What should be the Academy’s role in CER?

In addressing the AAOS Council on Research, Quality Assessment, and Technology, James N. Weinstein, DO, MS, listed the many problems contributing to the current state of our nation’s health care, among them poor quality, an increasing number of uninsured, and spiraling costs.

Dr. Weinstein noted that economic healthcare disparities exist across factors such as age, race, and sex, and that regional variances in care are prevalent across the country. Doctors are also failing at alarming rates to provide evidence that they are giving ‘effective care’ to patients even though the efficacy of many orthopaedic interventions is clinically proven, he said.

To promote real change, advised Dr. Weinstein, physicians need to ask themselves tough questions about what’s really happening in health care and present a unified voice for action. Otherwise, “advocacy efforts are simply self-serving,” he said. Specifically, he advised taking the following steps:

• Understand and address causes of unwarranted variations in clinical practice and health outcomes
• Reform provider education and improve communication with the public to correct flawed assumptions and beliefs
• Foster organizational change through leadership development and improvement initiatives
• Engage with policy makers and stakeholders to develop practical approaches to system reform because the current payment system rewards fragmentation, clinical silos, and overuse

Follow the evidence
The focus for improving healthcare needs to be on providing value, Dr. Weinstein believes, and comparative effective research (CER) is a means to that end.

“CER identifies what works best for which patients under what circumstance,” he explained.

“Currently, the geographic areas of the country where we spend the most money on health care are often the areas where we have the worst health care—we’re spending more and getting less,” said Dr. Weinstein.

As a member of the authoring committee for the Institute of Medicine’s (IOM) Initial National Priorities for Comparative Effectiveness Research, Dr. Wein-stein helped define the purpose of CER: to assist consumers, clinicians, purchasers, and policy makers in making informed decisions that will improve health care at both the individual and population levels.

Using a study population typical of daily practice, CER compares the benefits and harms of alternative treatment options to prevent, diagnose, treat, and monitor a clinical condition, or to improve the delivery of care.

Get in the game
The Academy needs to produce the data that show how well orthopaedic surgeons actually perform procedures such as joint replacement, according to Dr. Weinstein.

“This is a huge issue that affects our profession and our ability to provide care for the nation,” he explained.

“It’s important that our voices be heard—we have a lot of good things to say. We do a lot more than other professions, and we do it very well,” he said.

He warned that, independent of what the AAOS decides to do, payors will be collecting data “and they will start measuring us against benchmarks to decide whether or not we are providing value. As an Academy, we need to continuously examine best practices to make ourselves better,” he stressed.

In addition, patients’ opinions or interpretations of how well physicians perform will become very important.

Successfully mobilizing the voices of orthopaedic patients would put the AAOS in a very strong position, Dr. Weinstein believes. Furthermore, “if the Academy chose to adopt the doctrine of informed choice and its principles, I think it would be a wonderful opportunity for us to take the lead nationally in doing the right thing, and not something that is just going to pay us more money,” he said.

Make a difference
In February 2009, the American Reinvestment and Recovery Act (ARRA) appropriated $1.1 billion for CER, and the IOM was tasked to recommend national priorities for research questions (Table 1).

As a result, hundreds of millions of research dollars are available—and the Academy should be applying for some of that funding, said Dr. Weinstein. The AAOS could contribute or develop research on the effectiveness of alternative therapies to reduce symptoms of osteoarthritis and predictors of individual responses to rheumatoid arthritis treatment; on improving trauma systems, triage, and delivery; and on injury prevention programs for the elderly, especially fall prevention. All of these are covered by the AAOS Unified Musculoskeletal Research Agenda (Table 2).

Since the 1-year mortality rate after hip fracture of 30 percent is actually higher than for most cancers, Academy fellows could help develop best protocols for hip-fracture patients, he said.

“Wouldn’t it be wonderful to see a headline in the New York Times that reads ‘The AAOS cuts hip-fracture mortality by 50 percent’?” he asked.

Just do it
Misconceptions surrounding CER may be creating barriers to its adoption. Some resistors theorize that CER is difficult to do—especially capturing patient outcomes data—and that the expertise to do it well is lacking.

“That’s not an excuse anymore,” said Dr. Weinstein, explaining that CER is actually about breaking down barriers.

He added, “You don’t need huge, multicenter clinical trial databases. Registries are a good beginning. The Academy could be a reservoir for these registries, and 10 years from now we could have a very robust database.”

When it comes to making a difference through CER, it’s about making a commitment and getting started, Dr. Weinstein believes.

“We need to educate our residents, fellows, faculty, and colleagues and just start,” he stressed. “I’m really tired of hearing why we can’t do it.”

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org