July 2, 2014

Today’s Top Story
1. AANS and CNS joint panel updates guidelines for fusion procedures for degenerative disease of the lumbar spine.
The American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Joint Section on Disorders of the Spine and Peripheral Nerves has released an updated set of guidelines for fusion procedures for degenerative disease of the lumbar spine. AAOS members Jason C. Eck, DO; William C. Watters III, MD; and Alok Sharan, MD, were on the team that updated the guidelines. The guidelines include graded recommendations, rationale for procedures, search criteria used to identify relevant literature, and a section on the scientific foundations for each recommendation. The guidelines address 17 different topics, including:

  • Assessment of functional outcome following lumbar surgery
  • Radiographic assessment of fusion status
  • Interbody techniques for lumbar fusion
  • Bone growth stimulators as an adjunct for lumbar fusion
  • Assessment of economic outcome

The authors state that the guidelines are not intended to provide rigid treatment algorithms, but to instead “serve as a comprehensive review of the current state of the literature and provide the reader with a foundation to formulate an appropriate individualized treatment plan for a given patient.” The update replaces a set of guidelines published in the Journal of Neurosurgery in 2005.   Read more…
Read the complete guidelines…

Other News
2. Survey: Quality metrics becoming a larger proportion of physician compensation.
According to a survey from the Medical Group Management Association, quality measures continue to account for an increasing percentage of total physician compensation, with specialist respondents reporting that 5.70 percent of their total compensation was based upon quality metrics last year, compared to 5.96 percent of compensation for primary care providers. Overall, both primary care and specialty care physicians reported that their compensation increased slightly in 2013, with specialists reporting a 1.5 percent increase to $402,233 in median compensation and primary care physicians reporting a 5.5 percent increase to $232,989. Both primary and specialty care physicians reported bonuses and incentives to be 9 percent of their total compensation. In addition, on-call specialty care physicians reported 23 percent higher total compensation than specialists without call duties.   Read more…

3. Study: Surgeons must often manage a range of collateral ligament imbalances after mechanically aligned TKA.
A study published in the June 18 issue of The Journal of Bone & Joint Surgery examines the frequency and range of certain negative outcomes after mechanically aligned total knee arthroplasty (TKA). The researchers simulated mechanical alignment on 50 normal three-dimensional bone models of the lower extremity from white subjects. They simulated the following four methods for setting the posterior joint line:

1.     Perpendicular to the anteroposterior axis of the trochlear groove

2.     Parallel to the transepicondylar axis

3.     Externally rotated 3° with respect to the posterior condylar axis

4.     Parallel to the tibial resection in 90° of flexion with the use of gap-balancing aligned internal-external rotation of the femoral component

They found that 34 percent of TKAs required a ≥2-mm release of a tight collateral ligament for the medial collateral ligament; 30 percent of TKAs required a similar release for the lateral collateral ligament. The proportion of TKAs with ≥2mm of instability between 0 and 90 degrees was 56 percent in the medial compartment and 6 percent in the lateral compartment for method 1, 74 percent and 6 percent for method 2, and 42 percent and 0 percent for method 3. Method 4 did not cause ligamentous instability.
Read the abstract…

4. FDA issues new policy documents to cover compounded drugs.
The U.S. Food and Drug Administration (FDA) has issued several policy documents regarding compounded drug products for human use. The documents made available include:

  • A draft interim guidance describing the agency’s expectations regarding compliance with current good manufacturing practice requirements for facilities that compound human drugs and register with the FDA as outsourcing facilities.
  • A proposed rule to revise the FDA’s current list of drug products that may not be compounded.
  • Final guidance for individuals or pharmacies that intend to compound drugs under section 503A of the Federal Food, Drug, and Cosmetic Act (FD&C).

In addition, FDA has published two notices in the Federal Register, stating that the agency is reopening the nomination process for two lists of bulk drug substances that may be used to compound drug products—one each for drug products compounded in accordance with sections 503A and 503B of the FD&C Act.
Read more, with associated links…
Read section 503A (PDF)…
Read section 503B (PDF)…

5. Massachusetts.
An audit conducted by the Massachusetts Office of the State Auditor finds that courts in the commonwealth often fail to report physicians who face criminal charges to the Massachusetts Board of Registration in Medicine. According to the report, the board received only two court reports of criminal activity for physicians with active licenses between 2002 and 2012, but a check with the Department of Criminal Justice Information Services found 82 physicians with active full licenses with either a conviction for a felony or serious misdemeanor or a continuation without a finding that individual trial courts had not reported. A summary by The Boston Globenotes that 59 offences were vehicle-related, but nine physicians were charged with assault and battery and four with fraud; other cases involved distributing drugs, malicious destruction of property, threatening a person, and larceny.   Read more…
Read the complete report (PDF)…
A press release from the Office of the State Auditor states that, in the wake of the findings, the Massachusetts Board of Registration in Medicine has initiated new processes to improve the criminal information collection and reporting process.   Read more…

6. Oregon.
According to The Oregonian, a new Early Discussion and Resolution program overseen by Oregon Patient Safety Commission allows for mediation of disputes when medical errors are alleged. Under the program, any patient or direct family member may file a notice with the commission as an alternative to filing suit in a medical liability case. The notice triggers a confidential discussion in which all parties work with a mediator to offer an apology or financial settlement. If the discussion proves unsuccessful, filing suit remains an option. The paper states that only incidents that occur July 1, 2014 or later are eligible for the program.   Read more…
Visit the Early Discussion and Resolution program website…

7. Wisconsin.
An article in the Milwaukee Journal Sentinel looks at the status of medical liability in Wisconsin. The writer notes that there were 140 medical liability suits filed in the state during 2013—a decline of more than 50 percent since 1999. Medical groups credit the decline on improved performance by healthcare professionals. However, some critics view state restrictions on medical liability suits, including a law that allows only spouses and minor children to sue for loss of companionship in medical liability death cases, as a contributing factor.   Read more…

8. Call for volunteers: Bylaws, Ethics, and Resolutions Committees.
July 18 is the last day to submit your application for a position on the Bylaws Committee (one member opening), Ethics Committee (chair, one member opening), and Resolutions Committee (one member opening). The Bylaws Committee makes recommendations to the fellowship on all proposed amendments to AAOS Bylaws and Standards of Professionalism. The Ethics Committee is responsible for the ethics and professionalism initiatives of the Academy and Association. The Resolutions Committee makes recommendations to the fellowship on resolutions proposed for adoption.
Openings also exist on a number of other committees, subcommittees, councils, and cabinets. Visit the Committee Appointment Program website regularly to view new openings and find one that interests you.   Learn more and submit your application…(member login required)

July 7, 2014

Today’s Top Story
1. CMS proposal includes CME in Sunshine Act program.
The U.S. Centers for Medicare & Medicaid Services has released its proposed rule for the 2015 Physician Fee Schedule. Modern Healthcare reports that, included among the changes in the 2015 fee schedule is a proposal to eliminate the exclusion for continuing medical education (CME) in the Open Payments (Sunshine Act) program. Based on safeguards assumed already to be in place, CMS initially exempted industry sponsorship of CME activities from reporting requirements under the Open Payments program. However, CMS reversed this policy to avoid the appearance of encouraging industry support of CME activities. Becker’s Healthcare notes that the 2015 rule also creates a process for increased transparency in the development of payment rates, and proposes changes to the Physician Compare Website, the Physician Quality Reporting System, the Medicare Shared Savings Program, the Value-Based Payment Modifier, and the Physician Feedback Program. CMS will accept public comments on the proposed rule until Sept. 2, 2014.
Read more in Modern Healthcare(paid subscription may be required)
Read more in Becker’s Heatlhcare
Read the complete proposed rule (large PDF)…

Other News
2. Study: Kinematic alignment may offer improved outcomes over mechanical alignment for TKA patients.
Data from a study published in the July issue of The Bone & Joint Journal suggest that use of a kinematic alignment technique may offer improved outcomes for patients undergoing total knee arthroplasty (TKA) compared to a mechanical alignment technique. The authors conducted a randomized, controlled trial of 88 patients treated with either kinematically aligned TKA using patient-specific guides or mechanically aligned TKA using conventional instruments. At 2-year follow-up, they found that Oxford, WOMAC, and Knee Society scores were significantly better in the kinematically aligned cohort, compared to the mechanically aligned cohort. In addition, patients in the kinematically aligned group had 8.5 degrees more flexion compared to the mechanically aligned group. Overall, limb and knee alignment was similar for both cohorts, although the authors note that the femoral component in the kinematically aligned group was 2.2 degrees more valgus and the tibial component was 2.1 degrees more varus, compared to the mechanically aligned group.   Read more…

3. Study: Patients changing hospitals may increase complication risk for revision TJA.
A study published in the July issue of the journal Clinical Orthopaedics and Related Research examines the implications of changing hospitals for revision total joint arthroplasty (TJA). The researchers reviewed information on 17,018 patients who underwent primary and subsequent revision TJA between 1997 and 2005. They found that 30 percent of patients overall changed hospitals for revision. Overall, changing hospitals was associated with higher complication risk, and changing to a lower-volume hospital was associated with an additional increased risk of complications. Older patients were less likely to change hospitals, but no other patient characteristics were associated with changing hospitals. In addition, patients who had index TJA at the highest-volume hospitals were less likely to change hospitals. The authors write that their findings build on existing evidence of a volume-outcomes benefit for revision TJA.
Read the abstract…

4. Study: Initial use of advanced surgical innovations may negatively affect patient safety.
Findings published online in the July 2 issue of the journal JAMA Surgery suggest that surgical innovations may require an improved integration process in order to reduce an observed negative impact on patient safety. The research team conducted a cohort study of 401,325 patients who underwent radical prostatectomy during the diffusion period for minimally invasive radical prostatectomy (MIRP; study period Jan. 1, 2003 to Dec. 31, 2009, with rapid diffusion onset occurring during 2006). They found that in 2005, compared against open radical prostatectomy, MIRP was associated with an increased adjusted risk for any U.S. Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs). In addition, stratification by hospital status demonstrated similar patterns, with rapid diffusion onset among teaching hospitals being associated with an increased risk for PSI, and later onset among nonteaching hospitals also linked to an increased but nonsignificant risk for PSI. “To promote safety and protect patients,” the research team writes, “the processes by which surgical innovations disseminate into clinical practice require refinement.”   Read more…
Read the abstract…

5. Do hospital mergers drive up costs?
An editorial published in The New York Times argues that hospital mergers may increase healthcare costs. As an example, the authors cite the 1994 merger between Massachusetts General Hospital and Brigham and Women’s Hospital into Partners HealthCare. They note that one purpose of the merger was to prevent insurers from undercutting one hospital by threatening to send patients to the other. Although that effect has been achieved, the Massachusetts Health Policy Commission now estimates that a proposed merger between Partners and South Shore Hospital and related physician practices is likely to drive up total medical spending in the region by $23 million to $26 million per year.   Read more…

6. Call for volunteers: Workgroup members needed for CPG on treatment of OA of the hip.
The Committee on Evidence-Based Quality and Value seeks AAOS fellows to participate on a workgroup to develop an AAOS clinical practice guideline (CPG) on Osteoarthritis (OA) of the Hip—Conservative and Surgical Treatment. Workgroup members must be knowledgeable about evidence-based methods and prior to the introductory meeting must complete the following three CME Courses on Evidence-Based Medicine (located on the Orthoportal): Developing an Evidence-Based Clinical Practice Guideline; Evidence Based Orthopaedics: An Introduction; and Evidence-based Orthopaedics: Clinical Practice Guidelines. Applicants must have no financial conflicts of interest relevant to this topic, and be willing to sign an attestation form declaring that they will maintain an absence of relevant conflicts for the duration of the guideline process and for 2 full years after Board of Directors’ approval. Workgroup members must also be available to attend two mandatory meetings in Rosemont, Ill. For further information, please contact Leeaht Gross or Jayson Murray by Aug. 8, 2014, at ebm@aaos.org.
Learn more about guidelines and the development process (PDF)…

7. Free ePub edition of July AAOS Now now available for download and offline reading.
In addition to being available on the AAOS website, the July 2014 issue of AAOS Now magazine is available for electronic devices and e-readers capable of reading files in ePub format. These include iOS devices such as the iPhone and iPad, Android devices, and desktop computers. (At this time, Amazon Kindle does not recognize ePub files.) To download and view the electronic version of AAOS Now, visit the link below and log in using your AAOS username and password. Instructions for many devices are provided on the site. If you have comments or questions about the ePub version of AAOS Now, please email Peter Pollack, electronic content specialist, at ppollack@aaos.org.
Download and read the ePub version of AAOS Now(member login required)

8. Last call: Evaluation Committees.
July 11 is the last day to submit your application for a position on an Evaluation Committee. Members of Evaluation Committees write questions for the various orthopaedic Self-Assessment Examinations. The following positions are available:

  • Anatomy-Imaging
    • Foot and Ankle (one member)
    • Hand and Wrist (two members)
    • Spine (two members)
    • Tumors (two members)
  • Hand & Wrist (chair, nine members)
  • Musculoskeletal Tumors & Diseases (chair, five members)
  • Shoulder & Elbow (three members)

Applicants for a chair position must be active fellows who have served at least one term on the Central Evaluation Committee or an Evaluation Committee, and who have a practice emphasis in the relevant area. Applicants for member positions must be active fellows, emeritus fellows, candidate members, or candidate member applicants for fellowship with a practice emphasis in the relevant area.
Openings also exist on a number of other committees, subcommittees, councils, and cabinets. Visit the Committee Appointment Program website regularly to view new openings and find one that interests you.
Learn more and submit your application…(member login required)

July 9, 2014

Today’s Top Story
1. Study: Despite higher revision rates, UKA may be safer than TKA.
According to data from a British study published online in the journal The Lancet, unicompartmental knee arthroplasty (UKA) surgery may be safer than total knee arthroplasty (TKA), despite higher rates of revision for the former. The researchers conducted a retrospective review of 101,330 matched patients found in the National Joint Registry for England and Wales—25,334 of whom underwent UKA and 75,996 of whom underwent TKA. At 8-year follow-up, they found that UKA procedures had lower implant survival rates than TKAs, but mortality was significantly higher at all time points for patients who underwent TKA compared to those who underwent UKA. In addition, length of stay, complications, and readmission rate were all higher for TKA compared to UKA.   Read more…
Read the abstract…

Other News
2. Study: Nonsurgical management may be safe for certain children with a high-grade spondylolisthesis.
Findings published in the July/August issue of the Journal of Pediatric Orthopaedics suggest that nonsurgical management of minimally symptomatic or asymptomatic children with a high-grade spondylolisthesis may be safe. The research team conducted a database review of 49 patients with a high-grade (Meyerding grade III to V) spondylolisthesis. Overall, 24 patients were treated surgically and 25 were initially treated nonsurgically (10 of the nonsurgically treated patients eventually required surgical intervention). No significant difference in outcome was found between cohorts. The research team noted that a more kyphotic slip angle was associated with worse SRS-30 outcome scores across all groups; in the nonsurgical group, the slip angle was significantly larger in patients who eventually required surgery than in those who remained nonsurgical at final follow-up. Among surgical patients, an older age at surgery was associated with better SRS-30 outcome scores.
Read the abstract…

3. Study: MOM hip resurfacing linked to increased likelihood of revision and reoperation, compared to THA.
According to a study published in the July issue of the journal Clinical Orthopaedics and Related Research, revisions and reoperations are more frequent and occur earlier with metal-on-metal (MOM) hip resurfacing, compared against total hip arthroplasty (THA) (all types of implants). The authors reviewed 236 studies published after 1996 and found that the average time to revision was 3.0 years for MOM hip resurfacing and 7.8 years for THA. In addition, for all devices, revisions and reoperations were more frequent with MOM hip resurfacing than THA, but dislocations were more frequent with THA than with MOM hip resurfacing. The researchers noted that, when discontinued devices were excluded, adverse event rates changed, with revisions and reoperations moving to statistical similarity between treatments.
Read the abstract…

4. Not all electronic payment models are created equal.
An article in HealthLeaders Media looks at the issue of electronic payments in health care. Although electronic funds transfer (EFT) systems may reduce overhead and help providers more easily track bills and payments, some health plans send electronic payments using virtual credit cards, resulting in fees to the provider of 1 percent to 4 percent. According to a policy advisor at the Medical Group Management Association, some insurers have arrangements with credit card companies to take back a share of such fees. In addition, medical practices can lose key information in virtual credit card transactions compared to EFTs, because most virtual credit card transactions combine patients into one billing cycle reimbursement and discard individual identifier information found in the EFT model.   Read more…

5. HHS OCR to begin random HIPAA audits.
AMA Wire reports that the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) plans to begin implementing random Health Insurance Portability and Accountability Act (HIPAA) audits to monitor compliance. Failure to comply with HIPAA privacy, security, and breach notification requirements may result in financial penalties. The American Medical Association recommends three basic steps to protect against a breach in security and the loss of patient information:

  • Educate all staff about the importance complying with HIPAA requirements
  • Ensure all electronic patient information is encrypted when in transit and at rest
  • Perform a privacy and security risk assessment for all healthcare information technology (not just electronic health records)

Read more…
Read “HIPAA Highlights: What Orthopaedists Need to Know” from the May 2014 issue of AAOS Now
Learn more at the AAOS Practice Management Center…

6. Illinois.
The Associated Press reports that an annual licensing fee for Illinois hospitals will be used to fund a medical error reporting system established by the state in 2005. Under the system, a fee of $55 per hospital bed will help finance new safety measures and a system for addressing patient complaints, as well as the error reporting system. The Illinois Department of Public Health currently employs only 17 hospital inspectors across the entire state. A spokesperson says that the measure will help the department move from a punitive to a consultative approach to improving safety.   Read more…

7. Almost there: AAOS vote total tops 16 percent.
As of 8 a.m. on July 9, 3,918 AAOS fellows have voted on AAOS resolutions and bylaws amendments—just 817 ballots short of the 20 percent required for an official fellowship vote. Your participation and vote today can quickly help close out this round of voting. The resolutions under consideration cover the following topics:

  • Support for orthopaedic research
  • Education and promotion of volunteerism and orthopaedic advocacy
  • Orthopaedic work force assessment

In addition, the bylaws amendments being considered would add a new category (“reprimand”) to the Professional Compliance Program, clarify notification requirements about official actions taken under the Professional Compliance Program, and create a new membership category (associate candidate member–orthopaedic).
Cast your ballot…

8. Call for volunteers: JAAOS editor-in-chief designee.
AAOS seeks an editor-in-chief designee for the Journal of the AAOS (JAAOS). JAAOS is a monthly, peer-reviewed journal that publishes approximately 900 editorial pages annually. The editor-in-chief is engaged by the Academy as an independent contractor on an annual basis, with contract subject to renewal. As an independent contractor, the editor-in-chief has overall responsibility for meeting the educational and content objectives of JAAOS as set forth by the Council on Education and approved by the AAOS Board of Directors. Prior to assuming the role of editor-in-chief, an individual must first serve as editor-in-chief designee, during the final-year term of the incumbent editor-in-chief. This designee year is considered volunteering, but subsequent years serving as editor-in-chief are compensated. Applicants for this position must be active or emeritus fellows with previous high-level editorial experience on a major orthopaedic text or peer-reviewed journal. Applicants must submit an online CAP application, and also submit a current curriculum vitae, a cover letter detailing their interest and qualifications, and three references no later than July 25, 2014, to Hans Koelsch, PhD, publications director, at  koelsch@aaos.org.
Learn more and submit your application…(member login required)

July 11, 2014

Today’s Top Story
1. Senate report argues that increased investigation of Medicare payees has been ineffective in reducing fraud.
According to the Associated Press, a report from the U.S. Senate Special Committee on Aging criticizes the federal government for ineffective use of resources for tracking down Medicare fraud. The authors note that healthcare companies say they are losing millions of dollars appealing an increasing number of Medicare audits, but increased investigations have not correlated to a decrease in fraud. According to the report, improper payments within Medicare’s largest sector increased for the first time in 5 years, even as health officials launched a $77 million technology screening system designed to proactively prevent fraudulent providers from joining the system and prevent bogus claims from being paid. In addition, the authors point out that recovery audit contractors (RACs) are paid based on the dollar amount of fraud they identify, and argue that it would be more effective to pay RACs based on their ability to reduce fraudulent payment instead of merely identifying large amounts.   Read more…
Read the complete report (PDF)…

Other News
2. Study: Allograft ACL reconstruction may be more likely to fail compared to autograft.
According to research presented at the annual meeting of the American Orthopaedic Society of Sports Medicine, young, athletic patients who undergo anterior cruciate ligament (ACL) reconstruction are at increased risk of graft failure when an allograft, rather than an autograft, is used. The researchers conducted a randomized trial of 96 patients (97 knees) who underwent ACL reconstruction. At minimum 10-year follow-up, they found that there were 4 (8.3 percent) autograft and 13 (26.5 percent) allograft failures that required revision reconstruction. The researchers note that, among remaining patients whose graft was intact, there was no difference in the mean SANE, Tegner, or IKDC scores at last follow-up.   Read more…
Read the abstract (PDF; paper 21)…

3. Study: Immune marker may help identify pediatric trauma patients likely to develop infection.
Data published online in the journal Shock suggest that an immune marker may predict the likelihood of pediatric trauma patients to develop a hospital-acquired infection. The authors conducted a longitudinal, prospective, observational study of 76 critically injured children and 21 outpatient controls. Overall, 16 critically injured patients developed nosocomial infection. Those who developed infection had higher plasma IL-6 and IL-10 levels on post-trauma day (PTD) 1-2, compared to outpatient controls and those who recovered without infection. In addition, ex vivo lipopolysaccharide-induced tumor necrosis factor-a (TNF-a) production capacity was lower on PTD 1-2 and during the first week following injury (p=0.04) among children who developed infection. The authors noted that a TNF- a response of < 520 pg/ml at any time during the first week following injury was highly associated with infection risk. Among children who underwent blood transfusion, longer red blood cell storage age, not transfusion volume, was associated with lower innate immune function.   Read more…
Read the abstract…

4. Study: Many vets found to be unfit due to musculoskeletal injuries.
A study published in the July 2 issue of The Journal of Bone & Joint Surgery suggests that orthopaedic injuries are among the primary drivers for U.S. soldiers who served in Iraq to leave the military. The research team conducted a longitudinal, observational study of 4,087 surviving soldiers from a single Army brigade deployed to Iraq from 2006 to 2007. They found that 163 soldiers sustained combat-related musculoskeletal trauma and 587 soldiers had musculoskeletal injuries not related to battle. Overall, 374 soldiers were declared unfit by the Physical Evaluation Board and 236 were referred for at least one musculoskeletal condition. Of those 236 soldiers, 116 also had a behavioral health diagnosis. The research team found that musculoskeletal injury, presence of a psychiatric condition, and lower rank explained 78 percent of the risk of being found unfit by the Physical Evaluation Board.   Read more…
Read the abstract…

5. IDSA releases updated guidelines for treatment of SSTI.
The Infectious Diseases Society of America (IDSA) has released updated guidelines for the treatment of skin and soft tissue infection (SSTI). The guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion. Among other things, the guidelines include recommended approaches to:

  • Surgical site infections
  • Methicillin-resistant Staphylococcus aureus
  • Assessment of SSTI in immunocompromised patients
  • Assessment of SSTI in patients with cellular immunodeficiency
  • Animal bite wounds

The guidelines are published online in the journal Clinical Infectious Diseases.
Read the complete guidelines…

6. Residents and fellows in Seattle organize for collective bargaining.
An article in Slate looks at the issue of resident pay. The author notes that a perspective piece published in the June 19 issue of The New England Journal of Medicine points out that, in inflation-adjusted terms, resident compensation has remained essentially the same for 40 years, yet over that same period, the costs of housing, child care, and medical school debt have skyrocketed. “Organized medicine is hard-wired to artificially (and profoundly) depress wages of physicians in training,” the author writes. In response, he notes that a group of residents and fellows in Seattle are organizing to form an independent collective bargaining unit. What they are seeking, he says, is “an ongoing voice in the system. Until training hospitals acknowledge that voice, or Congress allocates more resources to train the next generation of physicians, formal collective bargaining may be the only option residents have.”   Read more…

7. California.
The Center for Investigative Reporting reports that a series of lawsuits have been filed alleging that some physicians in California participated in a scheme to manufacture counterfeit spine devices including screws and rods and implanted them in patients. Spinal Solutions LLC, a now-shuttered company, is accused of distributing and inflating the cost of the hardware in at least one lawsuit and in a separate whistleblower claim. The U.S. Food and Drug Administration had previously cited the company for quality control violations, and in 2013 the company recalled a series of spinal implant products due to “inadequate testing and documentation.”   Read more…

8. Call for volunteers: NASS Diagnosis and Treatment of Low Back Pain evidence-based guideline panel.
AAOS seeks one member to participate in the development of the North American Spine Society (NASS) Diagnosis and Treatment of Low Back Pain: Evidence-Based Guideline. NASS guidelines are developed utilizing an evidence-based process with multidisciplinary involvement. Because this is a NASS-convened effort, the final guideline product will be submitted only to the NASS Board of Directors for final approval. Individual society representatives will be credited as authors. The final guideline will be published on the NASS website and submitted for inclusion to the National Guideline Clearinghouse, and a summary will be published in The Spine Journal. Applicants for this position must be active fellows, candidate members, candidate members osteopathic, candidate member applicants for fellowship, or candidate member applicants for fellowship osteopathic. In addition, all applicants must provide the following: an online AAOS CAP application, current curriculum vitae, a 100-word biosketch, and a letter of interest highlighting their expertise in subject area and a statement on their ability to participate in full capacity. Supporting materials must be submitted by Thursday, July 24, 2014 at 11:59 p.m. CT.to Kyle Shah at shah@aaos.org.
Learn more and submit your application…(member login required)

July 14, 2014

Today’s Top Story
1. Is it time to loosen restrictions on off-label marketing?
An article in The Washington Post looks at the issue of off-label marketing by representatives of drug manufacturers. The writer notes that for decades the U.S. Department of Justice has “aggressively pursued” companies that market their products for off-label use, and the U.S. Food and Drug Administration (FDA) has “held firm to the idea that sales pitches generally should not include information on uses not approved by the agency.” The writer states that FDA is currently reviewing its rules on off-label marketing, with the goal of issuing new guidelines by the end of the year. Those who support loosening restrictions on off-label marketing argue that it will benefit patients by allowing physicians to make better-informed decisions. Critics respond that such marketing could expose patients to ineffective and potentially harmful treatments.   Read more…

Other News
2. Study: Most pitchers return to MLB after UCL reconstruction, but many see decline in performance.
Findings presented at the annual meeting of the American Orthopaedic Society for Sports Medicine examine outcomes for ulnar collateral ligament (UCL) reconstructive surgery performed on Major League Baseball (MLB) pitchers. The researchers reviewed data on 168 pitchers who threw at least one season at the MLB level and underwent subsequent UCL reconstruction. They found that 87 percent returned to play at the major league level. Of those, the researchers noted a statistically significant decline in earned run average, walks plus hits per inning pitched, and innings pitched, compared to pre-injury levels. The researchers also noted a statistically significant decline in pitching performance during the year leading up to reconstructive surgery, and that decline was found to be a risk factor for requiring surgery. Younger age at entering the major leagues was associated with an increased risk of requiring UCL reconstructive surgery.   Read more (PDF)…
Read the abstract (PDF; paper 13)…

3. AAOS and AMA ask CMS to delay rule that would alter hospital-staffing regulations.
A coalition of 83 medical societies, including AAOS and the American Medical Association (AMA), have signed a letter to the administrator of the U.S. Centers for Medicare & Medicaid Services (CMS), expressing “extreme disappointment” with a final rule that they say “makes unprecedented changes to the Medicare hospital Conditions of Participation that will dramatically alter the make-up and efficacy of hospital medical staffs nationwide.” The letter notes that under the rule, “multi-hospital systems may now have a single, integrated medical staff for the hospital system at large, and are no longer required to have a medical staff structure at each individual hospital.” The signatories state that provisions in the rule create “the possibility that a physician could be subject to peer review by a system-wide medical staff that has little familiarity with the standard of care or needs in the physician’s community.” The rule has an effective date of July 11, 2014, but the medical societies have asked CMS to delay its implementation until May 12, 2015, to give medical staffs time to ascertain the rule’s ramifications.
Read the letter (PDF)…

4. Report finds increase in medical liability suits related to obese patients.
An analysis from medical liability insurer The Doctors Company notes what the company calls “an alarming increase in lawsuits that involve obese patients.” The report finds a 64 percent increase in claims during the 6-year period from 2007 to 2012, compared to a previous study that encompassed a 10-year span. Orthopaedics accounted for the greatest number of claims per specialty, with 67 of 415 claims. Family medicine was second, with 65, followed by a sharp drop to 42 for both anesthesiology and plastic surgery. The authors note that many physicians may be uncomfortable speaking with patients about weight loss, but argue that proactively addressing weight gain may help reduce the need for later surgical intervention.
Read the report…
An unrelated article in The New York Times examines methods some healthcare facilities use to accommodate obese patients.  Read more…

5. Editorial calls for third party assessment for return to play for athletes with TBI.
An editorial in the August issue of The Lancet Neurology looks at the issue of concussion in the World Cup and other sports. The authors note that “the causes of post-concussion syndrome are unclear and do not seem to correlate with the severity of injury.” They argue that research efforts are key to understanding the short- and long-term effects of traumatic brain injury (TBI), and that more needs to be done to reduce its incidence and improve the assessment, monitoring, and care of those with sports-related concussions. “Because signs and symptoms of concussion can be delayed,” they write, “removing an athlete when there is any suspicion of injury would seem to be the safest approach.” In that regard, they argue that the decision to remove an athlete from play should “surely be taken out of the hands of those with a vested interest in the player’s performance.”
Read the complete editorial…

6. Florida.
According to the Miami Herald, some patients in South Florida are running into resistance from physicians who accept their medical plans, but are unwilling to accept patients who purchased insurance on Affordable Care Act exchanges. The reporter states that some physicians report concerns that they won’t be paid for their services by either the insurer or the patient. There are also reports that some insurers may not have adequately informed physicians of their inclusion in the exchange plan networks.   Read more…

7. Act now to nominate future AAOS leadership!
The 2015 Nominating Committee is actively soliciting your suggestions for individuals who might serve in the following positions:

  • Second Vice President
  • Member-at-Large [Age 45 or Older]
  • Member-at-Large [Under Age 45] (younger than age 45 on March 26, 2015)
  • National Membership Committee Member
  • Nominees to the American Board of Orthopaedic Surgery (ABOS)

Nominations will close on Friday, Aug. 15. You may submit nominations by mail to Daniel J. Berry, MD, chair, 2015 Nominating Committee, c/o AAOS Office of General Counsel, 6300 N. River Road, Rosemont, Ill. 60018-4202. You may also submit nominations electronically at http://www.aaos.org/nominations(member login required).

8. Last call: CME Courses Committee.
July 18 is the last day to submit your application for a position on the CME Courses Committee. Members of this committee participate in planning the Academy’s annual continuing medical education (CME) calendar, and act as committee liaisons for relevant Academy courses and webinars. The following positions are available:

  • Adult Reconstruction Hip and Knee (one member opening)
  • Spine (one member)
  • Sports Medicine (one member)
  • Trauma (one member)

Applicants for these positions must be candidate members, candidate members osteopathic, active fellows, associate members orthopaedic, associate members osteopathic, emeritus fellows, emeritus associate members orthopaedic, or emeritus associate members osteopathic with experience in planning and organizing CME courses and a practice emphasis in the relevant area. Openings also exist on a number of other committees, subcommittees, councils, and cabinets. Visit the Committee Appointment Program website regularly to view new openings and find one that interests you.
Learn more and submit your application…(member login required)


July 16, 2014

Today’s Top Story
1. Sunshine Act data now available to registered physicians for review before public disclosure.
The U.S. Centers for Medicare & Medicaid Services (CMS) has now made Open Payments (Sunshine Act) data available to physicians who have registered in the CMS Enterprise Portal and Open Payment systems. Registration is optional, but required if a physician wishes to review data relating to his or her financial interactions with industry. CMS states that there is no official end date for when physicians need to finish the registration steps, but in order to review or dispute data submitted by industry for the 2013 reporting period, physicians must be registered and have reviewed any data reported about them no later than Aug. 27, 2014. CMS recommends completing the registration process as soon as possible and not waiting until the end of this initial 45-day review and dispute period. The information will be made available to the public on Sept. 30, 2014.   Read more…
For a step-by-step outline of how to register, see “What you must do this week before your financial data goes public.”   Read more…

Other News
2. Study looks at risk factors for VTE and PE in pediatric spinal fusion patients.
A study published in the July 15 issue of the journal Spine examines the incidence of venous thromboembolic (VTE) complications and pulmonary embolism (PE) in children 18 years and younger who undergo spinal fusion surgery. The researchers drew data from the Nationwide Inpatient Sample database from 2001 through 2010 and found that the incidence of VTE in children per year varied from 9.6 to 38.5 events per 10,000 spinal fusions (mean: 21 per 10,000), while the incidence of PE varied from 0 to 6 events per 10,000 spinal fusions (mean: 2 per 10,000). They found no incidences of in-hospital VTE-associated mortality. Based on a multivariate logistic regression analysis, the researchers noted that only patient diagnosis was significantly associated with VTE development, with VTE incidence significantly higher in children with congenital scoliosis, syndromic scoliosis/kyphoscoliosis, and thoracolumbar fractures compared to children with idiopathic scoliosis. However, on univariate analysis, age was found to be significantly associated with VTE development; for each year of age, VTE incidence increased 1.37-fold.   Read more…
Read the abstract…

3. Study: Telemedicine may be viable alternative to in-clinic follow-up for some orthopaedic trauma patients.
According to a pilot study published online in the Journal of Orthopaedic Trauma, telemedicine may serve as a viable alternative to some in-person clinic visits for follow-up of patients who have sustained orthopaedic trauma. The authors conducted a prospective, randomized, controlled trial of 17 patients who were seen at a Level 1 trauma center. All patients had four follow-up appointments during a 6-month period, with eight patients having their 6-week and 6-month follow-ups through video calls and nine patients having those same follow-ups in-clinic. The authors found no significant difference between cohorts in patient satisfaction. In addition, no patients in the telemedicine group took time off work for their appointment, compared to 55.6 percent of participants in the control group. Telemedicine patients also spent significantly less time on their visits. Overall, 87.5 percent of patients in the telemedicine group reported clear visual quality, and 75.0 percent of telemedicine patients agreed to future follow-up visits through telemedicine.
Read the abstract…

4. CMS proposal would bundle some orthopaedic payments into ambulatory payment classifications similar to DRGs.
CMS plans to implement new, more inclusive bundled outpatient codes—akin to inpatient diagnosis-related groups (DRGs)—as part of an attempt to better align Medicare’s payment systems. Under a proposed rule, CMS plans to begin using “device dependent comprehensive ambulatory payment classifications (APCs)” starting Jan. 1, 2015. APCs represent a specific outpatient service and incorporate all other related ancillary services into a single, lump-sum payment. The classifications will cover procedures that include costly devices, such as orthopaedic implants, implantable cardioverter-defibrillators, and stents.   Read more…

5. Many physician employment contracts will soon come up for renewal.
According to an article in Modern Healthcare, many physician employment contracts signed with hospitals in the early days of healthcare reform will soon be coming up for renewal. One expert predicts that future value-based payments will be similar to capitation models and may be affected by the current emphasis on value. In addition, having physicians involved in governance and decision-making may make the negotiating process run more smoothly while simultaneously helping to identify areas where integration and reimbursement issues intersect. Another expert observes that, “Once they become employed, doctors never again have the leverage they had during negotiations to sell their practice,” but points out that physicians who are savvy about data strengthen their negotiation position by showing they met certain metric goals and generated a certain level of revenue.   Read more…(paid subscription may be required)

6. Are narrow networks the future of health insurance?
An article published in HealthLeaders Media suggests that the practice of narrowing provider networks is likely to increase in coming years. A spokesperson for one insurer argues that, as consumers become a more important factor in the health insurance market, they are likely to demand greater value, and limiting provider networks is one want to achieve that. In addition, a drive toward increased efficiency through the shift to affordable care organizations creates de facto narrow networks. However, at least one expert disagrees, noting that an observed backlash against health maintenance organizations was driven in part by a demand for broader provider networks.   Read more…

7. Physician practice sues insurer over underpaid claims.
AMA Wire reports that an appeals court is considering a case in which a physician practice that received assignments of benefits from patients with employer-sponsored health plans has sued the insurer for denying and underpaying medically necessary surgeries. At issue are three cases in which patients were insured by an employer-provided health plan, but treated by an out-of-network provider. The physician practice argues that the insurer agreed in advance to cover the patients’ surgeries, but later refused to pay the total costs of treatment. A district court previously ruled in the suit that physicians must have more than the standard assignment of benefits to give them grounds for a lawsuit.   Read more…

8. Call for volunteers: Annual Meeting Program Committees.
Aug. 7 is the last day to submit your application for openings on several Program Committees. Members of program committees grade symposia in May and abstracts in June and July, and may serve as moderators for paper sessions and critical evaluators of courses at the AAOS Annual Meeting. Applicants must be active fellows with a practice emphasis in the relevant topic. Program committees with open positions include:

  • Adult Reconstruction Hip (two member openings)
  • Adult Reconstruction Knee (three members)
  • Foot and Ankle (three members)
  • Hand and Wrist (chair)
  • Practice Management/Rehabilitation (one member)
  • Shoulder & Elbow (three members)
  • Spine (four members)
  • Sports Medicine/Arthroscopy (one member)
  • Trauma (four members)

Openings also exist on a number of other committees, subcommittees, councils, and cabinets. Visit the Committee Appointment Program website regularly to view new openings and find one that interests you.
Learn more and submit your application…(member login required)

July 21, 2014

Today’s Top Story
1. Study: Minority populations receive fewer autologous blood transfusions for elective orthopaedic surgery.
Findings published online in the journal Clinical Orthopaedics and Related Research suggest that historically disadvantaged patient populations may be less likely to receive autologous blood transfusions for elective orthopaedic surgery. The authors reviewed information on more than 3,500,000 patients found in the Nationwide Inpatient Sample database who underwent elective orthopaedic surgery. They found that, between 2008 and 2011, 2.4 percent received autologous blood transfusion, while 12 percent received allogeneic blood transfusion. Compared with white patients, Hispanic patients had lower odds of autologous blood use for elective hip and knee arthroplasties, while black patients had lower odds of receiving autologous blood transfusion for hip arthroplasty. In addition, uninsured and publicly insured patients were less likely to receive autologous blood for total joint arthroplasty (TJA) and spinal fusion, compared with privately insured patients, and patients with low and medium income were less likely to receive autologous blood transfusion for TJA and spinal fusion compared to patients at higher income levels. Even at comparable income and insurance levels, the authors found that Hispanic and black patients were less likely to receive autologous blood transfusion, compared to white patients.
Read the abstract…

Other News
2. Study: Immediate postoperative continuous passive motion may not improve outcomes for patients treated for intra-articular fracture.
Data from a study published in the July 16 issue of The Journal of Bone & Joint Surgery suggest that the use of continuous passive motion in the immediate postoperative period following the treatment of intra-articular fractures may be of little benefit. The research team conducted a prospective, randomized study of 40 patients with intra-articular fractures of either the proximal part of the tibia or the distal end of the femur. In the first 48 hours postoperative, patients were treated with either continuous passive motion (n = 20) or standardized physical therapy (PT; n = 20). At 48-hour follow-up, that patients in the passive motion cohort were found to have significantly greater knee flexion than those in the PT group. However, no significant difference in knee flexion or extension at any other time point out to 6 months was found. In addition, six patients in the passive motion group were unable to tolerate the use of the continuous passive motion device.
Read the abstract…

3. Study: Compared to primary RTSA, revision RTSA more likely to have complications.
A study published online in the Journal of Shoulder and Elbow Surgery suggests that revision reverse total shoulder arthroplasty (RTSA) may have a significantly higher rate of complications than primary RTSA. The researchers conducted a retrospective review of 137 patients who underwent primary (n = 111) or revision (n = 26) RTSA. Overall complication rates were 25 percent after primary RTSA and 69 percent after revision RTSA. Overall, minor complications accounted for 80 percent of the complications after primary RTSA and 94 percent of the complications after revision RTSA. The researchers noted that revision status was the most significant predictor of overall, minor, surgical, intraoperative, and postoperative complication rates, while medical complications were predicted by body mass index.
Read the abstract…

4. Report looks at state laws designed to encourage competition in healthcare markets.
A report released jointly by the National Academy of Social Insurance and Catalyst for Payment Reform examines the effectiveness of state laws that attempt to regulate or encourage competition within healthcare markets in the face of consolidation. The authors cataloged state laws and conducted targeted interviews with state attorneys general, the Federal Trade Commission, academics, and various other experts to identify state activity. Included among the findings are the following:

  • 42 states have laws on price transparency, but the information is frequently not easily accessible to consumers
  • 18 states have banned anti-competitive “favored nation” clauses that can prevent new health plans from entering local markets
  • 5 states have Certificate of Public Advantage statutes that permit exemption from antitrust provisions for providers merging or consolidating for the purposes of cooperation and healthcare delivery improvements
  • A number of states are forming regulatory bodies to monitor healthcare prices

Read more…
Read the report…

5. Hand washing program increases compliance at medical center.
An article on the Yahoo News website profiles one hospital’s efforts to improve hand sanitation. In addition to the installation of convenient hand sanitizer dispensers at all patient rooms and bays, the hospital educated all staffers on the link between hand washing and preventable infections, committed at least one staff member in each department or unit to monitor and document hand washing 20 times per month, and compared performance both between individual units and departments and against a target goal set for the medical center. The author reports that, since institution of the program, the organization’s hand washing compliance has nearly doubled, and three major types of infections linked to the insertion of tubes and catheters have been reduced considerably.   Read more…

6. Opinion: Cutting payments to physicians a “self-defeating strategy.”
An opinion piece published in The New York Times looks at the issue of reimbursement reduction as a method of controlling healthcare costs. The writer argues that one effect of reimbursement reductions is that most physicians have had to see more patients to maintain their incomes, limiting the amount of time spent with each patient and increasing the likelihood of patient harm. “Racing through patient encounters,” he writes, “we practice with an ever-present fear that we will miss something, hurt someone and open ourselves up to legal (not to mention moral) liability. To cope with the anxiety, we start to call in experts for problems that perhaps we could handle ourselves if we had more time to think through a case.” The writer agrees that healthcare costs must be contained, but explains that “cutting payments to doctors is a self-defeating strategy.” He argues that policymakers must focus instead on drivers of waste.   Read more…

7. California.
The San Francisco Business Times reports that California’s Medi-Cal program has removed about 26,400 physicians from its rolls because they didn’t comply with application requirements or hadn’t billed the state’s Medicaid program for at least 12 months. In addition, the number of enrollees in the program has increased by about 2 million under the Affordable Care Act. The article notes that many physicians in California refuse to accept Medi-Cal patients due to historically low reimbursement rates, and that a number of traditional Medi-Cal providers are in deep financial distress.   Read more…

8. Call for volunteers: AMA alternate representative to The Joint Commission PTAC.
AAOS seeks to nominate one member as the American Medical Association (AMA) alternate representative to The Joint Commission Professional and Technical Advisory Committee (PTAC) for the Home Care Accreditation Program. PTACs assist The Joint Commission in the development and refinement of accreditation standards and elements of performance, and provide observations to the organization regarding environmental trends, educational needs, and other important issues. Applicants for this position must be active fellows, candidate members, candidate members osteopathic, candidate member applicants for fellowship, or candidate member applicants for fellowship osteopathic, and must also be active members of AMA. In addition, applicants may not be board members, advisory committee members, elected officers, employees, or paid independent contractors of other accrediting organizations, nor may they hold leadership positions in healthcare organizations accredited by other accrediting organizations. All applicants must provide the following: an online AAOS CAP Application, current curriculum vitae, a 100-word biosketch, a letter of interest highlighting his or her expertise in the subject area, a statement that he or she is able to participate in full capacity and an AMA Nomination Form. All supporting materials must be submitted by July 28, 2014 at 11:59 p.m. (CT), to Kyle Shah at shah@aaos.org.
Learn more and submit your application…(member login required)

July 23, 2014

Today’s Top Story
1. Conflicting federal appeals court rulings leave legality of ACA subsidies in doubt.
Two federal courts of appeals have come to opposite conclusions in lawsuits that could have implications for the viability of the Affordable Care Act (ACA). In a 2–1 decision, judges from the D.C. Circuit Court of Appeals ruled that the U.S. Internal Revenue Service (IRS) does not have the authority under ACA to extend tax credits to an estimated 4.7 million people in 34 states who purchased subsidized coverage through the federal Healthcare.gov healthcare exchange. In a separate suit, judges in the 4th Circuit Court of Appeals voted 3–0 to uphold a district court ruling that the IRS does indeed possess the authority to extend the tax credits. Both lawsuits are based on wording in a single provision in the ACA that authorizes tax credits for consumers who purchase insurance through state healthcare exchanges. The IRS interpretation (and ACA supporters agree) is that Congress did not intend to limit subsidies to only those who purchased through state-based exchanges. ACA critics argue that the IRS interpretation to include Healthcare.gov users is overly broad and outside the letter of the law. Parties in the DC Circuit suit are expected to seek review by the full panel, and it is possible that both lawsuits ultimately may be appealed to the U.S. Supreme Court. Should the high court determine that the IRS does not have authority to extend tax credits under ACA, only consumers in states that opted to run their own exchanges would be eligible for subsidies.
Read more in HealthLeaders Media
Read more in MedPage Today
Read more in Politico

Other News
2. Physicians experience glitches on Open Payments website.
ProPublica reports that a number of physicians have experienced glitches while attempting to review their information on the federal Open Payments (Sunshine Act) website. Some have reported waiting an hour or more for the site to verify their identities. In addition, physicians who have received no payments from industry have reported receiving error messages. The U.S. Centers for Medicare & Medicaid Services (CMS) has made Open Payments data available to physicians who have registered in the CMS Enterprise Portal and Open Payment systems. Registration is optional, but required if a physician wishes to review data relating to his or her financial interactions with industry. To review or dispute data submitted by industry for the 2013 reporting period (August–December, 2013), physicians must be registered and have reviewed any data reported about them no later than Aug. 27, 2014. CMS recommends completing the registration process as soon as possible and not waiting until the end of this initial 45-day review and dispute period. The information will be made available to the public on Sept. 30, 2014.   Read more…
The American Medical Association has published a brief guide to disputing incorrect Open Payments data.  Read more…

3. Do narrow networks increase financial pressure on providers?
An article in Modern Healthcare looks at the possible effect insurance companies’ narrowing of provider networks may have on physician reimbursement. According to the author, “…insurance companies have sought to save money by narrowing their provider network, and doctors are lowering compensation demands to keep from being dropped.” The author also references statements attributed to Thomas C Barber, MD, chair of the AAOS Council on Advocacy, regarding the roles that narrow provider networks and Medicare payment cuts have in limiting compensation.   Read more…

4. Study: CDT appears to offer little benefit over anticoagulation alone for treatment of DVT, yet may increase risk of adverse events.
Data from a study published online in the journal JAMA Internal Medicine suggest that the use of catheter-directed thrombolysis (CDT) plus anticoagulation for treatment of acute proximal deep vein thrombosis (DVT) may increase risk of adverse events, with little effect on mortality, compared to anticoagulation alone. The authors conducted an observational study of 90,618 patients hospitalized for DVT, of whom 3,649 (4.1 percent) underwent CDT. In-hospital mortality was not significantly different between the CDT and the anticoagulation groups but the rates of blood transfusion, pulmonary embolism, intracranial hemorrhage, and vena cava filter placement were significantly higher in the CDT group. In addition, patients in the CDT group had longer mean length of stay and higher hospital charges compared with those in the anticoagulation group.   Read more…
Read the abstract…

5. FDA issues alert regarding sterility failures in products from NuVision Pharmacy.
The U.S. Food and Drug Administration (FDA) has alerted healthcare professionals and consumers not to use drugs marketed as sterile produced by Downing Labs LLC, also known as NuVision Pharmacy (Dallas), because they may be contaminated. The agency states that healthcare professionals should immediately check their medical supplies, quarantine any sterile drug products from NuVision, and not administer them to patients. FDA investigators inspected NuVision and observed sterility failures in 19 lots of drug products intended to be sterile, endotoxin failures in three lots of drug products, and inadequate or no investigation of these failures. FDA has issued a number of alerts regarding concerns with NuVision products dating to at least April 2013.   Read more…

6. Study: Sling immobilization and immobilization in external rotation may offer similar outcomes for patients with recurrent instability after primary anterior shoulder dislocation.
According to a Canadian study published online in the August issue of the journal Clinical Orthopaedics and Related Research, immobilization in external rotation may not confer significant benefit versus sling immobilization for the prevention of recurrent instability after primary anterior shoulder dislocation. The authors conducted a randomized, controlled trial of 60 patients younger than 35 years with primary, traumatic, anterior shoulder dislocation. Shoulders were immobilized with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean 4 days after closed reduction. All patients were immobilized for 4 weeks with identical therapy protocols thereafter. At mean 25-month follow-up, they found no significant difference in the rate of recurrent instability or Western Ontario Shoulder Instability Index scores between groups. The authors noted that the difference in ASES scores approached statistical significance, but the magnitude was small and of uncertain clinical importance.
Read the abstract…

7. Scribes may make patient interactions flow more smoothly.
An item on the Medical Group Management Association’s In Practice blog looks at hiring medical scribes as a solution to issues involving electronic health records (EHR) systems. The writer notes that many physicians find entering information into EHR systems to be intrusive during patient visits, and that scribes can allow physicians to spend more time focusing on the patient. The writer profiles the experience of one physician practice, which found that hiring scribes increased productivity, as physicians were no longer required to stay late to finish dictation—they simply reviewed and signed off on what the scribe had documented.   Read more…

8. Call for volunteers: Central Evaluation Committee.
August 1 is the last day to submit your application for a position on the Central Evaluation Committee. Members of the Central Evaluation Committee write questions for the Orthopaedic In-Training Examination (OITE) annually and the Orthopaedic Self-Assessment Examination (OSAE) triennially. Applicants for these positions must be active fellows, candidate member applicants for fellowship, candidate member applicants for fellowship osteopathic, associate members orthopaedic, associate members osteopathic, or emeritus fellows with specialty knowledge in the relevant topic. The following positions are available:

  • Adult Reconstruction Hip and Knee (one member opening)
  • Foot and Ankle (two members)
  • Oncology (one member)
  • Pediatric Orthopaedics (two members)
  • Shoulder and Elbow (two members)
  • Spine (one member)
  • Trauma (one member)

Openings also exist on a number of other committees, subcommittees, councils, and cabinets. Visit the Committee Appointment Program website regularly to view new openings and find one that interests you.
Learn more and submit your application…(member login required)

July 25, 2014

Today’s Top Story
1. Study: Patient response to acetaminophen may be similar to placebo for treatment of low back pain.
Data from an Australian study published online in the journal The Lancet suggest that treatment with acetaminophen (paracetamol) for low back pain may not reduce recovery time compared to placebo. The research team conducted a multicenter, double-dummy, randomized, placebo-controlled trial of 1,646 participants treated with either 4 weeks of regular doses of acetaminophen (n = 550), as-needed doses of acetaminophen (n = 549), or placebo (n = 547). They found that the median time to recovery was 17 days in the regular group, 17 days in the as-needed group, and 16 days in the placebo group. In addition, the research team noted no significant difference between groups in adherence to regular tablets or adverse events.   Read more…
Read the abstract…

Other News
2. FDA announces recall of non-expired sterile drugs from Unique Pharmaceuticals.
The U.S. Food and Drug Administration (FDA) is alerting the public of a voluntary recall of all non-expired drug products produced for sterile use by Unique Pharmaceuticals Ltd., of Temple, Texas. The recalled products include lot 86513, N-Acetyl Cysteine 20%, and all other non-expired, purportedly sterile drug products. Two recent inspections of the Unique Pharmaceuticals facility conducted by FDA revealed insanitary conditions that result in a lack of sterility assurance of drug products produced at that facility. The inspections revealed sterility failures in several lots of drug products intended to be sterile, recurring environmental contamination problems, and poor sterile production practices.   Read more…

3. Trend toward risk-sharing payment models marches forward.
An article in HealthLeaders Media looks at the trend toward risk-sharing reimbursement models, which reward providers for improvement in health outcomes and costs. The writer notes that Cigna recently met its goal of covering one million healthcare consumers under its so-called Collaborative Accountable Care program—a quality and performance-based reimbursement model, and UnitedHealthcare announced earlier this year that $27 billion of its annual reimbursements to physicians and hospitals are now tied to accountable care and performance-based programs. The insurer hopes to increase that payout to $65 billion by 2018. The writer cites research suggesting that smaller provider groups may be less likely to have the resources to transition smoothly to risk-sharing payment models.   Read more…

4. Dabigatran treatment may require monitoring and dose adjustment.
An article published in the journal The BMJ suggests that use of the oral coagulant dabigatran may require monitoring of plasma levels or anticoagulant activity and subsequent dose adjustment, contrary to manufacturer claims. The manufacturer “failed to share with regulators information about the potential benefits of monitoring anticoagulant activity and adjusting the dose to make sure the drug is working as safely and effectively as possible,” the author writes. “The company also withheld analyses that calculated how many major bleeds dose adjustment could prevent. The company says that this information was not shared because the analysis did not provide a reliable prediction of patient outcomes.” According to the author, dabigatran was “marketed to be used in fixed dose regimens without the need for dose titration or monitoring of blood levels.”   Read more…

5. CMS data suggests many hospitals still don’t use surgical checklists.
According to information presented in HealthLeaders Media, as many as 10 percent of hospitals report that they do not use surgical safety checklists, despite evidence that such checklists may reduce mortality and complications. The writer draws data from the U.S. Centers for Medicare & Medicaid Services (CMS) Hospital Compare website, which recently began reporting on the use of surgical checklists across 4,136 hospitals in the United States. Overall, 366 hospitals said they still don’t use surgical checklists, while 497 couldn’t say whether they did or not. According to one expert, the use of such checklists is further clouded by the fact that the Hospital Compare site only tracks hospital policies, not actual usage.   Read more…
View the Hospital Compare website…

6. Visits to EDs by children often linked to insurance issues, lack of physician access.
A data brief released by the U.S. Centers for Disease Control and Prevention National Center for Health Statistics looks at emergency department (ED) use among U.S. children. The brief, which is based on 2012 data from the National Health Interview Survey, finds that children covered under Medicaid were more likely than uninsured children and those with private coverage to have visited the ED at least once in the past year. Additional findings include:

  • Nearly 75 percent of children’s most recent visits to an ED took place at night or on a weekend, regardless of coverage status.
  • Seriousness of the medical problem was less likely to be the reason that children with Medicaid visited the ED compared with children with private insurance.
  • Most of those who visited the ED for reasons other than the seriousness of the medical problem did so because their physician’s office was not open.

Read more…

Read the Data Brief (PDF)…

7. Study: Helmet brand, condition not linked to increased likelihood of concussion among high school football players.
A study published online in The American Journal of Sports Medicine suggests that helmet brand may not affect the incidence of sports-related concussion among high school football players. The researchers conducted a cohort study of 2,081 players grades 9 to 12, who were enrolled during the 2012 and/or 2013 football seasons. They found that 206 players (9 percent) sustained a total of 211 concussions. They found no significant difference in concussion incidence among players wearing any one of three brands of helmet, nor was helmet age and recondition status linked to increased incidence of concussion. However, the researchers noted that players were more likely to sustain a concussion if they wore a custom mouth guard or had sustained a sports-related concussion in the previous 12 months.
Read the abstract…

8. Call for volunteers: Residents needed for Annual Meeting Committee; Biological Implants Committee; Council on Education.
Aug. 4 is the last day to submit your application for resident positions on several AAOS Committees: Applicants for these positions must be PGY-1, 2, or 3, and submit a letter of support from his or her residency program directors (see individual listings for details). The following positions are available:

  • Annual Meeting Committee (one resident-at-large member)
  • Biological Implants Committee (one resident member)
  • Biomedical Engineering Committee (one resident member)
  • Council on Education (one resident member)

Openings also exist on a number of other committees, subcommittees, councils, and cabinets. Visit the Committee Appointment Program website regularly to view new openings and find one that interests you.
Learn more and submit your application…(member login required)

July 28, 2014

Today’s Top Story
1. Study: All-polyethylene tibial components may offer improved outcomes compared to metal-backed implants for TKA.
Findings published in the July 16 issue of The Journal of Bone & Joint Surgery (JBJS) suggest that all-polyethylene tibial components may be associated with improved outcomes compared to metal-backed modular components for total knee arthroplasty (TKA). The authors reviewed data on 16,584 primary TKAs (11,992 patients) performed at a single institution between 1985 and 2005. They found that, compared against metal-backed modular implants, all-polyethylene tibial components had a significantly lower risk of revision, regardless of age, sex, or body mass index (BMI). With all-polyethylene tibial components, there was no significant difference in survivorship between cruciate-retaining and posterior-stabilized designs. With metal-backed modular tibial designs, cruciate-retaining knees performed better than the posterior-stabilized knees, but the finding was limited to a single specific metal-backed modular tibial component.
Read the abstract…

Other News
2. What are the risk factors for readmission after THA?
A study published in the July 16 issue of JBJS examines risk factors for readmission after total hip arthroplasty (THA). The researchers reviewed information on 9,441 patients and found that there were 345 readmissions within the first 30 days post-surgery. Comorbidities associated with increased likelihood for readmission were diabetes, chronic obstructive pulmonary disease, bleeding disorders, preoperative blood transfusion, corticosteroid use, dyspnea, previous cardiac surgery, and hypertension. In addition, BMI of =40 kg/m2and preoperative use of corticosteroids were independently associated with a higher likelihood of readmission, while a high preoperative serum albumin was independently associated with a lower risk for readmission. Postoperative surgical site infection, pulmonary embolism, deep venous thrombosis, and sepsis were also independent risk factors for readmission.
Read the abstract…

3. Study: Adoption of “best practices” program linked with reduction in SSIs after cardiac procedure.
According to information presented at the annual conference of the American College of Surgeons National Surgical Quality Improvement Program, adoption of a “best practices” program was associated with a significant reduction in the number of surgical site infections (SSIs) after coronary artery bypass graft (CABG) procedures at a single hospital in Vancouver, B.C. Under the program, a quality improvement team identified areas of improvement, including:

  • Improving guidelines for prophylactic antibiotic use
  • Cleaning hands before touching dressings
  • Using clippers used for hair removal
  • Nasal decolonization using ultraviolet light
  • Engaging patients and staff on best practices for SSI prevention

After implementation of the protocol, the researcher team noted a decrease in the rate of SSIs associated with CABG from 7 percent to 1.6 percent.   Read more…

4. Report: Medicare HI Trust Fund to be depleted in 2030.
A report released by the trustees of the Social Security and Medicare trust funds projects the depletion date for the Medicare Hospital Insurance (HI) Trust Fund to be 2030—4 years later than estimated in the 2013 report. “The improvement in the outlook for HI long-term finances is principally due to lower-than-expected spending in 2013 for most HI service categories,” the authors write, “which reduced the base period expenditure level about 1.5 percent and contributed to the Trustees’ decision to reduce projected near-term spending growth trends. The authors note that their projections assume “that reductions in Medicare payment rates for physician services called for under the Sustainable Growth Rate (SGR) formula will be overridden in the future as they have been from January 2003 through March 2015.”   Read more…

5. Alaska.
The Peninsula Clarion reports on issues faced by one ambulatory surgery center (ASC) in Alaska, which is unable to accept Medicare and Medicaid patients, because the U.S. Centers for Medicare & Medicaid Services requires ASCs to arrange transfer agreements with local hospitals, and the center has been unable to come to such an agreement with one institution. A spokesperson for the hospital states that it is required under its operating lease to remain self-sufficient and “off the taxpayer rolls.” A spokesperson for the ASC argues that the hospital’s stance forces the ASC to accept only more profitable, privately insured patients, despite the operators’ stated willingness to serve all patients.   Read more…

6. Maryland.
An article in The Baltimore Sun looks at the reporting of preventable adverse events in Maryland, and suggests that many such incidents may be underreported in the state. From 2004 to 2006, Maryland hospitals reported that no patients had advanced pressure ulcers. After initiatives to improve reporting, the number increased to 144 in FY 2011, before falling to 52 in FY 2013. Based on national averages, the state should expect more than 4,000 such cases per year.   Read more…

7. OKOJ August updates now online!
Check out the new topics and video in the Orthopaedic Knowledge Online Journal (OKOJ) on the AAOS OrthoPortal website. The following topics have been recently added or updated: “Coverage Techniques for Soft-tissue Defects Around the Knee,” “Dermatologic Conditions of the Foot,” and “Scapulothoracic Fusion.” In addition, a new video, “Scapulothoracic Fusion,” has been made available.
View these topics and more…

8. Last call: Committee positions closing soon!
A number of openings on the AAOS Committee Appointment Program website are closing in the next week. Act now to apply for the following positions:

  • Anatomy-Imaging Evaluation Committee (closes July 30)
    • Chair
    • Foot and Ankle (one member opening)
    • Hand and Wrist (two members)
    • Spine (two members)
    • Tumors (two members)
  • Bylaws Committee (July 30; one member)
  • Candidate, Resident, and Fellow Committee (July 31; one resident member)
  • Central Evaluation Committee (Aug. 1)
    • Adult Reconstruction Hip and Knee (one member)
    • Foot and Ankle (two members)
    • Oncology (one member)
    • Pediatric Orthopaedics (two members)
    • Shoulder and Elbow (two members)
    • Spine (one member)
    • Trauma (one member)
  • Diversity Advisory Board (July 31; one member, one resident member)
  • Hand & Wrist Evaluation Committee (July 30; chair, nine members)
  • Musculoskeletal Tumors & Diseases Evaluation Committee (July 30; chair, five members)
  • Patient Education Committee (July 31; three members-at-large)
  • Research Development Committee (Aug. 1; chair, two members-at-large, one resident member)
  • Resolutions Committee (July 30; one member)
  • Shoulder & Elbow Evaluation Committee (July 30; three members)
  • Women’s Health Issues Advisory Board (Aug. 1; liaison to Council on Research and Quality; one resident member)

Openings also exist on a number of other committees, subcommittees, councils, and cabinets. Visit the Committee Appointment Program website regularly to view new openings and find one that interests you.
Learn more and submit your application…(member login required)

July 30, 2014

Today’s Top Story
1. Physicians groups urge CMS to simplify Open Payments registration, include context for data.
A number of medical organizations, including the American Association of Orthopaedic Surgeons (AAOS), have written a letter to Marilyn B. Tavenner, administrator for the U.S.Centers for Medicare & Medicaid Services (CMS), regarding their concerns with the implementation of the Physician Payments Sunshine Act. The organizations note that stakeholders have not yet received information from the agency about what sort of context will be provided to the general public when data are made available under the Open Payments system in September. “In reviewing the Medicare Part B data released earlier this year, we note that the only information included and made available to the public was related to names and numbers with no context explaining the data,” the authors write. “We do not believe this is an effective way to share data with the public and, in fact, can lead to confusion and misinterpretation.” The authors also argue that many physicians may not be aware of the multiple requirements of the Sunshine Act, and urge CMS to increase educational efforts and work to simplify the physician registration process.   Read more…
Read the letter (PDF)…
The American Medical Association (AMA) has published a brief guide to disputing incorrect Open Payments data.   Read more…
AAOS has collected a variety of resources regarding the Sunshine Act and Open Payments process.   Read more…

Other News
2. IOM report argues for overhaul of GME system.
A report released by the Institute of Medicine (IOM) argues that to ensure that the U.S. healthcare system can continue to meet the increasing demand for physicians, the country must reform the federal system for financing physician training and residency programs. The authors note that the United States has a “robust” graduate medical education (GME) system, but point out that “the need for improvements to the GME system has been highlighted by blue ribbon panels, public and private-sector commissions, provider groups, and IOM committees.” Such groups have highlighted a range of concerns, including the following:

  • A mismatch between the health needs of the population and the specialty make-up of the physician workforce
  • Persistent geographic maldistribution of physicians
  • Insufficient diversity in the physician population
  • A gap between new physicians’ knowledge and skills and the competencies required for current medical practice
  • A lack of fiscal transparency

The authors propose that the U.S. Department of Health and Human Services (HHS) establish a two-part governance infrastructure, with an office within HHS to oversee policy and decisionmaking, and another office within CMS to oversee fund distribution. In addition, to encourage training at a variety of sites, the authors suggest that funds be distributed directly to organizations that sponsor physician training programs, and that the current payment methodology be replaced with a single, national, per-resident amount.   Read more…
Read the complete report (PDF)…(registration may be required)

3. Study: PRP injection may help hasten hamstring recovery.
Data from a small study published online in The American Journal of Sports Medicine suggest that an autologous injection of platelet-rich plasma (PRP) combined with rehabilitation may offer improved outcomes for patients with hamstring injuries compared to rehabilitation alone. The authors conducted a randomized, controlled trial of 28 patients with grade 2 hamstring muscle injuries, and found that patients who received a single, autologous PRP injection along with a rehabilitation program returned to play after a mean 26.7 days, compared to 42.5 days for control patients who received only rehabilitation. In addition, the authors noted that patients in the PRP group had significantly lower pain severity scores throughout the study, but found no significant difference between cohorts in pain interference scores.
Read the abstract…

4. Florida.
According to MedPage Today, several medical associations, including AMA and the American College of Physicians (ACP), are criticizing a recent verdict upholding a Florida law that bans healthcare providers from speaking to their patients about firearm ownership. The president of the American Academy of Pediatrics (AAP) issued a statement calling the decision “an egregious violation of the First Amendment rights of pediatricians,” while the president of the American Academy of Family Physicians said in a separate statement, “Make no mistake—this issue is much bigger than guns or gun ownership. This is about governmental intrusion on the patient/physician relationship.” According to AAP, 10 other states have introduced similar legislation to restrict physician counseling about firearms, although none have been enacted.   Read more…(registration may be required)
Read the AMA response…
Read the ACP response…

5. Oregon.
The Associated Press reports that the Oregon Insurance Division is developing a bill for submission to the Oregon Legislature next year that would, if enacted, grant the agency the authority to require private insurers to carry enough healthcare providers in their networks to adequately serve all their customers. Although the draft is still under negotiation, it currently suggests the following two methods for insurers to meet the mandate:

  • A standard based on existing federal requirements for companies offering Medicare Advantage plans, which include factors such as the number of providers, travel time, and distance.
  • An alternate method, such as one that would take into account a set of standards based on customers’ health.

Observers say the proposal may be linked to the increasing number of narrow networks set up by insurers in order to control costs.  Read more…

6. Just 17 days left to nominate future AAOS leadership!
This is a reminder that the 2015 Nominating Committee is actively soliciting your suggestions for individuals who might serve in the following positions:

  • Second Vice President
  • Member-at-lLarge [Age 45 or older]
  • Member-at-Large [Younger than age 45 on March 26, 2015]
  • National Membership Committee Member
  • Nominees to the American Board of Orthopaedic Surgery (ABOS)

Nominations close on Friday, Aug. 15. Please send nominations to Daniel J. Berry, MD, chair, 2015 Nominating Committee, c/o AAOS Office of General Counsel, 6300 N. River Road, Rosemont, IL 60018-4202. Nominations may also be submitted electronically at http://www.aaos.org/nominations(member login required)

7. August AAOS Now is online now and in your mailbox soon!
AAOS members will soon receive the print edition of the August issue of AAOS Now, but the online edition is already available on theAAOS Now website. This month’s issue includes an examination of the use of cell-based therapies in sports medicine, a look at proposed changes to the Medicare Physician Fee Schedule for 2015, a report on value studies in orthopaedic surgery, and much more.  Read more…
Read “Cell-based Therapies in Sports Medicine”…
Read “CMS Releases Proposed Rule for 2015 PFS”…
Read “The Value of Orthopaedic Surgery: A Paradigm Shift”…

8. Call for volunteers: AHRQ National Advisory Council for Healthcare Research and Quality.
AAOS seeks to nominate members to the Agency for Healthcare Research and Quality (AHRQ) National Advisory Council for Healthcare Research and Quality. The council advises the secretary of HHS and the director of the AHRQ on efforts to improve the quality, safety, efficiency, and effectiveness of healthcare. AHRQ seeks individuals who are distinguished in a variety of areas, including healthcare research and the practice of medicine. Selected candidates will be asked to provide detailed information concerning financial interests, consultant positions, and research grants and contracts. In addition, all applicants must provide the following: an online AAOS CAP Application, a current curriculum vitae, a 100-word biosketch, and a letter of interest highlighting his or her expertise in the subject area and a statement that he or she is able to participate in full capacity. Supporting materials must be submitted by next Friday, Aug. 8, 2014 at 11:59 p.m. (CT), to Simit Pandya at  pandya@aaos.org.
Learn more and submit your application…(member login required)

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