplasty, which may be an alternative to the ACCP guidelines.

Leg injury may presage VT
study published in the journal Archives of Internal Medicine (AIM) finds that minor leg injuries such as muscle ruptures and ankle sprains may be associated with a higher risk of blood clots in the legs or lungs. Researchers compared 2,471 patients in whom venous thrombosis (VT) developed and 3,534 controls between 1999 and 2004. They found that 289 VT patients (11.7 percent) had a minor leg injury in the 3 months prior to VT development, yet only 154 of the controls (4.4 percent) had a minor leg injury in the 3 months prior to filling out a survey questionnaire. Injuries in the leg were strongly associated with VT; injuries in other locations were not.

Arthritis gene linked to premature death
According to a
study published in the February 2008 issue of the journal Arthritis and Research, the HLA-DRB1 genotypes, already associated with rheumatoid arthritis (RA) susceptibility and severity, also serve as predictors of premature death from cardiovascular disease for inflammatory arthritis patients. Researchers drew DNA samples from 1,022 patients with inflammatory polyarthritis (IP), and found that, at follow-up, 751 (74 percent) satisfied the American College of Rheumatology 1987 criteria for RA, and 242 (24 percent) had died. Researchers found that the combination of shared epitope alleles, smoking, and anticyclic citrullinated peptide antibodies was associated with a high risk of premature death in patients with IP and RA, which raises the possibility of a targeted strategy to prevent cardiovascular disease in these patients.

Low testosterone linked to fractures in older men
Fracture risk may be tied to low blood testosterone levels in older men, according to another
study published in AIM. Between January 1989 and December 2005, researchers observed 609 men older than age 60. A total of 149 incident fractures were reported among 113 patients, with risk of fracture being significantly higher among those with low testosterone levels—even after adjusting for major risk factors such as age, weight, or bone mineral density; fracture history; smoking status; calcium intake; and sex hormone-binding globulin.

Study supports regular recertification for physicians
According to a
study published online in the journal Circulation, the length of time since a primary care physician’s last board certification may be associated with a decline in the quality of care provided to patients. Researchers conducted a retrospective cohort study of 8,127 hypertensive patients with diabetes mellitus treated by 301 internists at primary care practices affiliated with two large academic hospitals. Patients with documented blood pressure of 130/85 mm Hg between Jan. 1, 2000, and Aug. 31, 2005, were studied. The association between the number of years since the physician’s last board certification and the probability of pharmacologic antihypertensive treatment intensification at a given visit was analyzed. Frequency of treatment intensification was highest (27 percent) for 103 internists who had passed their boards during the year prior to the visit and lowest (7 percent) for the 6 physicians who were last certified 31 years ago. Further analysis revealed, on average, a 21 percent drop in likelihood of modifying therapy in every decade since a physician’s last board certification.

The AAOS has a Web page designed to assist orthopaedic surgeons with maintenance of certification issues.

IOM calls for national program to assess treatment effectiveness
The U.S. Institute of Medicine (IOM) has released a
report recommending that Congress establish a single national program to facilitate the development of standards and processes for synthesizing and assessing the effectiveness of medical treatments, services, and technologies. The IOM panel stated that lack of coordination among organizations that conduct evidence reviews and clinical practice guidelines has led to competing standards and uncertainty about objectivity. The report emphasizes that the future of healthcare quality and safety rests on the strength of the evidence collected, and on the ability to channel such evidence to providers, policymakers, payors, and consumers.

NEJM takes a look at the election from a healthcare perspective
A special
report published in the New England Journal of Medicine (NEJM) reviews the issue of health care in the upcoming presidential election. The report examines multiple opinion surveys to differentiate how Republican and Democrat candidates differ in values and beliefs and looks at the differences in healthcare preference among voters. According to the authors, candidates from the two parties differ substantially with regard to four issues that could affect future health policy: President Bush’s handling of health care, the healthcare system generally, their own care, and possible solutions to healthcare problems.

A recent series of AAOS Now articles examined the stances of the major presidential candidates concerning health care. The “Where do they stand on health care?” series appears in the November, December, January, and February issues.

Too many healthcare quality ratings sites?
According to an
article in the San Francisco Business Times, some experts believe that the growing number of healthcare quality rating systems is leading to increased consumer confusion. Factors such as credibility concerns, contradictory data, and the sheer number of sites available online have combined to reduce the potential influence of quality ratings. One healthcare economist points out that, even if consumers find the ratings difficult to parse, the public nature of the information does spur hospitals to improve.