Published 2/1/2018

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).

Informed consent
Findings from a study conducted in Canada and published in JAMA Internal Medicine (online) suggest the practice of overlapping surgery may be relatively rare, but notes potential for an increased risk of surgical complication. Members of the research team conducted a retrospective, population-based, cohort study of 38,008 surgically treated hip fractures, of which 960 were considered overlapping, and 52,869 total hip arthroplasties (THAs), of which 1,560 were considered overlapping. After matching, the researchers found that both overlapping hip fracture procedures and THAs were at increased risk of complication compared to nonoverlapping procedures. "These findings support the notion that overlapping provision of surgery should be part of the informed consent process," they write.

Overdose deaths
A data brief released by the U.S. Centers for Disease Control and Prevention finds that the age-adjusted rate of drug overdose deaths in the United States more than tripled from 1999 to 2016, with about two-thirds of such deaths opioid-related. An analysis by the nonprofit Trust for America's Health (TFAH) projects that, if current trends hold, the number of drug overdose deaths could reach 163,000 per year by 2025.

Liability and TJA
Findings published in The Journal of Arthroplasty (online) suggest that infection may be the most common reason for litigation following total joint arthroplasty (TJA). The researchers conducted a retrospective review of lawsuits filed in a five-county metropolitan area between 2009 and 2015. They found that 83 lawsuits were filed, 50 of which were dismissed or settled out of court, and 31 of 113 surgeons were named as a defendant in at least one suit. In descending order, the most common reasons for litigation were infection, nerve injury, chronic pain, vascular injury, periprosthetic fracture, retention of foreign body, dislocation, limb-length discrepancy, venous thromboembolism, loosening, compartment syndrome, and other medical complaints.

Liability and spine surgery
A study in Spine (online) analyzes medical liability claims associated with incidental durotomy. The researchers conducted a retrospective cohort study of 48 dural tear-related medical liability cases. They found that 56.3 percent resulted in a ruling in favor of the defendant physician. Among cases involving a payment, the average payment was $2,757,298 in 2016-adjusted dollars. The researchers note that 86.7 percent of cases alleged neurological deficits, and that 83.3 percent of cases without neurological sequelae produced an outcome in favor of the defendant. Overall, additional surgery was required in 56.3 percent of cases, a delay in diagnosis or treatment of durotomy was present in 43.8 percent, and alleged improper durotomy repair was present in 22.9 percent. A favorable outcome for the plaintiff occurred in 61.9 percent of cases with alleged delay in diagnosis or treatment, compared to 29.6 percent of cases lacking such a delay.

Device approval
The U.S. Food and Drug Administration (FDA) plans to publish guidance to refine the 510(k) medical device approval process. Devices approved under the 510(k) pathway must demonstrate comparable efficacy to existing devices. "FDA recognizes that such direct comparison testing creates burdens for 510(k) applicants, especially when many new devices are designed in novel ways, using more advanced technologies," wrote FDA Commissioner Scott Gottlieb, MD, on the agency website. In response, FDA intends to publish a draft guidance outlining a voluntary, alternative pathway designed to allow more flexibility using modern criteria as the reference standard. The draft guidance is expected to be released in the first quarter of 2018.

PVBPM participation
A study in Health Affairs (December) looks at the performance of participants in the first year of the Physician Value-Based Payment Modifier (PVBPM) program—a precursor to the upcoming Medicare Merit-based Incentive Payment System (MIPS). The researchers state that 1,010 practices met participation criteria, of which 899 had at least one attributed beneficiary. Of those, 263 (29.3 percent) failed to report performance data and received a 1 percent payment penalty. The researchers write that, among the 636 practices that reported performance data, those that elected quality tiering and those with high use of electronic health records (EHRs) displayed better performance on quality and costs compared to other practices.

EHR scribes
According to a research letter published in JAMA Dermatology (online), scribes may help reduce time physicians spend interacting with EHRs and reduce physician burnout factors. The authors describe a pilot program in which 12 dermatologists received scribe support in 19 weekly, half-day general dermatology sessions across three clinical sites. They found that implementation of the scribe program was associated with a reduction in physician documentation time from 6.1 minutes to 3.0 minutes per encounter. In addition, the authors identified a 7.7 percent increase in revenue for scribe-supported sessions, more than offsetting the cost of the scribes.

Outcomes data
According to a study in Clinical Orthopaedics and Related Research (December), the definition of outpatient status following THA and total knee arthroplasty (TKA) may be inconsistent, potentially influencing outcomes data. Members of the research team reviewed information on 72,651 THA patients and 117,454 TKA patients from the National Surgical Quality Improvement Program (NSQIP) database. They found that 529 THA patients were identified as outpatients but only 63 (12 percent) had a length of stay (LOS) equal to 0 days. Similarly, 890 TKA patients were identified as outpatients but only 95 (11 percent) had a LOS equal to 0 days. After controlling for potential confounders, the researchers found inpatient procedures to be associated with increased risk of any adverse event, serious adverse event, and readmission compared to outpatient procedures. However, given the same procedure and controlling for the same factors, patients who had LOS greater than 0 days were not associated with any increased risk compared with patients who had LOS of 0 days.

Healthcare spending
A report from the U.S. Centers for Medicare & Medicaid Services Office of the Actuary finds that growth in overall healthcare spending in the United States decelerated to 4.3 percent in 2016, following 5.8 percent growth in 2015. The report notes that during 2014 and 2015, the healthcare-spending share of the economy increased 0.5 percent from 17.2 percent in 2013 to 17.7 percent in 2015. Other findings from the report include the following:

  • private health insurance spending increased 5.1 percent in 2016, compared to 6.9 percent growth in 2015
  • Medicare spending grew 3.6 percent in 2016, compared to 4.8 percent in 2015 and 4.9 percent in 2014
  • Medicaid spending growth increased 3.9 percent in 2016, compared to 11.5 percent in 2014 and 9.5 percent in 2015
  • consumer out-of-pocket spending grew 3.9 percent in 2016, compared to 2.8 percent growth in 2015

Net neutrality
An article in Modern Healthcare looks at the potential impact on health care of repealing net neutrality. The U.S. Federal Communications Commission (FCC) voted to repeal net neutrality rules, which prevent internet service providers from preferentially throttling or enhancing consumer access to certain internet sites. Observers say the move could negatively affect telemedicine, unless future rules carve out exceptions to prevent such services from being throttled. In a separate vote, the FCC approved a proposal to increase funding to the Rural Health Care Program to help rural providers modernize their communications services.