Published 10/1/2010

Quality care means putting patients first

Since my last column, several issues concerning quality care have arisen. The first was the voluntary recall by DePuy Orthopaedics of its ASR Hip Resurfacing System and its ASR XL Acetabular System. The recall was announced by DePuy on Aug. 24, and the AAOS followed with a notice in Headline News Now on Aug. 27, and a Patient Safety Member Alert on Sept. 3.

John J. Callaghan, MD

The recall was based on data from the National Joint Registry of England and Wales, underscoring the importance of a national registry and the impact it can have on patient safety and quality care. The AAOS has long advocated the establishment of a national registry in the United States, resulting in the formation of the American Joint Replacement Registry (AJRR) earlier this year, and we will continue to work with all stakeholders—industry, specialty societies, payors, government agencies, and patients—to expedite implementation and data collection.

If you need additional information on this recall, I encourage you to see the online version of this article, which includes links to the notice and information for surgeons and patients. If you have any questions, you can contact Katherine Sale, AAOS manager of biomedical research and regulation, at sale@aaos.org

Disclosure and transparency
A second issue highlights the need for transparency—particularly in the relationships between orthopaedic surgeons and industry. A recent study in the Archives of Internal Medicine focused on the disclosure of conflicts of interest among orthopaedic journal authors. The AAOS is preparing a response, but the facts of the study underscore the need for orthopaedic publications to establish standard disclosure policies and for orthopaedic surgeons to be forthright in disclosing any relationships with industry.

The AAOS has long promoted transparency and in recent years has strengthened our disclosure policy and made disclosure mandatory for authors, editors, faculty, presenters, and volunteers. I encourage all members to take advantage of the AAOS Disclosure Database.

Quality Project Team
As I write this, I am preparing for the September meeting of the AAOS Board of Directors. I anticipate that during that meeting, the Board will be taking two steps that underscore not only our individual commitments to delivering quality care and serving the best interests of our patients, but also our Academy’s commitment to “serve the profession, champion the interests of patients, and advance the highest quality musculoskeletal health.”

At that meeting, the Board will hear the final report of the Quality Project Team. This team was formed 4 months ago to address the rapid and substantial changes now occurring in the healthcare environment. Chaired by AAOS Treasurer Frederick M. Azar, MD, the Quality Project Team also included Kevin J. Bozic, MD, MBA; M. Bradford Henley, MD, MBA; John R. Tongue, MD; Kristy L. Weber, MD; and Daniel W. White, MD, LTC, MC, and was staffed by AAOS Medical Director William Martin III, MD, and Charles Turkelson, PhD, director of the AAOS department of research and scientific affairs.

The AAOS has always been a quality-oriented organization. As the Project Team notes, virtually all AAOS activities and programs are quality-related. Consider the following, for instance:

  • Our advocacy efforts in Washington, D.C., are aimed not only at improving the quality of care for patients, but also the quality of practice life for our members.
  • Our educational programs—from communication skills to self-assessment exams to surgical skills training—are aimed at improving members’ ability to provide quality care to their diverse patient populations.
  • Our research programs are aimed at identifying evidence-based best practices through the development of clinical practice guidelines.
  • Our communication efforts to members, patients, the public, industry, and others are aimed at delivering information that is accurate, trustworthy, and accessible.

The Project Team report includes the recommendation that the AAOS develop long-term strategies to take advantage of these strengths and to become known not only as a quality-oriented organization but also as a leader in the national quality movement.

On the national level, the new Patient Protection and Appropriate Care Act created hundreds of committees and commissions, many focused on the delivery of quality care. As the Department of Health and Human Services seeks members for these committees, the AAOS has the opportunity to recommend fellows for open positions. If you are interested in serving—in being a voice for orthopaedics and helping to shape the future of healthcare reform—I urge you to contact Dr. Martin.

Appropriate use criteria
One recommendation from the Project Team is for the AAOS to begin developing appropriate use criteria (AUC). As implied by the name, AUC specify when it is appropriate to use a procedure. An “appropriate” procedure is one for which the expected health benefits exceed the expected negative consequences by a sufficiently wide margin that the procedure is worth doing, exclusive of cost.

We all understand the need to make decisions about when or whether to use a particular procedure. The rationale behind the development of AUC is that sound data are often not available, or they often do not provide evidence that is detailed enough to apply to the full range of patients seen in everyday clinical practice.

The development of AUC combines the best available scientific evidence with the collective judgment of experts to yield statements about the appropriateness of performing a procedure in a given patient. In this way, AUC complement and supplement the Academy’s current clinical practice guidelines and other evidence-based products.

I’m sure you will be reading more about the team’s recommendations and the development of AUC in AAOS Now in the coming months. The formation of these criteria relies on the collective experience of literally hundreds of orthopaedic surgeons, so the AAOS will actively be seeking your participation. Because AUC address the use of specific procedures, input from the various orthopaedic specialty societies will be critical, and the Board of Specialty Societies will be actively involved in their development. I hope you will consider sharing your clinical expertise in their creation.

AUC help ensure that our patients receive the quality care we want to provide and they deserve. Likewise, clinical practice guidelines provide us with the evidence base to make quality care decisions.

The issue of vertebroplasty
One such guideline being considered at the September Board meeting is on the treatment of osteoporotic compression fractures of the spine. (See cover story “
Treating osteoporotic spinal compression fractures.”) Although the guideline includes 11 separate recommendations, only one—on the issue of vertebroplasty—is likely to garner media attention and generate significant discussion.

Although I am not a spine surgeon, I know that osteoporotic spinal compression fractures are common and that vertebroplasty is frequently used to treat these fractures. I also know that the work group that developed these guidelines did include spine surgeons, some of whom performed this procedure.

Based on the evidence, they took a courageous step in putting patients first—before their own self-interest—and recommended against the procedure. As someone committed to quality and patient care, I applaud these fellows.

We should discontinue a treatment when the evidence shows it has little effect. We should inform our patients if Level I studies show little or no benefit to a course of treatment—particularly when more than one study comes to that same conclusion. Even though a treatment may be well-established—as was arthroscopic debridèment for knee osteoarthritis—when the evidence is clear that such a procedure does not deliver results that justify its cost and risk to the patient, we should reconsider its inclusion in our armamentarium of treatments.

Orthopaedic surgeons are life-long learners. By adopting appropriate use criteria and adhering to clinical practice guidelines, we show that we have learned new lessons about quality—lessons that enable us to provide better care for our patients.

Quality tip: Two ways to improve a process
A process is nothing more than a collection of individual steps strung together to achieve a desired outcome. And the probability that the process will deliver its desired outcome is actually the collection of individual probabilities that each of these steps will occur when and how they are designed.

Consequently, we have two ways to improve a process—we can reduce the number of steps by eliminating unnecessary steps or combining steps, and we can improve how well people perform the steps.

The delivery of health care cannot tolerate unreliable system performance. Thus, organizations embracing quality improvement should encourage staff at every level to look at basic everyday functions and ask: “What steps could be removed?” and “How could each step be made more reliable?” These simple questions are paramount in the drive toward excellence.