Think about it: As physicians, we do not make a single decision about a patient without first thinking about quality. However, we are now being asked to measure that quality. During any discussion about health care in the United States, you will hear the words “quality” and “value.” These buzzwords are being applied as rationales for change in the way health care is delivered and the way healthcare services are being reimbursed.


Published 12/1/2014
Frederick M. Azar, MD

Turning Buzzwords into Business Plans

The “value equation” calls for high-quality, low-cost health care and is likely a euphemism for lower reimbursement. As orthopaedic surgeons, we know that the services we provide offer the greatest social and economic value in all of medicine, and we have demonstrated this in recent studies undertaken by your Academy under the leadership of Past President John R. Tongue, MD.

Without question, we must continue to turn these buzzwords—quality and value—into business plans—not only for the AAOS but also for our individual practices. For some time, the AAOS has been investing heavily in quality initiatives, such as evidence-based clinical practice guidelines (CPGs), appropriate use criteria (AUC), patient safety initiatives, registries, the Orthopaedic Quality Institute, and, most recently, performance measures. We must continue these efforts, because they are directly linked to both delivery and payment reforms.

More importantly, as physicians whose patient care efforts and patient access are at stake, we need to be the ones developing quality initiatives such as performance measures. For too long, we have been held to proprietary measures that lack evidence. We must adhere to the Institute of Medicine standards, which identify the pursuit of quality with care that is safe, effective, patient-centered, timely, and equitable.

Presenting alternatives that are relevant to the work we already do and that are based on valid methodologies is the best way to highlight what we do and to leverage our services during advocacy discussions on payment reform and access to care. Under the leadership of Joshua J. Jacobs, MD, AAOS past president, we have worked to leverage our credibility in the quality arena into a seat at the table with healthcare stakeholders.

Experience and evidence
During its September meeting, your Board of Directors held a strategic discussion on the future of AAOS quality initiatives. During that discussion, we reviewed the Academy’s experience to date in developing CPGs and derivative products such as AUC; learned more about the expansion of quality efforts to address performance measures, patient safety, and risk adjustment; identified the “missing link” (data); and reviewed our options for partnerships to expand data collection initiatives.

To date, the AAOS has published 17 CPGs and has 3 new CPGs and 1 update in development. The Academy’s CPGs are evidence-based and almost unparalleled in their rigor and methodology. However, the lack of high-quality evidence for many of the treatments we employ is problematic. In addition, as noted by Kevin J. Bozic, MD, MBA, chair of the Council on Research and Quality, practicing orthopaedic surgeons are often reluctant to adopt recommendations—even those based on strong evidence—that contradict their anecdotal experiences with their patients.

We can all sympathize with this reaction. We did not earn our medical degrees by studying expert opinions in medical school; our knowledge was based mostly on scientific evidence. However, during our years of training and practice, we have often studied successful colleagues and incorporated their techniques into our practices. We have heard their stories of what does and does not work, and at times, those words uttered by the giants of our field have meant more to us than literature reports of studies conducted by people we did not know.

But we all realize that “experts” can be found to support practically every technique, approach, or treatment. And it is sometimes difficult to distinguish which “pearls of wisdom” will have a positive impact on patient care.

Without a reproducible effect based on science, care delivery will remain uneven and patient outcomes a mystery. Without quantitative research, we will never be able to understand why a technique that works well for one patient is an absolute disaster for another. Nor will we be able to identify which patients will benefit from which techniques. In the end, we must be able to balance the art and the science of medicine, the real and the ideal, to enable us to individualize patient care.

To improve our own skills, we need to be measuring outcomes. To make the case for the value of the services we provide, we need to be measuring outcomes. To validate orthopaedic-specific performance measures, we need to be measuring outcomes. To enhance our advocacy efforts with effectiveness data that support our positions, we need to be measuring outcomes.

Thus, your Board of Directors has established a “Big Data” Project Team to look at measuring outcomes, to consider what we should do, what data we need, and who would be good partners in this initiative. This project team is led by Gerald R. Williams Jr, MD, our second vice president, and composed of orthopaedic leaders. The project team would also develop strategies to build relationships with other organizations, particularly specialty societies, so that we can focus on outcomes measurement and prioritize inpatient, outpatient surgical, and outpatient office outcome measures of interest.

The AAOS is currently working on a pilot project with the American College of Surgeons’ National Surgical Quality Improvement Program for outcomes measurement for inpatient hip fracture procedures. In addition, we have refined the focus of our CPG program to eliminate smaller topic items and offer the alternative of a systematic review for important topics that do not meet the criteria (volume, cost, and variability) necessary for a CPG.

Playing to our strengths
The AAOS has more than 20 years’ experience in the quality arena. During that time, your Academy has refined and honed the skills of our volunteers and our staff. The dedication and efforts of our volunteers—including Dr. Bozic; David S. Jevsevar, MD, MBA; William J. Robb III, MD; Kevin G. Shea, MD; James O. Sanders, MD; and Warren Dunn, MD, MPH—have been and continue to be crucial in moving these efforts forward.

Our research staff, led by Deborah Cummins, PhD, has provided unparalleled support. Their creativity and ingenuity in developing workable tools and proprietary technology have resulted in mobile apps and web-based instruments to facilitate the evidence-based and peer-reviewed processes that support our quality initiatives.

The culture among our members is changing and we are beginning to see the fruits of these efforts. Because the review process for developing CPGs identifies important recommendations for clinical care and assesses the quality of supporting evidence, guidelines may serve as road maps for future clinical research. For the past 3 years, the multicenter Research Group for Osteochondritis Dissecans of the Knee has used the AAOS CPG on the diagnosis and treatment of osteochondritis dissecans to define areas of research.

Last year, the AAOS received a grant from the Agency for Healthcare Research and Quality to improve patient care in orthopaedics through innovative dissemination of CPGs, quality tools, and supporting information. We are currently testing a searchable online platform and mobile application that is accessible from computers, smart phones, and tablets with several residency programs. In 2015, we plan to roll it out for orthopaedists in practice.

Just this year, the Surgical Care Improvement Project listed aspirin as an acceptable prophylaxis for the prevention of venous thromboembolism after hip and knee arthroplasty. This decision is based in part on AAOS CPGs and addresses surgeon concerns about increased risk of bleeding resulting from the use of other types of prophylaxis. In addition, the AAOS AUC seem perfectly structured to become decision-support tools for orthopaedic electronic health records.

We hear and share your concerns!
It is frustrating to put forth Academy resources to find that we lack evidence to support a quality topic. We need to select quality topics that have sufficient evidence to support our quality initiatives.

In addition, recognizing that CPGs and AUC are complementary tools, we are also working on closing the time gap between the release of a new CPG and its corresponding AUC.

It is also important to note that it is capricious to use these guidelines for coverage decisions and malpractice cases, as there are no associated cost/benefit or risk/harms analyses, and we continue to fight the misuse of our guidelines on all fronts. AAOS guideline recommendations are not intended for use as benefits determination documents because they do not cover allocation of resources, business and ethical considerations, and other factors needed to determine the material value of orthopaedic care. Additionally, all evidence-based medicine efforts recognize that myriad factors—including clinician experience, patient preferences and values, and comorbid conditions—will affect the very complex clinical decision-making process.

What does all this mean to you?
AAOS and specialty societies are working together on many quality initiatives, including the development of CPGs, AUC, and performance measures. By working together, we will be able to develop the most effective quality-related instruments to help orthopaedic surgeons provide the highest quality care to our patients. At the same time, we hope to provide you with tools that take just a few simple clicks in the electronic health rec­ord to enable you to comply with healthcare delivery and payment reform models.