The American Board of Orthopaedic Surgery (ABOS) appreciates the opportunity to comment on the value of comparative effectiveness research. Founded in 1934, the ABOS provides a two-step process for initial certification of candidate orthopaedic surgeons and is responsible for the recertification process in orthopaedic surgery, hand surgery, and sports medicine subspecialties. As a part of our dual mission to serve the public and the medical profession, we have ingrained specific elements of ethics, professionalism, and evidence-based practice in multiple areas of our process.

To be eligible for the Board certification process, residents must satisfactorily complete an accredited 5-year training program in orthopaedic surgery. For the initial certification process, we have developed a psychometrically valid examination that tests cognitive expertise in orthopaedic surgery (Part I). If successful in Part I, candidates may apply for an oral examination (Part II) after approximately 2 years of independent practice.

For the second part of the initial certification, candidates must successfully pass a 360 degree peer review evaluation process prior to sitting for the part II oral examination. Our peer review process employs a standard tool that represents the six core competencies, accrues input from multiple types of observers (colleagues, partners, administration, and nursing), specifically assesses ethics and professionalism, and is unique to our orthopaedic surgery process.

The part II examination is an oral examination for which the candidate must submit 6 months of operative cases in a standard format to our proprietary database. In the part II examinations, candidates present their own cases to 6 different Board-certified volunteer examiners. Candidates are graded on a variety of skills including use of evidence-based medicine, ethics and professionalism, and systems-based practice. Further, the ABOS owns and operates a recertification processes that includes a variety of recertification alternatives that are equally robust and are designed to both protect the public and meet the needs of busy practicing orthopaedic surgeons.

Integral to the recertification process is the option of a recertification oral examination. Again for this examination, candidates who have been in practice for almost 10 years submit cases to our proprietary database providing another important evaluation of orthopaedic practice. We believe that this process developed by the ABOS has high value to the diplomate and serves to protect the public good.

Though a small percentage of physicians, orthopaedic surgeons provide “cradle to grave” medical care to nearly 25 percent of the population. As such, orthopaedic care is a high priority to the public. The direct cost for musculoskeletal care and rehabilitation is on the order of $800 billion. In 2004, the U.S. Department of Health and Human Services (HHS) identified the care of arthritis and nontraumatic joint disorders as conditions of special significance and among the first to be addressed by the Effective Health Care Program. The ABOS recognizes the need for effective healthcare programs in arthritis, nontraumatic joint disorders, and care of the injured patient. The ABOS believes continued evaluation of practice patterns of practicing orthopaedic surgeons gives it the unique opportunity to report on and improve certain aspects of care.

Support for comparative effectiveness programs
The ABOS is strongly supportive of comparative effectiveness research as an important tool in the fabric of medical decision making; its accumulation of information on orthopaedic practice, including procedures and outcomes, through the certification process provides ABOS a unique opportunity to conduct such research.

As part of our commitment to this research, the ABOS has partnered with the Dartmouth Institute of Health Policy and Clinical Practice to design, execute, and publish a number of articles that are based on observed orthopaedic practices using our proprietary database. We have published or will soon publish articles that describe geographic variation in various orthopaedic practices, trends in practice patterns for the treatment of various conditions, the differential effectiveness of certain procedures in the treatment of various conditions, and the effectiveness of educational programs in orthopaedic surgery. These manuscripts, published in rigorous peer reviewed journals can improve orthopaedic practice and are, therefore, useful to both our colleagues and the public.

Because we have useful data in our proprietary database that has been systematically collected over a number of years, the ABOS is in a unique position to continue to report on issues of effectiveness, device utilization, geographic practice variation, and other important issues in orthopaedic surgery. Constructively employed, works of this type should be reported to give both physicians and patients a better understanding of the ramifications of personalized medical decisions. Hopefully, works of this type will stimulate innovation, further research, and not stymie progress.

We will continue our independent work in this area for the benefit of the profession and for the value to the public. Such initiatives will also have translational benefit in related fields of surgery and musculoskeletal health. We are eager to work with HHS in furthering the work that will lead to improved, clinically useful, evidence-based guidelines and new educational formats that provide safe, effective treatment, while conserving the resources available for health care.

Novel projects that partner with the individual Boards that control the certification process for their diplomates in the various specialties could yield the next generation of performance improvement in the specialty of orthopaedic surgery and other specialties.

John Gray Seiler III, MD
ABOS President

Harry Herkowitz, MD
ABOS President-elect

Shep Hurwitz, MD
ABOS Executive Director

Editor’s note: This statement was submitted by the American Board of Orthopaedic Surgery to the Federal Coordinating Council for Comparative Effectiveness Research in response to a request for comment on the value of comparative effectiveness research under The American Recovery and Reinvestment Act (the Economic Stimulus Program).

It is reprinted here to provide AAOS fellows with an understanding of the potential application of case studies in the ABOS proprietary data base.

Background References:

1. Clancy CM MD. AHRQ’s Research Efforts in Comparative Effectiveness. Statement before the US House of Representatives Committee on Ways and Means, Subcommittee on Health. June 2007.
2. Ellis P. Research on the Comparative Effectiveness of Medical Treatments. A CBO paper. Congress of the United States. 2007
3. Garber AM, Tunis SR. Does Comparative –Effectiveness Research Threaten Personalized Medicine. New England Journal of Medicine. Vol. 360, 9, 1925-1927, 2009

Bibliography of recent ABOS publications

1. Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius. The evolution of practice over time. Where’s the evidence. Journal of Bone and Joint Surgery. 90, 1855-1861, 2008.
2. Anglen JO, Weinstein JN and the ABOS Research Committee. Nail or Plate Fixation of Intertrochanteric Hip Fracture: Changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. Journal of Bone and Joint Surgery. 90, 700-7007, 2008.
3. Garrett We, Swiontkowski MF, Weinstein JN, Callaghan J, Rosier RN, Berry DJ, Harrast J, DeRosa GP and the research committee of the American Board of Orthopaedic Surgery. Journal of Bone and Joint Surgery. 88, 660-667, 2006.
4. Herkowitz HN, Weinstein JN, Callaghan JJ, DeRosa GP and the American Board of Orthopaedic Surgery. Spine Fellowship Education and its Association with the Part II Certification Examination. Journal of Bone and Joint Surgery. 88, 668-670, 2006.

Current ABOS Research Projects

1. Board Certified and Non Board Certified Orthopaedic Surgeons- differences in outcomes, cervical spine.
2. Arthroscopic shoulder surgery, changes in practice for subacromial decompression.
3. Shoulder surgery, changes in practice for rotator cuff conditions.