On March 15, 2012, the American Association of Orthopaedic Surgeons (AAOS) held its Spring Orthopaedic Quality Institute (OQI) in Washington, D.C. The goal of the meeting was to refine the mission and purpose of AAOS quality initiatives and to formulate a strategy for moving forward.

Participants included John R. Tongue, MD, AAOS president; Joshua J. Jacobs, MD, first vice-president; Kevin J. Bozic, MD, MBA, chair of the Council on Research and Quality and co-chair of the OQI; David Jevsevar, MD, MBA, chair of the Evidence-Based Practice Committee; William C. Watters III, MD, chair of the Appropriate Use Criteria (AUC) Committee; Craig A. Butler, MD, MBA, chair of the Health Care Systems Committee and co-chair of the OQI; William Martin III, MD, medical director; and current and former representatives from the AAOS Board of Councilors (BOC) and Board of Specialty Societies (BOS).

Quality initiatives past and future
AAOS has been involved in quality initiatives since the 1980s, but increased its activities under President John J. Callaghan, MD, who established a Quality Project Team (QPT) under the leadership of Frederick M. Azar, MD. The QPT report prioritized objectives and laid the groundwork for both the AUC and the OQI.

The OQI was developed to enhance AAOS relationships with external stakeholders such as payers, purchasers, policymakers, and other governmental and nongovernmental agencies in the quality arena. Although current quality initiatives have certainly solidified the AAOS position as a player in the quality arena, these efforts are still maturing and the AAOS lags behind some other medical specialty societies such as the Society of Thoracic Surgeons and the American College of Cardiology.

Dr. Watters provided participants with a brief overview on the lessons he has learned as a leader in AAOS quality efforts and outlined a blueprint for moving forward. One of the challenges facing the AAOS is the orthopaedic community’s inability to reach consensus on the purpose of quality initiatives. Many orthopaedic surgeons are cynical of quality initiatives and question the value of evidence-based medicine. According to Dr. Watters, orthopaedists generally tend to trust what their mentors did, particularly in the absence of large, randomized controlled trials.

The current cost crisis in the U.S. healthcare system, however, is forcing public and private payers to take unprecedented steps to reduce costs. To avoid a negative impact on orthopaedic surgeons and their patients, payers need to be convinced of the value of orthopaedic procedures. Dr. Watters suggested several steps that would reinforce quality as a core value of the AAOS and support the case for orthopaedics.

Prioritizing quality
One step would be to restructure quality efforts within the AAOS. Currently, quality efforts are “siloed,” and a small group, rather than a diverse assortment of members, is tasked with making decisions. According to Dr. Watters, the current structure does not support an environment that fosters long-term quality projects and reliable funding.

“AAOS presidents are each given free rein to set their own agendas each year and are permitted to divert resources from existing projects,” he said. This does not bode well for the development of clinical practice guidelines (CPGs), which can take 12 to 18 months to produce. He suggested implementing a “sustained leadership structure” to oversee, maintain, and revise ongoing projects.

A second step would be strengthening the relationship between quality and advocacy efforts. “We are doing great things, but we need policymakers and patients to be aware of these accomplishments and our ongoing mission to improve quality in orthopaedics,” he said. Dr. Watters suggested that the Councils on Advocacy and
Research and Quality “forge a policy of quality initiatives as advocacy for AAOS members, orthopaedic patients, and healthcare stakeholders.”

Dr. Watters also suggested that the AAOS invest in educational efforts focused on quality to familiarize practitioners with the meaning and implications of evidence and economic analysis in orthopaedic care. Such efforts should start with the resident training core curriculum and continue through continuing medical education and Maintenance of Certification requirements.

Addressing CPGs
AAOS quality improvement endeavors have had a significant impact. For example, the CPGs on osteoarthritis of the knee and preventing venous thromboembolic disease after total hip and total knee arthroplasties have had a national impact on treatment. Emerging guidelines on antibiotic prophylaxis for dental procedures in patients with joint replacements and the management of pediatric hip dysplasia are expected to have a similar impact.

In addition, CPGs have helped the AAOS develop a robust clinical research agenda and have strengthened relationships with the National Institutes of Arthritis and Musculoskeletal and Skin Diseases and other stakeholders, by identifying gaps in research through systematic literature reviews. In his presentation on CPGs, Dr. Jacobs maintained that the AAOS must work better with available evidence to develop CPGs.

Although lack of evidence is not unique to orthopaedics, some medical societies develop CPGs more efficiently than does the AAOS. Dr. Jacobs acknowledged members’ concern that ‘inconclusive’ recommendations resulting from no evidence or conflicting evidence may lead to payment denials. However, determining that the evidence for a treatment or procedures is inconclusive and that research is needed to fill this gap is, he believes, better than reporting nothing at all. CPGs can always be revised to reflect new evidence as it becomes available.

Dr. Jacobs also acknowledged member concerns about “weak” recommendations based on low-quality evidence. When making coverage determinations, however, payers rank these weak recommendations significantly higher than non–evidence-based position or consensus statements.

BOC and BOS representatives suggested that a diverse group of members, including specialty and state society members, should be invited to participate in the development of CPGs so that the topics chosen are applicable to general orthopaedic surgeons. Dr. Jacobs agreed, and further suggested that the AAOS select broad topics that require multistakeholder collaboration and focus on the comprehensive care of a patient.

Bridging the gap between evidence and practice
Although CPGs are vital to determining what procedures work to diagnose and treat specific conditions, they may be difficult to apply in some clinical settings. Physicians and payers not only want to know what procedures work to treat a condition, they also want to know when and on whom those procedures should be performed. As a result, the emphasis is shifting to developing AUCs and user-friendly checklists to help physicians decide when a certain procedure is indicated, based on patient comorbidities, available resources, and other scenarios.

CPGs precede derivative products like AUCs and checklists because the underlying systematic reviews of the literature are a necessary foundation for these products. Going forward, suggested Daniel J. Berry, MD, AAOS past president, CPGs, AUCs, and other derivative products should be developed in tandem.

Deborah Cummins, PhD, director of the department of research and scientific affairs, affirmed that as long as a systematic review of the evidence is conducted, CPGs, AUCs, and other derivative products can be developed and opportunities for shortening the development timelines found. In addition, developing plain language summaries and creating smart phone and tablet apps may help disseminate and encourage wider use of these products.

Future directions
“AUCs and CPGs offer a tremendous opportunity for the AAOS to impact orthopaedic practice to the benefit of our patients,” said Dr. Bozic. “If we don’t develop these tools on our own, there is a robust industry ready to take our place.”

Dr. Butler echoed Dr. Bozic’s remarks and suggested that skeptics of this movement should view quality as a solution to shortcomings of the current healthcare system rather than as a threat posed by payers. In other words, the AAOS, its members, and their patients are better served by leading quality initiatives rather than reacting to ideas and definitions of quality put forward by others.

Madeleine Lovette is the communications specialist in the AAOS office of government relations.