Published 10/1/2015

Second Look – Advocacy

These items originally appeared in AAOS Headline News Now, a thrice-weekly enewsletter that keeps AAOS members up-to-date on clinical, socioeconomic, and political issues, with links to more detailed information. Subscribe at www.aaos.org/news/news.asp (member login required)

CMS help with ICD-10 transition
The U.S. Centers for Medicare & Medicaid Services (CMS) has released
ICD-10: Clinical Concepts for Orthopedics—part of a series of guides that include common ICD-10 codes, clinical documentation tips, and a series of example clinical scenarios to familiarize providers with coding under ICD-10. Other guides in the series cover areas such as pediatrics, family practice, and internal medicine.

FDA: Diabetes drug linked to severe joint pain in some patients
The U.S. Food and Drug Administration (FDA) is
warning that the type 2 diabetes medicines sitagliptin (marketed as Januvia), sitagliptin + metformin (Janumet), saxagliptin (Onglyza), linagliptin (Tradjenta), and alogliptin (Nesina) may cause severe and disabling joint pain. A search of the FDA Adverse Event Reporting System database and the medical literature identified cases of severe joint pain associated with the use of dipeptidyl peptidase-4 (DPP-4) inhibitors. Adults with type 2 diabetes started having symptoms from 1 day to years after they started taking a DPP-4 inhibitor. After patients discontinued the DPP-4 inhibitor medicine, symptoms were relieved, usually in less than 1 month. Severe joint pain developed again when they restarted the same medicine or another DPP-4 inhibitor. The agency has added a new Warning and Precaution about this risk to the labels of all DPP-4 inhibitor medications. Healthcare professionals should consider DPP-4 inhibitors as a possible cause of severe joint pain and discontinue the drug if appropriate.

The FDA has also strengthened the warning for the type 2 diabetes medicine canagliflozin related to an increased risk of bone fractures and has added new information about decreased bone mineral density to the labels for Invokana and Invokamet. Healthcare professionals should consider factors that contribute to fracture risk before starting patients on canagliflozin. The FDA continues to evaluate the risk of bone fractures with other drugs in the SGLT2 inhibitor class—including dapagliflozin and empaglifozin—to determine if additional label changes or studies are needed. Healthcare professionals and patients are urged to report side effects involving canagliflozin or other SGLT2 inhibitors to the FDA MedWatch program.

CDC report looks at TKA trends
report from the U.S. Centers for Disease Control and Prevention (CDC) examines hospitalization trends for total knee arthroplasty (TKA) among inpatients aged 45 years and older. The researchers drew data from 2000 through 2010 from the National Hospital Discharge Survey. Over the term of the study, rates of TKA increased by 86 percent for men and 99 percent for women, yet the mean age decreased for all patients.

HHS proposes changes to “Common Rule” on research
The U.S. Department of Health and Human Services (HHS) has announced proposed changes to the “Common Rule,” regulations that govern research on research participants. Current regulations have been in place since 1991 and are followed by 18 federal agencies. HHS issued an Advance Notice of Proposed Rulemaking in July 2011 to solicit the public’s input on modernizing the Common Rule. The
Notice of Proposed Rulemaking reflects the public’s input. The following changes are among those proposed:

Enhanced informed consent provisions

  • Requirements for institutional review board (IRB) or administrative review
  • New information protection and data security standards
  • Written consent requirements for use of a study participant’s biologic samples for research, with the option to consent to use of those samples in the future for unspecified research
  • Requirement for use of a single IRB for multisite research, in most cases

All clinical trials—regardless of funding source—would be required to adhere to the proposed rule if performed in a U.S. institution that receives funding from a Common Rule agency for studies with human participants.

Expedited licensure process now approved in 11 states
reports that 11 states have now enacted the Interstate Medical Licensure Compact Act—an initiative designed to streamline the licensure process for physicians who seek to practice in multiple states. The legislation does not permit physicians to practice across state lines, but offers a simplified process to physicians who practice in states that have approved the Act to apply for licensure in other such states. At least eight additional states have introduced legislation to adopt the Act.

Top reason for filing orthopaedic malpractice claims?
report released by medical liability insurer The Doctors Company attempts to identify the most common factors in orthopaedic medical liability cases. The review of 1,895 closed claims against orthopaedists found that improper performance of surgery, improper management of the surgical patient, and diagnosis-related issues, such as failure or delay in diagnosis or wrong diagnosis were the three most common patient allegations. The top five factors associated with possible injury were technical performance, patient factors, selection and management of therapy, communication between patient or family and provider, and patient assessment issues, such as failure or delay in ordering diagnostic tests. Further, in 29 percent of cases, patient behaviors such as not following a treatment plain or missing scheduled appointments affected the outcome of care.

Florida laws linked to reductions in opioid prescribing
Findings from a
study published in JAMA Internal Medicine (online) suggest that implementation of two Florida laws may have been associated with modest reductions in opioid prescribing and use. Comparative interrupted time-series analyses were used to characterize the effects of the state’s Prescription Drug Monitoring Program (PDMP) and pill mill laws. Implementation of the laws was associated with statistically significant declines in opioid volume and morphine milligram equivalent (MME) per transaction, without any change in days’ supply. At 12 months after the laws took effect, there was an approximately 1.4 percent decrease in opioid prescriptions, 2.5 percent decrease in opioid volume, and 5.6 percent decrease in MME per transaction.

Too old to practice?
article on the KPBS Public Broadcasting website looks at the issue of aging physicians, noting that one in four currently practicing physicians in the United States is estimated to be 65 years or older. The American Medical Association House of Delegates recently advocated the development of “guidelines and methods of screening and assessment to assure that senior/late career physicians remain able to provide safe and effective care for patients.” (See “The Senior Physician: Acknowledging Age and Ability,” AAOS Now, October 2015). Some hospitals have implemented screening programs for older physicians who wish to retain their staff privileges.

Reducing use of CT among pediatric patients
study published in Pediatrics looks at trends in the use of computed tomography (CT) scans among pediatric patients. The multicenter, cross-sectional study of children admitted to 33 pediatric tertiary-care hospitals from Jan. 1, 2004, through Dec. 31, 2012, found that across 10 All-Patient Refined Diagnosis Related Groups (APR-DRGs), the number of children imaged with any modality increased over the course of the study. However, there was an overall decline in the use of CT.

Does value-based payment equal lower revenues?
article in HealthLeaders magazine argues that a move toward value-based reimbursement need not negatively affect revenue. The profile of two health systems looks at one that began a shift to value-based pay in 1995 and another that has seen revenue hold steady even though value-based reimbursement now accounts for 22 percent of the system’s revenues.

Report looks at physician payment systems
report from the American Medical Association examines trends in physician payment, based on surveys of post-residency physicians. During 2014, about 51 percent of respondents said they were paid by multiple methods. Additionally, the report notes the following:

  • Salary and productivity-based payments were the most common payment methods.
  • About one-half of physicians’ total compensation was earned from salary.
  • Nearly a quarter (23 percent) of employed physicians didn’t receive salaried payments at all.
  • Salary was more likely to be a key factor for physicians working outside of a group practice than for those inside a practice.
  • Physician payment methods varied widely across specialties.

Hospital ownership of physician practices and admittance trends
According to a
report from the National Bureau of Economic Research, hospital ownership of physician practices increases the likelihood that patients will go to the hospital that employs their physicians. Data on hospital admissions was matched with information on physician practice ownership. Hospital ownership of an admitting physician’s practice “dramatically” increased the probability that the physician’s patients would choose the owning hospital. Patients whose admitting physician practices were not owned by a hospital were more likely to choose low-cost and higher-quality facilities.

Adult bike injuries rose from 1998 to 2013
published in The Journal of the American Medical Association examine trends in traumatic bicycle injuries among adults from 1998 through 2013. Data from the National Electronic Injury Surveillance System—a national probability sample of approximately 100 emergency departments—show that, over the course of the study period, the 2-year age-adjusted incidence of injuries increased by 28 percent, from 96 to 123 per 100,000 population, and the 2-year age-adjusted incidence of hospital admissions increased by 120 percent, from 5.1 to 11.2 per 100,000 population. In addition, the percentage of injured cyclists with head injuries increased from 10 percent to 16 percent, while torso injuries increased from 14 percent to 17 percent.

Physician-owned hospitals do not “cherry-pick”
Findings from a
study published in The BMJ (online) suggest that physician-owned hospitals (POHs) in the United States do not systematically select more profitable patients or provide lower value care. The observational study of 2,186 acute care hospitals, 219 of which were physician-owned found that patients at POHs tended to be slightly younger and less likely to be admitted via emergency department than those treated at non-POHs. However, POH patients and non-POH patients were equally likely to be black or use Medicaid, and had similar numbers of chronic diseases and predicted mortality scores. Overall, POHs and non-POHs performed similarly on patient experience scores, processes of care, risk adjusted 30-day mortality, 30-day readmission rates, costs, and payments for acute myocardial infarction, congestive heart failure, and pneumonia.

Approximately 7 million Americans are living with THA, TKA
recently published in The Journal of Bone & Joint Surgery finds that around 7 million Americans are living with total hip arthroplasty (THA) or TKA, with most of them being mobile, despite advanced arthritis. Historical incidence data from the National Hospital Discharge Survey and the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases from 1969 to 2010 were combined with mortality counts and general population census to estimate the prevalence of living patients who have undergone THA or TKA. After accounting for relative differences in mortality rates between the general population and THA and TKA patients, there were 2.5 million THA patients and 4.7 million TKA patients in 2010. A substantial rise in prevalence over time and a shift toward patients of younger ages was found.

Hospitals adopt initiatives to reduce SSI
article in HealthLeaders Media looks at efforts to reduce the incidence of surgical site infection (SSI). SSI occurs in an estimated 2 percent to 5 percent of patients who undergo inpatient surgery, and may cost up to $10 billion annually.