Embracing evidence-based clinical practice guidelines (CPGs) in orthopaedics isn’t easy—in part due to the fact that the evidence for many treatments isn’t strong. But the surgeons at Resurgens Orthopaedics in Atlanta have found a way to use the CPGs prepared by the AAOS in their ongoing efforts to improve the quality of patient care.
Douglas W. Lundy, MD
AAOS Now: What factors influenced Resurgens to take this approach to the Academy’s CPGs?
Dr. Lundy: Resurgens has 79 orthopaedic surgeons and 14 physiatrists who cover practically the full spectrum of orthopaedic surgery (excluding complex pediatric orthopaedics and musculoskeletal oncology). As such, we are constantly seeking methods to improve clinical quality.
Through my friendship with Kevin J. Bozic, MD, chair of the AAOS Council on Research and Quality, I became aware of the Academy’s efforts in constructing CPGs. Hundreds of hours are spent reviewing reams of studies, and then days of review and discussion by orthopaedic surgeons well-versed in evidence-based medicine go into each CPG. To try and duplicate these efforts would be foolish. Because our orthopaedic surgeons are fellows of the AAOS, we didn’t have to be concerned about accepting the recommendations of an unknown organization.
I realized that we could significantly affect practice patterns if we made the content of the CPGs more apparent to our physicians. Champions of the cause need to be knowledgeable in the actual construction of the guidelines so that they can defend the process when inevitable disagreements occur.
AAOS Now: Did you get push-back from anyone in the practice about the CPGs?
Dr. Lundy: We received surprisingly little push-back from the orthopaedic surgeons and physiatrists in our practice—both groups were very receptive to the guidelines. During the process, we heard from specialty surgeons most directly affected by the CPGs who might disagree with a specific guideline. But they had to provide a valid reason for their point of view. Most of the physicians reviewed the documentation used to make the CPG recommendations and the education they received in the process makes them more capable to care for patients.
AAOS Now: The AAOS CPGs are evidence-based. What is Resurgens’ approach to evidence-based care?
Dr. Lundy: Evidence-based care is like “mom and apple pie,” that is, you can’t really be against it. Physicians may have issues with some of the specific recommendations that result from CPGs, but the evidence-based process is essential to those of us who practice scientific-based medicine.
Many CPG recommendations are softer than absolute dogma, meaning there is some room for orthopaedic surgeons to shape their practices. The orthopaedic surgeons and AAOS staff who developed the CPGs did so in a very controlled and measured process. These guidelines were not forced on us; rather they were developed by colleagues whom we all respect and admire for their clinical expertise.
AAOS Now: Did Resurgens’ implement all of the AAOS CPGs or did it choose only the ones that are most relevant to its practice?
Dr. Lundy: We began with some of the most relevant guidelines to our practice and are moving through the rest of them at a controlled pace. We are also in the process of implementing the Appropriate Use Criteria (AUC) that the AAOS is currently developing.
To achieve buy-in from our physicians, we focused our initial efforts on the most relevant guidelines. I would recommend this process to any orthopaedic group that is seeking to implement these CPGs. Not only is it overwhelming to take them on all at once, but a planned process to implement the CPGs progressively will result in higher physician alignment.
AAOS Now: What did the process involve?
Dr. Lundy: We made the process very inclusive—any Resurgens physician who wanted to be involved was included. The AAOS currently has 14 different CPGs, so we started with selecting four or five. We selected a chairperson from the appropriate specialty for each guideline. These subgroups also included all physician members of the specific specialties.
Each chairperson was responsible for organizing the group and providing links to the CPG summary and supporting documents. Meetings were held to discuss the content and recommendations of the guideline, though much of the discussion occurred on our intranet. The specialty groups worked to achieve a consensus understanding of the recommendations, and they discussed them at length.
After each subgroup had completed its review, a report was sent to the Resurgens board of directors. After final approval, we posted the CPG on our intranet, and sent the link to all Resurgens’ physicians. Newly adopted CPGs would also be announced at our quarterly physicians’ meetings.
AAOS Now: What advice do you have for other orthopaedic practices that may be considering implementing AAOS CPGs?
Dr. Lundy: I encourage all orthopaedic groups to start the process of reviewing the individual CPGs and AUC and to strongly consider incorporating them into their practices. The CPGs are a very thoughtful compilation of the available evidence to support or refute the available diagnosis and treatment of common orthopaedic conditions. These guidelines do not dictate standard of care, but rather review the literature for recommendations on certain clinical issues. Failure to follow the recommendations in the CPGs should never be viewed as negligence per se, since the guidelines do not dictate the standard of care.
Nonetheless, it is a very fruitful exercise for orthopaedic groups to review the material and discuss it with each other.
The intense methodology that the AAOS uses to construct CPGs causes them to be above reproach outside the orthopaedic community. The AAOS has done an outstanding job to disseminate the guidelines. Each CPG summary clearly describes what the current thought is, and the supporting documents discuss in length the thought process behind the recommendations. The AAOS also does a great job communicating the CPGs to its members through AAOS Now, AAOS Headline News Now, Journal of the AAOS, and the AAOS website.
The development of AAOS evidence-based CPGs is overseen by the Committee on Evidence-Based Quality and Value. For more information, visit www.aaos.org/guidelines
Dr. Lundy is a member of the AAOS Now editorial board. He also serves on the AAOS Council on Advocacy and the Communications Cabinet.
Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at email@example.com