Reducing variations in practice and doing more for less are among the challenges facing orthopaedic surgeons in their efforts to maintain timely, effective care for their patients. However, according to David S. Jevsevar, MD, MBA, of Dartmouth-Hitchcock Medical Center, several “barriers to change” in the United States are hindering efforts to improve quality. Dr. Jevsevar outlined 10 of these barriers during the AAOS Annual Meeting symposium on “The International Musculoskeletal Time Bomb: Time for Action.”

Admitting the problem
According to Dr. Jevsevar, the failure to recognize that a problem exists is the first hurdle in meeting the quality challenge.

“In orthopaedics, most of the time we get results, so it’s hard for us to acknowledge in our own minds that there is actually a problem,” he said. “For example, an analysis of Medicare data shows a disparity in the outcomes for total hip and total knee arthroplasty procedures between high-volume and low-volume hospitals in the United States.

“Data on 30-day mortality and readmissions show marked differences both for hip and knee replacements. This doesn’t mean hip and knee arthroplasty procedures shouldn’t be performed at low-volume hospitals, but it does mean that we need to improve our approach to improve the overall quality,” he noted.

Missing data
A lack of data that would appropriately measure quality is the second hurdle. “Most of what is available is administrative data, which are good for measuring costs but may or may not be helpful for measuring quality,” Dr. Jevsevar said. “In the United States, the orthopaedic profession has been relatively slow to adopt registries, which are critically important to measuring quality.”

Dr. Jevsevar also addressed the debate about the importance of clinical versus patient-reported outcome measures. “The reality is that they are both important,” he said.

Sharing information
Regulatory limitations on sharing data present another hurdle to improving outcomes. “The United States has an abundance of these regulations, even for quality improvement efforts,” Dr. Jevsevar said. “Regulators fear collusion among providers. As providers, we may fear releasing unfavorable data or information on poor outcomes because we are worried about liability. Medicare-aided geographic cost disparities make accurate comparisons difficult.”

Placing blame
Supporting quality improvements calls for a shift in culture in many institutions as well as new strategies to address potential liability. “We need just cultures that allow for safe peer review and quality improvement strategies. We need harbors that protect providers from liability as we undertake quality improvement initiatives,” said Dr. Jevsevar. He also called for alignment of physicians, hospitals, and payers, as well as shared accountability for quality.

No quick fixes
Addressing what he called “flavor-of-the-month” quality improvement, Dr. Jevsevar said, “We want a quick fix for complex process systems. We change strategies quickly when early results do not achieve desired outcomes. Real change in orthopaedics will take time.”

He also noted that over time, the commitment to improving quality may wane. “I don’t think the model for improvement is as important as the commitment to improvement,” he said.

More is not better
“In the United States, we think that if we pay more for health care, we are going to get better health care. Health care in the United States is worse than other nations despite what we pay,” said Dr. Jevsevar. He pointed out that the United States has the lowest life expectancy at birth among wealthy nations—79 years versus a comparable-country average of 82 years.

Where’s the evidence?
The paucity of evidence and best practice analyses is another problem. Pointing to the AAOS clinical practice guidelines, Dr. Jevsevar noted that even the best ones don’t have many ‘strong’ recommendations.

“That doesn’t mean we should do nothing,” he cautioned. “We should be able to take the evidence we have and apply it in a uniform and standardized fashion. With government initiatives, there is a lot of pressure to produce guidelines and performance measures as quickly as we can.

“The quality of evidence in orthopaedics is significantly improving year to year,” he continued. He urged his colleagues to participate in registries and to visit the orthoguidelines.org website. The website, which focuses on evidence-based orthopaedics, serves as an online information resource providing up-to-date treatment guidelines to orthopaedic surgeons and professionals.

It’s hard to change
Even when the evidence points to the effectiveness—or lack of efficacy—of a specific treatment, providers are often slow to make changes in their personal practices. “As physicians, we all tend to struggle with this,” admitted Dr. Jevsevar. “Even when a strong recommendation or a strong evidence base exists, we are unlikely to adopt it. We have what I call ‘American guideline exceptionalism.’”

Physicians often believe their patients are different, noted Dr. Jevsevar. “But I believe 80 percent of patients will fall within a guideline, and in 20 percent, the guideline may not apply exactly.”

He pointed out that patients don’t like clinical practice guidelines either, viewing them as “a cookbook way to approach medicine,” and patients like to think they are unique. “We have to do a better job of educating our patients on the importance of guidelines,” said Dr. Jevsevar. “In 2010, the AAOS issued a guideline that said vertebroplasty does not work, yet the rate of vertebroplasty in the United States continues to increase every year.”

He pointed to two inherent biases shared by physicians. “Confirmation bias is our reliance on things we have done in the past, even though we haven’t analyzed the results closely. Eminence bias finds us paying attention to what experts in the field say, such as at meetings. They are critically important, but a lot of what is presented is anecdotal and based on a surgeon’s experience.”

The cost of change
From the adoption of electronic health records (EHR) to the collection of outcomes data, “whenever we have quality improvement in the United States, the cost of care goes down,” noted Dr. Jevsevar, “but the cost of improving quality has to be funded up front.” For example, according to the website HealthIT.gov, the cost of purchasing and installing an EHR may range from $15,000 to $70,000 per provider.

“How do we pay for it?” he asked. “These are hard areas that our system doesn’t address. The cost of data acquisition is significant. Most physicians and hospitals don’t have the luxury of high margins to fund these initiatives.”

Who’s in charge?
Finally, said Dr. Jevsevar, is the question of leadership. “If orthopaedic surgeons don’t provide the leadership for quality improvement,” he warned, “a lot of other groups would like to do it for us. The patients want us to be the leaders.”

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