AAOS Now

Published 1/1/2016
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Susan T. Mahan, MD, MPH; Donald S. Bae, MD; Rachel L. Difazio, RN, PhD; Peter M. Waters, MD

Decreasing Variation in Clinical Practice

Care Pathways, Care Process Models, and SCAMPs
The current "cost crisis" in health care has resulted in greater emphasis on increasing value in healthcare delivery, particularly in orthopaedics. As orthopaedic practitioners, we are best positioned to streamline musculoskeletal care and to guide changes in practice. Among the many tools that can be used to increase the value of orthopaedic care are Standardized Clinical Assessment and Management Plans (SCAMPs).

At Boston Children's Hospital (BCH), SCAMPS were first developed in 2009 and successfully implemented in the cardiology department for a variety of diagnoses, including congenital aortic stenosis, pediatric chest pain, and hyperlipidemia. To date, 21 active SCAMPs have been developed and an additional 13 are in development. SCAMPs have been implemented in 19 different institutions.

SCAMPs and CPGs
In many ways, SCAMPS are similar to Clinical Practice Guidelines (CPGs). Both start with a thorough literature review, followed by the development of a care pathway or algorithm containing multiple decision points. Both SCAMPs and CPGs depend on the highest quality evidence, which can be difficult or unavailable in many situations.

The primary difference, however, is that CPGs typically exclude outliers and only include patients who represent the typical patient with the specific condition. In contrast, SCAMPs include all patients with the condition; with data collected both on those who follow the recommended algorithm as well as outliers whom the treating clinician thinks should not follow the prescribed algorithm.

SCAMP development continues with empirical testing not typically done for a CPG. This additional analysis allows for examination of potentially controversial decision points and treatment decisions. In the SCAMP, enrollment and data collection occurs for all patients, regardless of whether the recommended clinical pathway is followed.

Deviations from the algorithm are encouraged and expected in about 15 percent of patients, with some variation depending on the clinical scenario. When deviations occur, providers are asked to explain the reasons for the deviation. It is the deviations—and the rationale for those deviations—combined with frequent data analysis that can potentially improve the algorithm and the SCAMP.

In allowing for deviations from the management plan, the SCAMP offers an important improvement in the care process. It maintains physician and care provider autonomy, while offering the ability to learn from that clinical acumen, improve patient care, and improve the SCAMP.

The key differences between a SCAMP and a CPG are that in a SCAMP, data is collected on all patients, some deviations are expected and can provide innovation, ongoing data evaluation allows for improvement and modification of the SCAMP, and thus the SCAMP can evolve over time as is often necessary in clinical practice.

A SCAMP for DRFs
Recently, the department of orthopaedics at BCH implemented a SCAMP for the care of pediatric distal radius fractures (DRFs). DRFs are both common—accounting for about 20 percent of all pediatric fractures and affecting 1 of every 100 children—and clinically challenging. Challenges include questions about acceptable alignment, risk of late displacement, evolving treatment options and surgical indications, and changing patient and family expectations.

Treatment of pediatric DRFs varied considerably in our practice group.  This was best seen in the treatment variation of torus fractures, even though several clinical trials showed best treatment was with a removable splint. The goals of the pediatric DRF SCAMP were as follows:

(1) to reduce practice variation

(2) to maintain or improve patient outcomes

(3) to identify unnecessary resource utilization

Ultimately, we wished to maintain or improve patient care while improving cost efficiency. Our team began developing the DRF SCAMP in 2011, following a standard multistep process. The SCAMP was implemented in July 2012.

Results
At the 2015 annual meeting of the Pediatric Orthopaedic Society of North America (POSNA), we presented the results of a study on the impact of the DRF SCAMP implementation. The comparison study showed the following changes after SCAMP implementation:

  • a significant increase in appropriate splinting of torus fractures (as opposed to casting) and decreased clinical visits
  • no change in remanipulation or surgical rate for bicortical and distal physeal fractures
  • significant decreases in initial rates of reduction, and increase in appropriate use of initial long arm casting for bicortical and distal physeal fractures (although several clinical trials have shown short-arm casts to be appropriate treatment for DRF, since in our institution we are unable to reproduce the cast index of the studies, we continue to use long-arm casts for the first four weeks)
  • a significant increase in appropriate alignment at 6 weeks post-injury in bicortical and physeal fracture (83 percent pre-SCAMP versus 98 percent post-SCAMP, P < 0.01)
  • a decrease in clinical visits and a significant decrease in unplanned follow-up visits after the fracture had healed for all DRF
  • high acceptance and adherence to the SCAMP protocol by providers

A separate analysis of only torus fractures found a 48 percent reduction in clinic visits, a 60 percent reduction in radiographs, and an overall 54 percent reduction in the cost of caring for these injuries after SCAMP implementation.

In addition to improving patient care through standardization of practice, SCAMPs have also fostered research, innovation, and clinical practice changes. Our analysis has shown that radiographs at 4 weeks post-injury do not change care, information that we have recently incorporated into the SCAMP. This will decrease radiation exposure to the patient and reduce costs of care, with no change in patient outcomes.

Lessons learned
We have learned that great variability can be found in the care of even simple fractures, leaving tremendous potential for improving efficiency and decreasing the cost of care. SCAMPs and other care improvement initiatives require dedicated leaders, supportive technology infrastructure, and cultural buy-in. Implementation of SCAMPs is possible, even in the busy workflow of an academic pediatric orthopaedic practice, and can affect and improve the care children with this common injury receive.

In summary, implementation of a pediatric DRF SCAMP resulted in at least equivalent—and possibly improved—clinical outcomes, as well as improved adherence to best practice guidelines, fewer clinical visits and radiographs, and high provider acceptance. SCAMPs may be a useful tool for value-based healthcare delivery, and we are planning to quantify the effect of this SCAMP on DRF care, as well as expand SCAMPs to other musculoskeletal conditions. SCAMPS can be one way to streamline care, improve outcomes, and reduce cost while still maintaining physician autonomy and fostering innovation.

Susan T. Mahan, MD, MPH; Donald S. Bae, MD; Rachel L. Difazio, RN, PhD; and Peter M. Waters, MD, are on the orthopaedic staff at Boston Children's Hospital.

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