Published 6/1/2016

Second Look – Advocacy

High-volume providers
According to Kaiser Health News, three health systems have recently agreed to the "Volume Pledge," which is designed to prevent certain surgical procedures from being performed by surgeons who perform relatively few such procedures, or at hospitals where few such procedures are performed. The systems, which cover 20 affiliated hospitals, will now require minimum annual thresholds for 10 high-risk procedures, including hip and knee arthroplasty procedures, which will require 25 per surgeon and 50 per hospital. The agreement includes provisions for emergency surgery and for surgeons who may not meet the threshold because they were on leave; such surgeons might be required to perform a certain number of procedures under supervision. The three systems have asked other hospital networks around the country to join them. A number of studies have suggested that higher institutional and per-surgeon volumes may be associated with improved outcomes for certain procedures.

How many deaths are linked to medical errors?
A study published in The BMJ (online) suggests that medical errors may be one of the leading causes of death in the United States. The research team analyzed data from four prior studies and, based on 35,416,020 hospitalizations, extrapolated 251,454 deaths linked with medical error during 2013. If correct, the study suggests that medical error may be associated with as many as 9.5 percent of deaths in the United States each year. The research team notes that assumptions made in extrapolating study data to the broader U.S. population may limit the accuracy of its projections, and also notes that "absence of national data highlights the need for systematic measurement of the problem."

MACRA payment rule
A post on the Health Affairs blog outlines key elements of a proposed rule recently released by the U.S. Centers for Medicare & Medicaid Services (CMS), which details the physician reimbursement framework required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Among other things, the proposal consolidates the Physician Quality Reporting System, the Value-Based Modifier Program, and Meaningful Use into the single Merit-based Incentive Payment System. Under the proposal, eligible clinicians would receive a composite score based on four annually selected categories. In the first year, those categories would include:

  • Quality: 50 percent of total score
  • Advancing Care Information: 25 percent of total score (formerly Meaningful Use)
  • Clinical Practice Improvement Activities: 15 percent of total score—a new domain
  • Cost or Resource Use: 10 percent of total score, based on Medicare claims data—no reporting necessary

In addition, CMS proposes an approach to implementing the MACRA Alternative Payment Model (APM) pathway. Advanced APMs would need to meet three proposed requirements:

  • Required use of certified EHRs
  • Payment for covered professional services based on comparable quality measures
  • Either being an enhanced medical home or bearing more than "nominal risk" for losses

CMS will accept comments on the proposed rule for 60 days following publication in The Federal Register.

Concurrent surgeries
The American College of Surgeons (ACS) has revised its Statements on Principles to specifically cover concurrent surgeries. "Concurrent or simultaneous operations occur when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time….A primary attending surgeon's involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate," the statement reads in part. It also provides that during multidisciplinary operations, "it is appropriate for surgeons to be present only during the part of the operation that requires their surgical expertise. However, the attending surgeon must be immediately available for the entire operation." In addition, ACS states that for a complex procedure at an academic medical center, multiple qualified medical providers in addition to the primary attending surgeon may be involved, and the patients should be informed "of the different types of qualified medical providers that will participate in their surgery and their respective role explained," and that "the performance of overlapping procedures should not negatively impact the seamless and timely flow of either procedure."

On April 18, the AAOS Board of Directors endorsed the revisions to the ACS Statements on Principles. In endorsing the ACS statement, AAOS President Gerald R. Williams, Jr., MD, said "the AAOS strongly supports open, ongoing and transparent dialogue between the orthopaedic surgeon and his/her patient. As part of that informed consent process, this discussion should include what the patient may expect throughout the course of treatment, including surgical timing, staffing, risks and outcomes."

In an editorial published in The Journal of the American Medical Association (JAMA; April 19), the writers note that concurrent procedures are not uncommon, particularly at teaching hospitals, but point out that many patients may not understand the practice. The authors address two issues: the boundaries of safe practice (and who should set them), and how surgeons should communicate with patients. "When patients enter the operating room, they have every right to know what is being done to them and by whom," the writers argue. "The medical community and surgical professionals must take the lead in addressing [patient] concerns; develop mechanisms to self-regulate if, when, and how overlapping operations are performed; and do so in a way that is free from perceived conflict of interest and that preserves public trust in surgical care."

Opioid concerns
A research letter published in JAMA (April 19) looks at opioid prescribing patterns following low-risk surgical procedures. The researchers reviewed data on 155,297 opioid-naive adults who underwent one or more of the following surgical procedures during 2004, 2008, or 2012: carpal tunnel release, knee arthroscopy, laparoscopic cholecystectomy, or inguinal hernia repair. They found that patient characteristics changed over time, becoming more likely to be older and male and less likely to have inpatient surgery. Within 7 days, 80.0 percent filled a prescription for any opioid. Of these prescriptions, 86.4 percent were for hydrocodone/acetaminophen or oxycodone/acetaminophen. Mean morphine equivalents dispensed increased over time for all procedures, with the highest adjusted increase for patients undergoing knee arthroscopy. The researchers state that the increase was driven by an increase in the mean daily dosages, with little change in prescription duration.

In an unrelated letter to the acting administrator of CMS, a number of healthcare experts have asked the agency to remove three questions regarding pain control from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey. "Setting unrealistic expectations for pain relief can lead to dissatisfaction with care even when best efforts have been made to resolve pain," the signatories state. "Aggressive management of pain should not be equated with quality healthcare as it can result in unhelpful and unsafe treatment, the endpoint of which is often the inappropriate provision of opioids."

Adverse events
Findings published in The Journal of Bone & Joint Surgery (April 20) suggest that, given a selected patient population, a very low adverse event rate can be achieved for patients who undergo hand and upper-extremity surgical procedures at freestanding ambulatory surgery centers (ASCs). The research team conducted a retrospective review of 28,737 cases at a single ASC. They found 58 reported adverse events (0.20 percent of cases), including 14 infections, 18 postoperative transfers to a hospital, 21 hospital admissions after discharge, one medication error, and four postoperative hematomas. There were no cases of wrong-site surgical procedures, retained foreign bodies, or patient deaths.

An article in The New York Times notes unintended consequences of an Affordable Care Act initiative designed to penalize hospitals that have higher rates of adverse events. The writer observes that hospitals that have implemented more aggressive screening programs may uncover more adverse events, increasing observed rates and resulting in Medicare reimbursement penalties. "Medicare is reducing a year's worth of payments to 758 hospitals," the writer states, "including some of the most prestigious teaching hospitals in the country, with the highest rates of infections and other potentially avoidable complications, including blood clots after surgery, bed sores, hip fractures and sepsis."

Orthopaedic trauma surgeon supply
Data from a study published in the Journal of Orthopaedic Trauma (May) suggest that the number of orthopaedic trauma surgeons increased over a 10-year period, alongside a decline in the number of operative pelvic and acetabular cases. The researchers estimated surgeon supply using 2002 to 2012 census data from AAOS and the Orthopaedic Trauma Association, and the annual number of operative pelvic and acetabular fractures reported by American College of Surgeons verified trauma centers in the National Trauma Data Bank (NTDB) over the same term. They found that, from 2002 to 2012, the number of operative pelvic and acetabular injuries increased by an average of 21.0 percent per year, while the number of reporting trauma centers increased by 27.2 percent per year. At the same time, the mean number of orthopaedic surgeons per NTDB center increased an average of 1.5 percent per year. Overall, the annual number of operative pelvic and acetabular fractures per NTDB center decreased from 27.1 in 2002 to 19.03 in 2012—a reduction of 2.0 percent per year.

Drug monitoring programs
National efforts to the curb the opioid epidemic include prescription drug monitoring programs (PDMPs) that track patients who attempt to get multiple prescriptions for controlled substances. Bloomberg reports that although 49 states and Washington, D.C., have authorized PDMPs, the systems are being underutilized by physicians. States have steps available, however, to increase prescriber enrollment by making these systems more usable, according to Cindy Reilly, director of the prescription drug abuse project at the Pew Charitable Trusts. These steps include enabling busy prescribers to delegate checking the patient's prescription history to other staff members, linking PDMPs to electronic health records, and ensuring that the software can alert doctors to risky patterns and deliver the information in a meaningful way.

Resident duty hour restrictions
Faculty overseeing general surgery residency programs with duty restrictions more flexible than those operating under the standard Accreditation Council for Graduate Medical Education requirements reported that the more flexible duty hours programs had a more positive effect on the safety of patient care, continuity of care, and resident ability to attend educational activities. The "FIRST Trial"—the Flexibility In duty hour Requirements for Surgical Trainees trial—as reported in the Journal of the American College of Surgeons, surveyed all directors of programs participating in the trial (n = 117, of 252 accredited U.S. programs; 100 percent response rate). All the directors in the flexible-policy group indicated that "residents utilized their additional flexibility in duty hours to complete operations they started or to stabilize a critically ill patient."

Hospital star ratings
Modern Healthcare reports that CMS has postponed the public release of the new overall quality star ratings for U.S. hospitals until July. The ratings had been scheduled for release on April 21, but some stakeholders argued that the ratings system "oversimplifies the complexity of delivering high-quality care." Over the next 2 months CMS plans to host calls with providers to clear up questions about current methodology and obtain feedback to refine the program. The set that was delayed this week gives hospitals one to five stars based on specific inpatient and outpatient reporting measures. According to the American Hospital Association, only 87 of more than 3,600 U.S. hospitals received five-star ratings, and just over half of the hospitals fell within the three-star range.

Customer service issues
A survey that combed through online reviews by patients found that 96 percent of their complaints relate to wait times and communication issues, while just 4 percent focused on quality of care or misdiagnosis. Vanguard Communications conducted an automated analysis of more than 34,000 patient reviews of their physicians and found that among the complaints categorized as customer service–related, 53 percent related to communication, 35 percent to wait times and waiting rooms, 12 percent to practice staff, and 2 percent to billing. In the compliments category, 40 percent of the "5 star" comments related to bedside manner, 28 percent to practice staff, and 24 percent to communication. Vanguard noted that the large majority of patients are eager to compliment their physicians, and seem least tolerant of surprises that come in the form of practice hassles versus those stemming from medical results.

In a letter to the chief executive of Medtronic and to the commissioner of the U.S. Food and Drug Administration (FDA), U.S. Senator Al Franken (D-Minn.) has voiced concerns regarding trials of the Minnesota-based company's recombinant human bone morphogenetic protein-2 (rhBMP-2) product Infuse, the Minneapolis Star Tribune reports. The manufacturer has admitted that it did not report more than 1,000 adverse events to FDA within the required 30-day time frame. The letter requests information on changes Medtronic may have made to address the issue, including improvements to employee training and assurances that the company can rule out any intentional lack of reporting of adverse event data.

Physician value to hospitals
Orthopaedic surgeons are among the highest earners in terms of personal compensation at their hospitals, but family care physicians generate a higher ratio of revenue to salary for their institutions, a study reports. Merritt Hawkins, a Texas-based physician recruiting firm, reported that orthopaedic surgeons were paid an average of $497,000 in 2015, which yielded about $2.7 million for their hospitals—5.5 times their compensation. The average starting salary for family physicians was $198,000, and their services provided $1.4 million for the hospital, a return of 7.5 times their compensation value. The average compensation for all medical specialties was $1.56 million, according to Merritt Hawkins, up from $1.44 million in 2013.

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)