With the ultimate goal of advancing science and research in orthopaedic care through a unified research strategy, the AAOS recently published a revised list of research priorities necessary to improve function and mobility and reduce the socioeconomic burden of musculoskeletal disorders in the United States.

This Unified Orthopaedic Research Agenda (URA) had its genesis nearly a decade ago, through a cooperative effort that included the AAOS and orthopaedic specialty societies. Originally a 20-page document developed as a communication tool for organizations like the Academy, specialty societies, and individual researchers, highlighting research priorities, it was subsequently condensed, revised, and used in research advocacy efforts.

The updated research agenda has been restructured as three separate documents crafted for the following specific audiences: the public and members of Congress, orthopaedic surgeons, and funding agencies. The AAOS Research Development Committee, along with the Council on Research and Quality (CoRQ), will oversee annual updates. Orthopaedic specialty societies through the Board of Specialty Societies (BOS) Research Committee and other organizations—including the Orthopaedic Research Society (ORS), Orthopaedic Research and Education Foundation, and the U.S. Bone and Joint Initiative—will provide input and data.

The initiative to renovate the research agenda was undertaken with several major goals, including the following:

• Focus the new URA on actionable items more directly related to orthopaedic surgeons.
• Broaden the “ask” to include federal funding agencies outside of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), extending it to other National Institutes of Health (NIH) affiliates, possibly with the funding request proportional to the burden of disease.
• Develop a process of updating the URA annually based on new evidence via the BOS Research Committee and the CoRQ committees.

With the new update process in place, the three URA documents were presented to and approved by the CoRQ and the AAOS Board of Directors at the end of 2013. This April, the public version of the URA will be deployed as an advocacy tool—with accompanying patient vignettes—during Research Capitol Hill Days, the Academy’s annual research advocacy event in Washington, D.C. The higher-level funding agency version will be distributed to the NIH leadership.

A deliberative process
According to Peter C. Amadio, MD, chair of the Research Development Committee, the three-part agenda was the result of a deliberative process involving input from the entire orthopaedic community.

“We asked why we should have a research agenda, and we decided there were three reasons,” he recalled. “First, to communicate with organizations like the federal government and foundations about what research topics they should be funding. Second, to inform the general public—including members of Congress—about why research for musculoskeletal health should be funded. Although members of Congress may not be as scientifically sophisticated as leadership at the NIH, they are very important in determining how much money gets allocated for musculoskeletal research. Third, within the community of orthopaedic surgeons, we sought to share with each other what we think is important and to let orthopaedic surgeons know what the AAOS is interested in and why.”

Educating the public
The URA targeted to the public and members of Congress highlights the fact that musculoskeletal diseases are the most common health condition in the United States and are the leading cause of disability, carrying a total cost of $950 billion annually. The URA provides a detailed breakdown of high-burden conditions, with an explanation of treatment challenges and specific recommendations for research goals. It notes the following priorities as relevant for all orthopaedic research:

• Patient safety and healthcare quality
• Creating value through orthopaedic care
• Eliminating disparities in access to and the outcomes of musculoskeletal care

In healthcare terms, it explains, “value is defined as achieving the greatest improvement in health for every dollar that is spent.” By studying how orthopaedic treatment can provide relief for various conditions, it notes, “orthopaedic research will lead to improved overall health, and thereby, create greater value to society by contributing to a stronger work force, an increase in productivity, and an enhanced quality of life.”

Patient safety is also emphasized as a primary priority: “Orthopaedic surgeons support minimizing—with a goal of eliminating—all types of preventable surgical harms.”

More detail for surgeons
The version of the URA oriented toward physicians is more specific and detailed about research priorities. In the clinical category, it calls for the staging of clinical trials of biologic treatments such as those using stem cells and growth factors and for expansion of research into musculoskeletal transplantation.

It also sets out a number of basic and translational research priorities, including study of molecular mechanisms that control growth and differentiation of cells, the effect of metabolism on basic cellular processes, cellular markers of stem cells, and regulation and expression of musculoskeletal cytokines.

This version also endorses several proposals to enhance patient safety and healthcare quality, including the following:

• better definitions of quality and measurable outcomes
• high-quality studies comparing surgical versus nonsurgical management for common conditions
• quantification of the impact of orthopaedic care on the individual and society
• development of “evidence-based programs to help patients and providers navigate the changing face of health care as mandated by the Affordable Care Act (ACA).”

Like the patient version, the document for the profession has a statement on value, defined as (Outcomes + Safety + Satisfaction) / Cost. The statement reads as follows:

“Dedicated research in orthopaedics is focused on attaining the best health possible at the lowest possible cost. Because improving health depends on how well the health status of our society is measured, ongoing orthopaedic research will spend a sizable portion of its efforts on appraising, defining, and then re-defining what quality means to our patients and to society.”

Recommendations for funding agencies
The URA targeting federal funding agencies provides detailed recommendations for each major musculoskeletal disease category, noting gaps in existing research.

It provides a more detailed outline of recommendations for research related to patient safety, calling for development of specific strategies to minimize complications and to implement large, multi-institution registries and studies to document the incidence of complications and adverse events.

The document also offers a specific research prescription in regard to the ACA:

• Perform epidemiologic studies assessing the implications of insurance networks/coverage, referrals, nonsurgical and surgical care, and accountable care organizations (ACOs) on delivery of musculoskeletal care.
• Educate the public on the public hospital quality reporting by the Centers for Medicare & Medicaid Services (CMS) and implications for musculoskeletal care.

A practical resource
For the practicing orthopaedic surgeon, Dr. Amadio said, the URA provides value as “a one-page, one-stop place to see the important issues in orthopaedic surgery, so orthopaedic surgeons can communicate with patients. If they have a chance to engage with funding agencies, this is useful information. It is significant that this information comes from and has been approved by other orthopaedic surgeons. It also serves to ensure the growth of research in the future, so that we have orthopaedic clinician-scientists engaged in research.”

He also noted that the URA strengthens the ethos of unity. “The unified agenda supports orthopaedic unity by directly engaging all parts of the orthopaedic community,” Dr. Amadio said. “It wasn’t just done within the Academy but was done by reaching out to all. The Academy provided the infrastructure, but the content came from the broad orthopaedic community, with all the specialty societies providing input.”

The URA documents are available on the AAOS website at www.aaos.org/research/documents/ura.asp.

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Image:
The first page of the Unified Research Agenda version for distribution to the public, including members of Congress.