Challenges and opportunities in developing quality initiatives in orthopaedics

With a renewed focus on quality in US health care, the field of orthopaedic surgery faces both challenges and opportunities to lead the way in providing high-quality musculoskeletal care for patients. Orthopaedics has historically been an eminence-based and tradition-based specialty, and the future will require more evidence in the form of higher-level clinical studies. The orthopaedic oncology literature in 1 leading journal is analyzed between 2005 and 2011 to highlight the published levels of evidence. Models of quality initiatives from leading medical specialty organizations such as the American College of Cardiology are provided. A brief history of past quality efforts from the American Academy of Orthopaedic Surgeons as well as a more detailed review of the current initiatives including clinical practice guidelines, technology overviews, and appropriate use criteria are listed.     

Internet-based learning

The Internet, with established and newly appearing websites, is becoming a more integral part of orthopaedic education every day. We review some of the well-known resources on the Internet (Orthogate, OrthoNet, American Academy of Orthopaedic Surgeons site, Orthopedic Hyperguide, WorldOrtho, Wheeless's Textbook of Orthopaedics, Orthoteers, AO North America site, University of Iowa Virtual Hospital texts, and South Australian Orthopaedic Registrars' Notebook) and reports the results of a survey of 35 orthopaedic surgery residents and 24 attending orthopaedic surgeons on the use of orthopaedic knowledge resources on the World Wide Web. The top three most commonly used online sites by the residents were Wheeless's Textbook of Orthopaedics, the American Academy of Orthopaedics Surgeons website, and Orthopedics Hyperguide. According to the survey, all 35 residents used online resources for learning, giving preference to online textbooks when looking for clinical information and online practice examinations when preparing for the in-training (OITE) or board examinations. Among the attending physicians, 19 (79%) used the Internet. Their most commonly used online sites were the American Academy of Orthopaedics Surgeons website, AO North America site, and Wheeless's Textbook of Orthopaedics. The attending physicians also preferred online textbooks to other online resources. Also provided in this article is a discussion of our idea for a future comprehensive, accurate, and constantly updated orthopaedic online resource that uses already available technology.     

The case for patient-centered care in orthopaedics

Now is a critical time to develop a patient-centered care model in the field of orthopaedic surgery. Patient-centered care is defined by the American Academy of Orthopaedic Surgeons as the provision of safe, effective, and timely musculoskeletal care achieved through cooperation between the orthopaedic surgeon; an informed, respected patient (and family); and a coordinated health care team. Patient-centered care, a paradigm shift from disease-centered care, is being championed by government agencies, patient advocacy groups, and insurance companies. Orthopaedic organizations must develop a comprehensive education program to provide surgeons the tools they need to navigate this paradigm shift.     

Development of a method to analyze orthopaedic practice expenses

The purpose of the current investigation was to present a standard method by which an orthopaedic practice can analyze its practice expenses. To accomplish this, a five-step process was developed to analyze practice expenses using a modified version of activity-based costing. In this method, general ledger expenses were assigned to 17 activities that encompass all the tasks and processes typically performed in an orthopaedic practice. These 17 activities were identified in a practice expense study conducted for the American Academy of Orthopaedic Surgeons. To calculate the cost of each activity, financial data were used from a group of 19 orthopaedic surgeons in Houston, Texas. The activities that consumed the largest portion of the employee work force (person hours) were service patients in office (25.0% of all person hours), maintain medical records (13.6% of all person hours), and resolve collection disputes and rebill charges (12.3% of all person hours). The activities that comprised the largest portion of the total expenses were maintain facility (21.4%), service patients in office (16.0%), and sustain business by managing and coordinating practice (13.8%). The five-step process of analyzing practice expenses was relatively easy to perform and it may be used reliably by most orthopaedic practices.     

Prevention of venous thromboembolism after hip or knee arthroplasty: findings from a 2008 survey of US orthopedic surgeons

A survey was mailed to a representative sample of US orthopedic surgeons to assess protocols for the prevention of venous thromboembolism after lower extremity total joint arthroplasty. Practices were examined by type of operation, annual surgical volume, and opinions of consensus guidelines issued by the American Academy of Orthopaedic Surgeons and the American College of Chest Physicians. Although there was near-unanimous agreement that routine thromboprophylaxis should be the standard practice for patients who undergo hip or knee arthroplasty, surgeons were divided as to the exact management approach.     

Joint arthroplasty, dental treatment, and antibiotics: a review.

Many patients with artificial joints seek guidance from their dental and orthopaedic surgeons on whether they should take prophylactic antibiotics for routine dental treatment. Advice on this has been conflicting in the past, and other than a joint statement from the American Academy of Orthopaedic Surgeons and the American Dental Association, there has been little official guidance. In view of the lack of consensus, we have reviewed the relevant literature and have concluded that antibiotic prophylaxis should not be routinely given to all patients undergoing dental treatment but should be reserved for those patients deemed at high risk.     

2018年美国关节置换术使用氨甲环酸的临床实践指南解读

2018年美国髋关节和膝关节外科医师协会(AAHKS),美国骨科医师协会(AAOS),髋关节学会(THS),膝关节学会(TKS)及美国局部麻醉与疼痛医学学会(ASRA)共同协作,针对氨甲环酸(TXA)在全关节置换术(TJA)中应用的有效性和安全性进行了循证研究,就氨甲环酸给药的方式、剂量和时机以及在血栓形成高风险患者中的使用等提出了推荐意见,并根据证据支持强度对推荐意见进行了分级。本文对该指南进行解读,旨在为中国的骨科医务工作者、患者、医疗管理人员和指南制定者提供参考。     

Orthopaedic workforce studies: 1980 to 1985

A committee was appointed by the American Academy of Orthopaedic Surgeons in 1981 to continue the orthopaedic workforce studies begun by D. Kay Clawson a decade earlier. The committee found that the rapid increase in orthopaedists graduating from residency programs between 1970 and 1982 had resulted in a workforce in which fully 1/2 of practicing orthopaedists certified by the American Board of Orthopaedic Surgery were younger than 45 years. At that time, orthopaedists graduated at the rate of 700 per year. If that rate continued and if nothing else changed, it was calculated that the number of practicing board-certified orthopaedists per 100,000 people in the United States would continue to increase for at least 20 more years. The effect of reducing resident output by 10% increments also was projected with the hope that this information might influence future planning. In fact, a 10% reduction in resident output was achieved and the current ratio of board-certified orthopaedists per 100,000 population is very close to that predicted. In addition, the 1981 orthopaedic workforce committee developed a map of the United States that showed the number of board-certified orthopaedists in each major zip code. This map was distributed to every allopathic residency program in the United States in the hope that displaying this map might encourage graduating residents to choose more underserved areas in which to begin their practices. Evidence obtained subsequently by interviewing candidates taking Part II of the American Board of Orthopaedic Surgery certifying examinations showed this map seemed to have had very little effect in correcting workforce maldistribution.     

Physician-patient communication: a lost art?

In the face of rapid advances in technology, there has been a progressive deterioration of effective physician-patient communication. The American Academy of Orthopaedic Surgeons has identified that patients rate the orthopaedic profession as high in technical and low in communication skills. Poor communication, especially patient-interviewing skills, has been identified in medical students as well as in practicing physicians. Effective communication is associated with improved patient and physician satisfaction, better patient compliance, improved health outcomes, better-informed medical decisions, and reduced malpractice suits, and it likely contributes to reduced costs of care. Recognition of the importance of communication has influenced medical schools to revise curricula and to teach communication skills in residency training and continuing medical education programs. National certifying examinations also are being designed to incorporate these skills. Although written material is useful in increasing awareness of the importance of good physician-patient communication, behavioral change is more likely to occur in a workshop environment. The American Academy of Orthopaedic Surgeons is taking leadership in designing and implementing such an approach for its membership.     

Assessing the recognition of female orthopaedic surgeons in Castle Connolly's “America's Top Doctors” from 2000 to 2020

BackgroundThe field of orthopaedic surgery has one of the lowest percentages of practicing female physicians. Studies have shown disparities in various academic societies’ award recipients by sex. Given the recent increased use of physician rating platforms by patients and focus on consumer-driven healthcare, our aim was to assess the recognition of female orthopaedic surgeons.MethodsA twenty-year quantitative analysis was performed comparing the rate of top female orthopaedic surgeons listed on Castle Connolly's “America's Top Doctors” to the percentage of practicing female orthopaedic surgeons as reported by the American Academy of Orthopaedic Surgeons.ResultsFrom 2000 to 2020, there was a statistically significant increase in the percentage of top female orthopaedic surgeons listed on Castle Connolly (1.3%–5.3%), as well as an increase in overall practicing AAOS female members (2.7%–5.8%). When comparing the rate of top female orthopaedic surgeons listed on Castle Connolly to the proportion of practicing female AAOS members from 2000 to 2020, there were no statistically significant differences.ConclusionsThe increase in the rate of top female orthopaedic surgeons recognized by Castle Connolly was proportionate to the increase in percentage of practicing female AAOS members over the past 20 years. This study highlights the persistence of a gender discrepancy in the academic sector of orthopaedic surgery.     

Variation in orthopaedic surgeons' perceptions about the indications for rotator cuff surgery

BACKGROUND: Epidemiologic studies have demonstrated substantial variations in per capita rates of many surgical procedures, including rotator cuff repair. The purpose of the current study was to characterize orthopaedic surgeons' attitudes concerning medical decision-making about rotator cuff surgery and to investigate the associations between these beliefs and reported surgical volumes. METHODS: A survey was mailed to randomly selected orthopaedic surgeons listed in the American Academy of Orthopaedic Surgeons directory. Only individuals who had treated patients for a rotator cuff tear, or had referred patients for such treatment, within the previous year were asked to complete the two-page survey. The survey comprised fifteen questions regarding clinical opinion, including four regarding hypothetical cases. Clinical agreement was defined as >80% of the respondents answering similarly. RESULTS: Of the 1100 surveys that were mailed, 539 were returned (a response rate of 49%). Of the 539 respondents, 316 (58.6%) had treated or referred patients with a rotator cuff tear in the previous year. There was a significant negative correlation between the surgeon's estimation of the failure rate of cuff repairs in the United States and that surgeon's procedure volume (r = -0.21, p = 0.0003), indicating that surgeons with a lower procedure volume are more pessimistic about the results of surgery than are those with a higher procedure volume. Arthroscopic, mini-open, and open cuff repairs were preferred by 14.5%, 46.2%, and 36.6% of the respondents, respectively. Surgeons who performed a higher volume of procedures were less likely to perform open surgery (p < 0.0001). There was clinical agreement regarding only four of the nine clinical questions and none of the four questions about the hypothetical vignettes. CONCLUSIONS: We found significant variation in surgical decision-making and a lack of clinical agreement among orthopaedic surgeons about rotator cuff surgery. There was a positive correlation between the volume of procedures performed by the surgeon and the surgeon's perception of outcome, with surgeons who had a higher procedure volume being more enthusiastic about rotator cuff surgery than those who had a lower procedure volume.     

Transmission of Human Immunodeficiency Virus Infection in the Surgical Setting

The emergence of the human immunodeficiency virus (HIV) has highlighted the need for orthopaedic surgeons to understand the epidemiology of percutaneous injuries and other blood exposures in the surgical setting. The American Academy of Orthopaedic Surgeons and the Centers for Disease Control and Prevention have worked to increase understanding and prevent transmission of blood-borne viral diseases in orthopaedic surgery. This article addresses the risk of HIV transmission in the surgical setting, with a focus on surveillance efforts to monitor the extent of occupational HIV infection, specific risk factors, and postexposure management. Health-care worker-to-patient transmission and patient-to-patient transmission are also addressed.     

What's new in foot and ankle surgery

This update summarizes recent research pertaining to the subspecialty of orthopaedic foot and ankle surgery that was published or presented between August 2009 and July 2010. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes), Foot & Ankle International, and the proceedings of Specialty Day at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), held on March 13, 2010, in New Orleans, Louisiana, and the summer meeting of the American Orthopaedic Foot & Ankle Society (AOFAS), held on July 7 through 10, 2010, in National Harbor, Maryland.     

The DASH questionnaire. French translation of a trans-cultural adaptation

The DASH (Disability of Arm-Shoulder-Hand) is a self-administered questionnaire developed in 1994 by representatives of the Institute for Work & Health (IWH) and the American Academy of Orthopaedic Surgeons (AAOS). It measures the physical disability and symptoms for all upper limb disorders in a heterogeneous population and for acute as well as chronic disorders. The original american version has been already tested for reliability and validity. Interest in the DASH was raised by several European publications. It appeared that the DASH could provide a common measure for upper extremity physical disability in Northern America and European countries. For this cross-cultural adaptation, we followed the guidelines developed by the Institute for Work & Health and American Academy of Orthopaedic Surgeons. Five translations and two "back-translations" were compared, aiming to semantic, idiomatic, experimental and conceptual equivalence. The final version has been tested in 223 patients presenting a variety of traumatic or non traumatic disorders. 208 questionnaires (93%) were valid because there was less than 4 missing answers. This final version has been proposed to American Academy of Orthopaedic Surgeons in order to be endorsed as an official translation. This could improve assessment for international studies by establishing standard measures.     

New technology and the orthopaedic surgeon: are you protecting your patients?

The treatment of patients with musculoskeletal disease will be revolutionized during the next two decades by advances in technology. Orthopaedic surgeons are eager to incorporate new technology into their practices to improve patient outcomes and practice efficiency. However, as the orthopaedic community embraces new technology and innovative surgical procedures, there is an increased need to consider issues of patient safety and to determine the best way to incorporate technology into our practices.     

Recreational injuries in children: incidence and prevention.

Participation in eight common types of recreational activities leads annually to more than 2 million medically treated musculoskeletal injuries in children aged 5 to 14 years. Many of these injuries could have been prevented if current safety guidelines and protective equipment had been used. Studies have demonstrated the value of safety education programs in preventing injuries. Parents consider their child's physician an important source of safety education, and orthopaedic surgeons have a unique opportunity to provide injury prevention counseling. The American Academy of Orthopaedic Surgeons recognizes the importance of injury prevention and has developed advocacy programs that are readily available to physicians and the public. Individual orthopaedists should be involved in injury prevention through patient education, research, community programs, and regulatory efforts that promote safe play for children.     

Orthopaedic operations in the United States, 1979 through 1983

Data from the National Center for Health Statistics were used to analyze the number of orthopaedic operations that were performed in the United States in 1979, 1981, and 1983. During the study period there was an increase of 24 per cent in the total number of orthopaedic procedures. During the same five-year period, the number of orthopaedic surgeons increased 28 per cent. Orthopaedic surgeons performed 3,549,000 operations in 1983, the most common orthopaedic procedure being open reduction and internal fixation of a fracture (331,000). This was also the eleventh most common operation performed in this country in 1983. The number of arthroscopic procedures (260,000) increased 100 per cent during the period of study, and this procedure was the sixteenth most common operation performed in the United States. In 1983, orthopaedic operations comprised 19 per cent of the surgery performed in this country. These figures illustrate the dynamics of the operative practice of orthopaedic surgeons in the United States. The figures show that the number of orthopaedic operations has markedly increased over the five-year period, but this increase is not as great as the increase in the number of orthopaedic surgeons. Future individual operative workloads of orthopaedists will decrease if these trends continue.     

Laparoscopic hernia repairs. The importance of cost as an outcome measurement at the century's end

At the dawn of this new millennium, surgeons not only must be masters of their craft but also are responsible for identifying and learning new techniques that are being introduced at an ever-increasing rate. Surgeons must overcome the instinctual mistrust of "the new" and, at the same time, avoid over enthusiastic, uncritical adoption of unproven procedures. Today's surgeons must also carefully assess and select the procedures and technologies that they will have time to learn and that will complement their practices and interests. More new things are coming along than any single individual can learn and practice with expertise, which makes general surgery a specialty with relative, as opposed to specifically, defined boundaries. Surgeons also should participate in the process of measuring the outcomes effective and to offer some advantages over open repair, namely less pain and a more rapid recovery period. On the other hand, this surgery has been shown to be difficult to learn and more costly. In a situation such as this, one can delete the procedure from the individual or institutional repertoire or use the modern tools of medical management to attempt to address the "outlier" issues and preserve the good. Laparoscopic hernia repair is a good procedure that can be done in a cost-effective manner if cost-conscious practice guidelines are initiated. It is not yet, however, a technique for all surgeons because of its difficulty to learn and advanced skills needed to perform it well.