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(Left) Preoperative AP radiograph of a patient with an infected TKA. (Right) AP radiograph of the same patient after a two-stage reimplantation was performed. Reproduced from Jacofsky DJ, Hanssen AD; The Infected Total Knee Arthroplasty, in Barrack RL, Booth RE Jr, Lonner JH, McCarthy JC, Mont MA, Rubash HE (eds): OKU Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 177-183.

AAOS Now

Published 5/1/2009
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David Jevsevar, MD, MBA

Evidence-based medicine in practice: The M&M conference

Use M&M conferences for enlightenment, rather than support

The evaluation of patient care and complications in surgery was first proposed by Ernest Codman, MD, at Massachusetts General Hospital in the early part of the last century. Since then, hospitals, physicians, and accrediting organizations have formalized the process of these assessments, now called morbidity and mortality (M&M) conferences.

Since 1983, the Accreditation Council for Graduate Medical Education has mandated a regularly occurring M&M conferences as part of the core of resident education. M&M—or peer review—conferences are also common in settings such as community hospitals, physician practice groups, and insurance companies. Although the structure for these meetings is quite variable, the purpose is similar: to improve patient care through the review of specific patient complications.

Applying EBM principles
Evidence-based medicine (EBM) involves the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Although the use of EBM benefits both physicians and patients, the task of applying EBM principles is often daunting.

Through a series of review articles, The Journal of Bone and Joint Surgery has attempted to apply EBM principles to residency program journal clubs. Unfortunately, many hospitals and practices do not conduct regular journal clubs. M&M conferences, however, offer an excellent opportunity to integrate EBM into patient care. A template and discussion on how to incorporate EBM into an M&M meeting, both in academic and nonacademic settings, follows.

The presentation example
A 72-year-old female with a history of obesity, hypertension, and diabetes mellitus underwent a right total knee arthroplasty (TKA) 7 weeks ago for a long history of right knee pain and osteoarthritis that had not responded to other measures. The surgeon performed the procedure with a cemented prosthesis and reported a tourniquet time of 129 minutes.

The patient received prophylactic cefazolin within 1 hour prior to the procedure, and the antibiotic was continued for 48 hours per surgeon preference. The surgeon prescribed Lovenox® venous thromboembolism prophylaxis for 14 days. A large postoperative hematoma developed, and the patient had prolonged wound drainage for 15 days.

On postoperative day 21, the patient saw her surgeon. The patient had recurrent drainage, increasing pain, and erythema. Laboratory evaluation showed a white blood cell (WBC) count of 10,600 cells/µL with 85 percent neutrophils, an erythrocyte sedimentation rate of 75, and C-reactive protein levels of 12 mg/dL.

An aspirate of the knee revealed bloody fluid with a WBC count of 24,657 cells/µL and 94 percent neutrophils. The culture revealed methicillin-resistant Staphylococcus aureus, and the patient was readmitted to begin an estimated 6-week course of intravenous (IV) vancomycin therapy. No further surgical intervention was planned.

When the surgeon presented the case at the M&M conference, he said that he had treated several patients similarly without adverse outcome. He explained that he frequently treated prolonged wound drainage expectantly, because in his experience it usually resolved spontaneously. He based the decision to treat with IV antibiotics only on several case reports that reported resolution of infection without additional surgery. Although his peers were skeptical, they made no further comments.

Adding EBM makes a difference
The logistics of an EBM M&M conference are a pertinent first step, recognizing that initially, it may be impractical to apply an EBM review to every patient presentation. In most M&M settings, one or two individuals (physician, resident, administrator, quality nurse) are responsible for setting the agenda. The agenda can focus on a review of several patient complications, which can be chosen based on mortality, significance of morbidity, and/or frequency of occurrence.

After the agenda is set and the EBM cases have been selected, one of the members is charged with determining the parameters of the review. Most hospitals have access to medical library acquisitions, and a preliminary review of the topic literature over a specified time horizon (such as 5 or 10 years) should be performed. A specified number of applicable studies (perhaps 2 to 5) are then obtained for review and presentation at the M&M conference.

Preferably, the abstracts from the original search can be used to obtain those articles that are amenable to EBM review. The patient’s surgeon is the best choice to both present his or her case and conduct the EBM review.

Although some hospitals may have a peer review form for use during M&M conferences, an EBM review form might have different categories, such as the following: diagnostic, therapeutic (surgical intervention), prognostic (outcome), and economic (cost-effectiveness/decision analysis).

EBM and diagnosis
In the above example, a literature review of TKA infections may find several articles that examine diagnostic studies. The preliminary paring criteria might be to choose those studies with the highest level-of-evidence rating. (See
www.aaos.org/levelstables.pdf for a description of levels of evidence as applied to a primary research question stratified by the four EBM categories.) In this case, one Level 1 and several Level 2 studies were available.

For M&M purposes, the most important question in reviewing these studies is “Will the results help me in caring for my patients?” In the M&M setting, the review should help to identify evidence that supports or contradicts the patient’s care. In this scenario, strong evidence is available to condemn ignoring prolonged drainage in this obese patient with a tourniquet time greater than 120 minutes. The diagnostic studies chosen, with their strong levels of evidence, would support the diagnosis of an infected TKA.

EBM and therapeutic intervention
The review also found several studies related to the treatment of infected TKA. These studies were generally of lower evidence levels because of their retrospective nature. A solid Level 3 study is selected, along with several Level 4 reports.

Remember that EBM relies on the best evidence available. Although Level 1 and Level 2 studies are preferred, the orthopaedic literature includes an abundance of Level 3 and Level 4 studies, which are still useful to the orthopaedic surgeon and the M&M process. A focus on results and applicability might find that surgical débridement, with or without implant removal, and IV antibiotic therapy is more effective than IV antibiotics alone.

EBM and outcomes
The likely prediction of outcome for this patient can also be ascertained by an EBM review. The importance of studies regarding outcome or prognosis is their applicability to patients or their use in determining patient care and therapeutic intervention.

An EBM review of the literature may find overlap with respect to the diagnosis and treatment of a condition, which are often analyzed for a given outcome. Again, however, a rational review of the literature is warranted, resulting in some Level 2 and Level 3 studies for use. In contradiction of this surgeon’s anecdotal review of his practice, the EBM review might reveal that his patient has a greater than 99 percent chance of a poor outcome with ongoing infection.

EBM and decision analysis
Economic and decision analyses are less common in the orthopaedic literature, but also lend themselves to an EBM M&M conference. The setting not only enables physicians to addressing typical complications, it also provides an opportunity to evaluate the economic aspects of care. Although EBM economic studies are becoming increasingly popular, some economic analyses may require a local or regional evaluation.

Because of the paucity of applicable studies, economic analysis in the context of an M&M gathering provides the opportunity to evaluate specific costs and specific patient financial impact. Although the EBM literature addressing these issues can be quite complex, even a simple review of the costs associated with a desirable result (cost/uncomplicated case) compared to costs associated with an undesirable result (cost/complication) can be an eye-opening educational tool. In cases where good EBM economic literature exists, cost-effectiveness and utility can be examined.

The EBM opportunity
The M&M conference is a tremendous opportunity for physicians to apply EBM principles. As shown, Levels-of-Evidence can be used as a tool to create a more objective M&M conference—and they are a great starting point for integrating EBM into clinical practice. This format can result in the creation of an EBM repository within a hospital or practice, recognizing that the EBM reviews will change as the literature evolves.

This method of peer review can also lead to a more objective means of evaluating physician performance for credentialing purposes. A surgeon who consistently relies on the poorest evidence in medical decision making may be viewed differently than one who relies on high levels of evidence. Finally, this small foray into EBM may lead to further investigation into study design, hypothesis testing, clinically significant differences, measures of outcomes, and the many other evidence-based parameters used to improve patient care.

David Jevsevar, MD, MBA, is a member of the AAOS Evidence-Based Practice Committee. He can be reached at david.jevsevar@ihc.com

1st Advances in Rare Bone Diseases scientific conference