September 30, 2014

September 3, 2014

Today’s Top Story
1. CMS continues to tune Open Payments site; pushes review deadline to Sept. 10.
The U.S. Centers for Medicare & Medicaid Services (CMS) has announced further delays and outages for the Open Payments (Sunshine Act) website. In response to questions raised by a trade group regarding transparency in rejecting data submissions from manufacturers, the agency has extended the review period deadline from Sept. 8 to Sept. 10. CMS is continuing with plans to release data to the public on Sept. 30. 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 Sept. 10, 2014.   Read more…
In a letter to Marilyn Tavenner, administrator of CMS, the American Association of Orthopaedic Surgeons and other organizations have asked the agency to delay the publication of the information collected in the Open Payments system until March 31, 2015.   Read the letter (PDF)…

Other News
2. HHS releases final rule on Stage 2 meaningful use.
The U.S. Department of Health and Human Services (HHS) has published a final rule that the agency says will give healthcare providers greater flexibility in using electronic health record (EHR) technology under the EHR Incentive Program. The rule also finalizes the extension of Stage 2 through 2016 for certain providers, and states that the Stage 3 timeline will begin in 2017 for providers who first became meaningful EHR users in 2011 or 2012. However, some stakeholders have criticized the rule, arguing that it does not contain enough exemptions from meeting Stage 2 during 2014.   Read more…
Read the CMS announcement…
Read the final rule (PDF)…

3. Study: Early passive ROM exercise linked to faster recovery after arthroscopic rotator cuff repair, but larger tears may recur.
According to findings published online in The American Journal of Sports Medicine, early passive range of motion (ROM) exercise may accelerate recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but is also associated with improper tendon healing in shoulders with large-sized tears. The authors conducted a systematic review and meta-analysis of six randomized, controlled trials covering 482 patients. They found that patients treated with early ROM demonstrated more improvement overall in shoulder forward flexion than the delayed rehabilitation group. However, early ROM was linked to a higher rate of recurrent tendon tears, with the effect becoming statistically significant after exclusion of 2 trials that recruited only patients with small- to medium-sized tears.
Read the abstract…

4. Study: Nighttime bracing for mild idiopathic scoliosis may not reduce likelihood of surgery, compared to observation alone.
Data from a study published in the September issue of the Journal of Pediatric Orthopaedics suggest little difference in progression to surgery among patients with mild idiopathic scoliosis who are treated with either nighttime bracing or observation. The researchers conducted a prospective, comparative study of 37 premenarchal, Risser 0 female patients with Cobb angle measurements between 15 degrees and 25 degrees. Overall, 16 patients were treated with observation and 21 with bracing. At 2-year follow-up, the research team found that all patients in the observation group progressed to the fulltime bracing threshold of 25 degrees, while 29 percent of patients in the nighttime bracing group did not progress to the 25 degrees primary curve magnitude. However, the rate of progression to surgical magnitude was similar across both groups.
Read the abstract…

5. First suit begins over DePuy Pinnacle Ultamet MoM hip device.
Bloomberg reports that jury selection has begun in the first lawsuit over the DePuy Orthopaedics Pinnacle Ultamet metal-on-metal (MoM) hip. The plaintiff claims that the device was defectively designed, causing metal debris to leech into patients’ bloodstreams. DePuy previously settled a series of suits that claimed that the company’s ASR hip devices caused dislocations, pain and required surgical removal. The Pinnacle Ultamet line was not covered by that settlement.   Read more…

6. California.
The California Department of Health Care Services has released a proposal for the state’s next 1115 Section Medicaid Waiver for public comment. The authors of the proposal note challenges to expanding the state’s Medi-Cal program, including the fact that “commercial payors have tended to be significantly higher payers than the Medicaid program, which means that doctors and other providers are likely to be more resistant to caring for Medicaid patients, since they can be fully occupied serving insured patients at a higher level of compensation.” With that in mind, the agency proposes a subsidy program for medical liability insurance would be offered to physicians who “are willing to devote significant portions of their practices to low income patients.”   Read more…
Read the proposal (PDF)…

7. September AAOS Now is online now and in your mailbox soon!
AAOS members will soon receive the print edition of the September issue of AAOS Now, but the online edition is already available on theAAOS Now website. This month’s issue includes an article on evaluating performance, a look at the use of stem cells in spinal surgery, information from a study on the use of simulation training in arthroscopy, and much more.   Read more…
Read “How Should Your Performance Be Measured?”…
Read “Interest in Using Stem Cells in Spinal Surgery Increasing”…
Read “Study: Simulator Training Improves Resident Performance in Arthroscopy”…

8. Call for volunteers: CMS TEP on Reevaluation of the Hospital-Acquired Condition Reduction Program Scoring Methodology.
AAOS seeks to nominate members to the CMS Technical Expert Panel (TEP) on Reevaluation of the Hospital-Acquired Condition (HAC) Reduction Program Scoring Methodology. The specific objectives of this TEP include review of potential revisions to the scoring methodology, providing advice on weighting and prioritization of measures included in the HAC Reduction Program, review of the benefits and tradeoffs of changes made to the scoring methodology, and providing feedback on which measures to include in the program. 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 disclose any current and past activities that may pose a potential conflict of interest for performing the tasks required of the TEP. In addition, all applicants must provide the following: an online AAOS CAP application, a current curriculum vitae (maximum of 10 pages), a 100-word biosketch, a statement of interest (not to exceed two pages) highlighting the candidate’s experience and knowledge relevant to the expertise described above, and a CMS Disclosure Form (available via email at the below address). All supporting materials must be submitted by Sept. 7, 2014 at 11:59 p.m. CT, to Kyle Shah at shah@aaos.org.


September 5, 2014

Today’s Top Story
1. State attorneys general argue that hospital employment of physicians increases healthcare costs.
According to Medscape, the attorneys general of 16 states have testified that hospital employment of physicians is driving up healthcare costs without necessarily improving the quality of care. In a federal appellate case in which the U.S. Federal Trade Commission has argued on antitrust grounds against a merger between a health system in Boise, Idaho and a nearby medical group, the attorneys general filed a friend-of-the-court brief stating that they have seen first-hand the effects of hospitals acquiring physician practices. Among the effects cited were increased bargaining power with health insurers, higher hospital facility fees for physician services, and loss of referrals to rival hospitals. The attorneys general also noted that higher prices charged by a dominant healthcare provider in a particular market rarely motivate patients to seek less expensive providers, often because out-of-pocket expenses constitute “only a small fraction of their total healthcare costs.”   Read more…(registration may be required)

Other News
2. Appeals court vacates ACA decision pending review.
The Hill reports that the D.C. Circuit Court of Appeals has agreed to revisit its previous ruling in Halbig v. Burwell, which struck down certain health insurance subsidies issued under the Affordable Care Act (ACA). On July 22, 2014, the court ruled in a 2–1 decision 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. The finding was 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 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. The en banc order issued by the court vacates the July decision, pending a review by the full D.C. appellate court. Arguments are scheduled for Dec. 17.   Read more…

3. Study: Hardware removal after posterior spinal fusion may carry risks for younger patients.
Findings from a study published in the September issue of the Journal of Pediatric Orthopaedics suggest that hardware removal after posterior spinal fusion may not offer patients complete pain relief, and removal carries a risk for curve progression, particularly in the setting of infection. The authors conducted a retrospective study of 75 patients aged 10 to 21 years, who underwent removal of instrumentation after posterior spinal fusion over a 10-year-period. They found that indications for removal of spinal instrumentation included pain (57 percent), infection (28 percent), hardware failure (8 percent), and prominent hardware (7 percent). Mean time from index procedure to hardware removal was 2.8 years. The authors noted that the average loss of curve correction following complete hardware removal was 23.1 degrees, and that patients who underwent removal of hardware due to infection had increased curve changes compared to those without infection. Of the 43 patients with pain, only 40 percent reported relief of their symptoms following removal of hardware.
Read the abstract…

4. CMS National Provider Call to offer guidance on avoiding negative payment adjustments in 2016.
The U.S. Centers for Medicare & Medicaid Services (CMS) has announced an MLN Connects™ National Provider Call, to provide an overview of several Medicare Quality Reporting Programs. The presentation will cover guidance and instructions on how eligible professionals and group practices can avoid a negative payment adjustment under the 2016 Physician Quality Reporting System, satisfy the clinical quality measure component of the Electronic Health Records Incentive Program, and avoid a negative payment adjustment due to the 2016 value-based modifier. The call will take place Wednesday, Sept. 17, from 1:30 p.m. to 3 p.m. ET.   Read more…
Register for the call…

5. Stakeholder report outlines objectives, recommendations for medical device registries.
A report released by The Pew Charitable Trusts, the Blue Cross Blue Shield Association, and the Medical Device Epidemiology Network outlines a series of recommendations for the establishment of medical device registries. The authors cite lessons learned from the development and use of metal-on-metal hip implants, arguing that lack of a national registry in the United States led to such devices “remaining in the marketplace amid an emerging pattern of failure.” In arguing in favor of the establishment of national device registries, they identify the following objectives:

  • Establish criteria for determining if a registry is the appropriate tool for postmarket surveillance
  • Deliver timely, actionable information from registries to all stakeholders, including the public
  • Streamline registry data collection through efficiencies that reduce the time and cost of reporting
  • Gain additional value from device registries by using them to accelerate device innovation and to fulfill other regulatory responsibilities
  • Provide clarity for registry owners, providers, and patients by resolving varying legal interpretations of the Health Insurance Portability and Accountability Act and the Federal Policy for the Protection of Human Subjects

The authors state that “all U.S. registries should implement these recommendations to better understand the safety and effectiveness of medical devices.”
Read the report (PDF)…

6. California.
The California Medical Association reports that the California State Legislature has passed a bill that, if enacted, would require Medi-Cal managed plans and insurers that offer individual plans through Covered California to provide to the California Department of Managed Health Care annual reports regarding the adequacy of their provider networks. In addition, the legislation would require the agency to post annual reviews regarding plan compliance on its website. Several reports have noted difficulties in locating in-network providers in the state, including a recent survey of more than 2,300 physicians, which found that more than half of respondents have experienced difficulty finding an in-network physician or facility to which they can refer their Covered California patients.   Read more…

7. Free ePub edition of September AAOS Now is now available for download!
The September edition of AAOS Now magazine is now available for electronic devices capable of reading files in ePub format, including the iPhone and iPad, Android devices, and desktop computers (unfortunately, Amazon Kindle does not currently accept ePub files). To download and view the ePub version of AAOS Now, visit the link below and log in using your AAOS username and password. 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 AAOS Now in ePub format…(member login required)

8. Call for volunteers: CMS TEP on Electronic Clinical Quality Measures.
AAOS seeks to nominate members to the CMS Technical Expert Panel (TEP) on Electronic Clinical Quality Measures (eCQM). The primary objectives of this project include identifying, developing, specifying, and testing new eCQMs to be implemented in CMS quality reporting programs in the areas of patient and family engagement, care coordination, and patients’ safety and evaluating and preparing the measures for consideration and potential endorsement by the National Quality Forum. 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 (maximum of 10 pages total), a 100-word biosketch, a statement of interest (not to exceed two pages) highlighting his or her experience and knowledge relevant to the expertise described above and involvement in measure development, and a CMS Disclosure Form (available via email at the below address). All supporting materials must be submitted by Sept. 15, 2014 at 11:59 p.m. CT, to Kyle Shah at shah@aaos.org.
Learn more and submit your application…(member login required)

September 8, 2014

Today’s Top Story
1. AAOS Board of Directors approves 3 new CPGs.
During its meeting last week, the AAOS Board of Directors approved the following three new evidence-based clinical practice guidelines (CPGs):

  • “Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip (DDH) in Infants up to Six Months of Age,” which has also been endorsed by the Society of Diagnostic Medical Sonography, the Society of Pediatric Radiology, and the Pediatric Orthopaedic Society of North America
  • “Management of Anterior Cruciate Ligament Injuries,” which has also been endorsed by the National Academy of Sports Medicine, the American Orthopaedic Society for Sports Medicine, and the National Athletic Trainers’ Association
  • “Management of Hip Fractures in the Elderly,” which has also been endorsed by the Orthopaedic Trauma Association, The Hip Society, the American Association of Clinical Endocrinologists, and the US Bone and Joint Initiative

CPGs are based on a systematic review of current scientific and clinical research, and are designed to help improve treatment and management based on current evidence.

The full CPG documents containing the systematic review of the literature, the work group disclosures, and all supporting documentation are available at www.aaos.org/guidelines.

Other News
2. AAOS Board of Directors approves AUC on Management of Pediatric Supracondylar Humerus Fractures.
The AAOS Board of Directors has approved new appropriate use criteria (AUC) on “Pediatric Supracondylar Humerus Fractures.” The Academy’s AUCs are developed by three clinician panels from the best available scientific evidence in combination with clinical expertise, using the RAND/UCLA Appropriateness Method. The literature search was derived from the CPG on “Treatment of Pediatric Supracondylar Humerus Fractures,” published in 2011, as well as an updated literature search. The AUC covers 14 treatments and presents 220 different patient scenarios to help clinicians identify for whom and when the treatments are appropriate.
View all AAOS AUCs, with supporting materials…
View the AUC in a mobile-optimized web app…

3. Study: Use of adjunct technology may help reduce incidence of retained surgical sponges.
Findings from a study published in the Journal of the American College of Surgeons suggest that the use of adjunct technology may help reduce the incidence of retained surgical sponges. The authors analyzed incident reports found in the University HealthSystem Consortium Safety Intelligence database, and found that five organizations that implemented radio frequency (RF) technology collectively demonstrated a 93 percent reduction in the rate of reported retained surgical sponges, compared to a 77 percent reduction in the rate of retained sponges at five organizations that did not use RF technology.   Read more…
Read the abstract…

4. Study: Sex bias may be a component of many biomedical research studies.
A study published in the September issue of the journal Surgery finds evidence of sex bias in biomedical research. The research team reviewed manuscripts from five major surgical journals and found that, of 2,347 articles reviewed, 618 included animals and/or cells. For animal research, 22 percent of the publications did not specify the sex of the animals. Of the reports that did specify sex, 80 percent of studies included only males, 17 percent only females, and 3 percent both sexes. For cell research, 76 percent of the publications did not specify sex, and of those that did, 71 percent included only males, 21 percent only females, and 7 percent both sexes. Only 7 studies (1 percent) reported sex-based results. The research team noted that international studies were more likely to study only males (85 percent) than studies based in the United States (71 percent). However, U.S. studies were less likely overall to specify sex.   Read more…
Read the abstract…
AAOS Now recently released an audio interview in which Joan McGowan, PhD, of the National Institute of Arthritis and Musculoskeletal and Skin Diseases, speaks with Senior Science Writer Jennie McKee about the need to consider both sexes when conducting preclinical studies.
Listen to the podcast (MP3)…

5. Hospital to offer warranty on routine TJAs.
An article in Modern Healthcare profiles one medical center’s program for offering a warranty to privately insured patients regarding avoidable complications stemming from routine total joint arthroplasties (TJAs). The institution plans to cover the costs of avoidable, surgery-related complications if a patient undergoes all care—including diagnosis, surgery and rehabilitation—at the hospital, and is covered by a bundled-service contract with a private insurer or employer. The timeframe for the warranty would be negotiated with the understanding that most complications occur within 90 days of the surgery. The warranty would not cover complications or revisions resulting from the failure of an implant itself.   Read more…(registration may be required)

6. CMS reverses previous decision to remove HAC data from Hospital Compare website.
USA Today reports that the U.S. Centers for Medicare & Medicaid Services (CMS) has reversed its decision to remove information on certain avoidable hospital-acquired conditions (HACs) from its Hospital Compare website. The agency had previously removed data on eight HACs from the publicly searchable portion of the site, but had retained the information on a public spreadsheet that could be accessed by researchers and others. In early August, the data were removed completely. In an email to stakeholders, CMS says that it will again make the data available, although data are not expected to be available until later this year.   Read more…

7. Illinois.
The Chicago Sun-Times reports that the Illinois Department of Healthcare and Family Services plans to collect $16.3 million in penalties from 82 hospitals as part of an effort to reduce preventable readmissions among Medicaid patients. The agency used 2010 inpatient claims data and trending analysis from 2009 to part of 2011 to determine amounts owed by the hospitals in FY 2013. Overall, 147 hospitals were determined to have unacceptable levels of readmissions, but 65 were able to enact measures to enable them to avoid paying a penalty. A spokesperson for one of the affected hospitals questions the department’s methodology in determining preventable readmissions.   Read more…

8. Call for volunteers: Program Committees.
Sept. 18 is the last day to submit your application for several Program Committee openings. Members of Program Committees grade symposia in May and abstracts in June and July, and may serve as moderators for paper sessions and as critical evaluators of courses at the AAOS Annual Meeting. The following positions are available:

  • Foot & Ankle (two member openings)
  • Musculoskeletal Tumor & Metabolic Disease (one member)
  • Pediatrics (one member)
  • Trauma (seven members)

Applicants for these positions must be active fellows or international affiliate members with a practice emphasis in the relevant topic.
Learn more and submit your application…(member login required)

September 10, 2014

Today’s Top Story
1. DOJ files False Claims Act suits alleging improper payments to surgeons made via PODs.
The U.S. Department of Justice (DOJ) has filed a complaint under the False Claims Act, alleging that a medical device manufacturer made improper payments to surgeons through the use of physician-owned distributorships (PODs). Under the POD model, hospitals purchase medical devices from the POD, while surgeons who perform procedures using the implants are often owners or investors in the POD. The agency alleges that four surgeons who were investors or owners of PODs received payments to perform surgeries using a preferred manufacturer’s implants. DOJ also alleges that some of the spinal fusions performed were medically unnecessary or more extensive than what was medically necessary. One observer notes that the lawsuit may be significant, as “it appears to be the first time any of the government’s POD investigations have caused the government to file its own [False Claims Act] lawsuit based on the theory” that a physician’s return on investment may be a kickback.   Read more…(paid subscription may be required)
In 2013, the U.S. Department of Health and Human Services (HHS) Office of Inspector General issued a fraud alert regarding PODs.
Read the OIG report (PDF)…

Other News
2. Sept. 11 is the last day to review physician payment data on CMS Open Payments website.
The “Physician Payments Sunshine Act” requires that data on payments and gifts made to physicians and teaching hospitals by medical device and pharmaceutical companies be made publicly available on a searchable federal database. The U.S. Centers for Medicare & Medicaid Services (CMS) is preparing for the release of these data, which have been collected since 2013, under the Open Payments program. 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 Sept. 11, 2014. The data will be released to the public on Sept. 30, 2014. AAOS has obtained a detailed set of instructions from CMS for physicians to register and review their data on the Open Payments website.   Read more…

3. Study: Osteoporosis medications work, but data on comparative effectiveness are limited.
Data published online in the journal Annals of Internal Medicine suggest that several medications used to treat osteoporosis may reduce fracture risk, but the comparative effectiveness of the drugs remains unclear. The researchers reviewed data from 294 articles and found “high-strength evidence” that bisphosphonates, denosumab, and teriparatide reduce fractures compared with placebo. Relative risk reductions range from 0.40 to 0.60 for vertebral fractures and from 0.60 to 0.80 for nonvertebral fractures; raloxifene has been shown to reduce only vertebral fractures. However, the researchers note that few studies have directly compared drugs used to treat osteoporosis, and that data on male patients are very sparse.   Read more…
Read the abstract…

4. Study questions evidence base for introduction of five device innovations.
A study published online in the journal The BMJ finds a lack of high quality evidence supporting the use of five substantial, well-known, and already implemented device innovations in orthopaedics—ceramic-on-ceramic bearings (hip), modular femoral necks (hip), uncemented monoblock cups (hip), high flexion knee replacement, and gender-specific knee replacement. The authors conducted a systematic review of 118 studies (94 unique study cohorts) on 15,384 implants across 13,164 patients. They found that comparative evidence per device innovation ranged from four low-to-moderate quality retrospective studies on modular femoral necks, to 56 studies of varying quality, including seven high quality (randomized) studies, regarding high flexion knee replacement. Overall, none of the five device innovations was found to improve functional or patient-reported outcomes. Furthermore, the authors found higher revision occurrence associated with modular femoral necks and ceramic-on-ceramic bearings in hip replacement, and with high flexion knee implants. The authors write that in some cases, “existing devices may be safer to use in total hip or knee replacement.”   Read more…
Read the complete study…

5. FDA reminds healthcare professionals about sterile products from Downing Labs/NuVision Pharmacy of Texas in light of an ongoing, FDA-initiated recall.
The U.S. Food and Drug Administration (FDA) is reminding healthcare professionals and consumers regarding safety concerns involving all sterile-use drug products made and distributed by Downing Labs LLC, also known as NuVision Pharmacy (Dallas). A recent FDA inspection of the Downing Labs facility revealed 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. The agency has issued a formal request to Downing Labs for the immediate recall of all lots of unexpired, purportedly sterile products currently on the market. In the letter, FDA outlined poor conditions and practices identified during a July 2014 inspection of Downing Labs’ Dallas facility.   Read more…

6. Does EHR adoption reduce a physician’s available time?
Information from a research letter published online in the journal JAMA Internal Medicine suggests that use of electronic health records (EHRs) may reduce the time some physicians have available to treat patients. The research team drew data from 411 survey responses regarding the use of EHRs in medical practices. They found that 89.8 percent of respondents reported that at least one data management function was slower after EHR adoption. In addition, 33.9 percent of respondents said the time spent finding and reviewing patient data took longer, 63.9 percent said the time spent taking notes increased, and 32.2 percent said they spent more time reading other clinicians’ notes. Overall, the research team noted that the mean time loss for attending physicians was 48 minutes per clinic day, and the mean time loss for trainees was 18 minutes per day.   Read more…
Read the abstract…

7. Kentucky, Maryland.
An article in The Baltimore Sun profiles a Kentucky database designed to track potentially dangerous and addictive prescriptions dispensed in the state over the past 15 years. The author notes that the database has become a model for Maryland as that state launches its own prescription drug monitoring system, through which state officials expect to guide drug abusers to treatment and observe larger prescribing trends.   Read more…(paid subscription may be required)

8. Call for volunteers: Healthcare Infection Control Practices Advisory Committee.
AAOS seeks to nominate members to serve on the Healthcare Infection Control Practices Advisory Committee (HICPAC). The committee provides advice and guidance to a variety of federal agencies, including HHS, the U.S. Centers for Disease Control and Prevention (CDC), and several offices within CDC, regarding the practice of infection control and strategies for surveillance, prevention, and control of healthcare-associated infections, antimicrobial resistance, and related events in settings where health care is provided. Applicants for this position must be U.S. citizens who are active fellows, candidate members, candidate members osteopathic, candidate member applicants for fellowship, candidate member applicants for fellowship osteopathic, or emeritus fellows. In addition, all applicants must provide the following: an online AAOS CAP application, a current resume or curriculum vitae, a short biography (maximum 750 characters) highlighting the candidate’s experience or knowledge, and a letter of interest confirming his or her ability to participate in full capacity. All materials must be submitted by Sept. 22, 2014 at 11:59 p.m. CT to Kyle Shah at shah@aaos.org.
Learn more and submit your application…(member login required)

September 12, 2014

Today’s Top Story
1. Study: Preoperative sepsis, systemic inflammatory response syndrome suggest increased odds of thrombosis.
Evidence from a Swiss study published online in the journal The BMJ suggests that a patient’s risk of thrombosis increases with the severity of an inflammatory response. The authors conducted a prospective cohort study of 2,305,380 adults who underwent surgical procedures across 374 hospitals. At 30-day follow-up, they found that patients with preoperative systemic inflammatory response syndrome or any sepsis had three times greater odds of having a postoperative arterial or venous thrombosis. Among patients with preoperative sepsis, both emergency and elective surgical procedures were at a two times increased likelihood of thrombosis. The authors argue that patients with sepsis who undergo surgery should be considered at increased risk for thrombosis.
Read the abstract…

Other News
2. Study: Little or no benefit for interspinous process device compared to spinal bony decompression for patients with intermittent neurogenic claudication due to lumbar spinal stenosis.
A Dutch study published online in The BMJ finds little advantage in the use of interspinous process device implantation over conventional “simple” decompression for patients with intermittent neurogenic claudication due to lumbar spinal stenosis. The research team conducted a randomized, controlled trial of 159 patients with intermittent neurogenic claudication due to lumbar spinal stenosis at one or two levels with an indication for surgery; 80 patients received an interspinous process device and 79 patients underwent spinal bony decompression. At 8-week follow-up, they found that, based on the Zurich Claudication Questionnaire, the success rate for the interspinous process device cohort was not superior to that for the standard bony decompression cohort. During the first year, the research team observed no differences in disability or other outcomes between groups. In addition, the repeat surgery rate in the interspinous implant group was substantially higher than that in the conventional group during the early post-surgical period.
Read the abstract…

3. U.K. report finds reduction in mortality after hip fracture.
An annual report from the United Kingdom National Hip Fracture Database notes a reduction in 30-day mortality after hip fracture in that country. Based on input from 182 eligible hospitals in England, Wales, and Northern Ireland, the report finds that 30-day mortality after hip fracture was 8.05 percent in 2013, compared to 8.1 percent during 2011 to 2012. One of the authors of the report notes that the improvements occurred amid an increase in the number of patients being treated and an increase in the average age of hip fracture patients as well as adoption of best practices.   Read more…
View the report, with related links…
AAOS recently released a clinical practice guideline on Management of Hip Fractures in the Elderly. Read more…

4. Study: GILZ protein may protect against bone loss linked to arthritis.
According to information from a mouse study presented at the annual meeting of the American Society for Bone and Mineral Research, the GILZ protein may protect against bone loss that often accompanies arthritis and its treatment. The researchers crossed mice bred to overexpress tumor necrosis factor alpha (TNFa) throughout the body with mice that overexpressed GILZ in just their mesenchymal stem cells. They found that mice that overexpressed only TNFa quickly developed arthritis along with significant bone and weight loss, while those that also overexpressed GILZ had significantly less bone loss.   Read more…

5. Study: Redundant antimicrobial therapy may be “pervasive” in U.S. hospitals.
Data from a study published in the October issue of the journal Infection Control and Hospital Epidemiology suggest that U.S. hospitals may overuse antimicrobial therapy. The authors conducted a retrospective analysis of inpatient administrative data drawn from 505 nonfederal hospitals in the United States. They found evidence of potentially inappropriate, redundant antimicrobial coverage for 23 different antimicrobial combinations in 394 (78 percent) institutions, representing 32,507 cases. In addition, they observed high-frequency redundancies in three antianaerobic regimens, accounting for 70 percent of cases. Of those, metronidazole and piperacillin-tazobactam accounted for 53 percent (n = 17,326) of all potentially redundant cases. There were 148,589 days of redundant therapy, representing more than $12 million in potentially avoidable healthcare costs.   Read more…
Read the abstract…

6. House passes “keep your plan” legislation.
The Hill reports that the U.S. House of Representatives has passed legislation that would, if enacted, allow people to keep their insurance plans under the Affordable Care Act (ACA), even if the coverage doesn’t meet minimum requirements. One key selling point of the ACA was that insured consumers would be able to remain on their current healthcare plans if they chose, but some insurance plans fall short of the 10 minimum requirements, which include coverage of such factors as maternity care, prescription drugs, outpatient services, and lab services. According to an estimate from the U.S. Congressional Budget Office, the bill would raise more than $1 billion in tax revenue over the next decade, as the pool of taxable dollars would likely increase as employees spent less on healthcare premiums. However, critics have called the bill a political attack on the ACA and pointed out that the healthcare reform act attempts to ensure that all Americans receive comprehensive coverage. The Senate is not expected to take up the legislation, and President Obama has threatened to veto should it pass both houses.   Read more…

7. Ambulatory providers concerned about attestation to meaningful use of electronic health records.
A study brief from HIMSS Analytics finds that many ambulatory providers have not successfully attested to meaningful use Stage 2. The researchers surveyed 563 executives from freestanding and hospital-owned ambulatory facilities and found that only 25.7 percent of free standing and 36.2 percent of hospital-owned ambulatory facilities had successfully attested to Stage 2. In addition, the survey notes that ambulatory providers are not very confident about their ability to meet criteria for Stage 3, with confidence levels falling from about 33 percent in 2012 to about 25 percent in 2014.   Read more…
Read the press release…

8. Call for volunteers: Communications Cabinet.
Sept. 22 is the last day to submit your application for a position on the Communications Cabinet (one member opening—technology expertise). The Communications Cabinet plans, organizes, directs, and evaluates AAOS communications vehicles and undertakes special communications projects. Applicants for this position must be active fellows or associate members osteopathic with experience and understanding of the Web, and electronic and social media as they relate to public and media relations programs.
Learn more and submit your application…(member login required)

September 15, 2014

Today’s Top Story
1. Study: Patient-specific instrumentation may increase accuracy in TKA, but difference may not be clinically relevant.
Data published in the October issue of the journal Clinical Orthopaedics and Related Research (CORR) suggest that the use of patient-specific instrumentation may offer only subtle improvement in accuracy compared to the use of conventional instrumentation when performing total knee arthroplasty (TKA). The authors conducted a randomized trial of 90 patients who were treated with either computed tomography (CT)-based patient-specific instrumentation, magnetic resonance imaging (MRI)-based patient-specific instrumentation, or conventional instrumentation. They found that, compared with conventional instrumentation, both MRI- and CT-based patient-specific instrumentation displayed higher accuracy regarding coronal limb axis, femoral rotation, and tibial slope. However, the differences were small. In addition, although there was a significant reduction of the duration of surgery in both patient-specific instrumentation groups in comparison to conventional instrumentation, there were no differences between cohorts in postoperative Knee Society pain and function and WOMAC scores.
Read the abstract…

Other News
2. Hospira institutes recall of one lot of Heparin Sodium.
Hospira, Inc. has announced a voluntary nationwide user-level recall of one lot of Heparin Sodium, 1,000 USP Heparin Units/500 mL (2 USP Heparin Units/mL), in 0.9% Sodium Chloride Injection, 500 mL, NDC 0409-7620-03 Lot 41-046-JT with expiration date of 01NOV 2015. The company states that there has been one confirmed customer report of particulate (a human hair) in a single unit, sealed between the tube and the film at the round seal of the unused administrative port on the non-print side of the container. According to the company, in the unlikely event that the particulate breaks and pieces are able to pass through the intravenous catheter, injected particulate material may result in local inflammation, phlebitis, and/or low-level allergic response. Patients with preexisting condition of trauma or other medical condition that adversely affects the microvascular blood supply are at an increased risk. The company states that anyone with an existing inventory of this product should stop use and distribution, and quarantine the product immediately.   Read more…

3. HIMSS argues that full-year meaningful use rule will be “extremely challenging” to providers.
In a letter to Sylvia Burwell, secretary of the U.S. Department of Health and Human Services (HHS), the Healthcare Information and Management Systems Society (HIMSS) has outlined its opposition to a full-year meaningful use reporting requirement for 2015 using 2014 certified electronic health records technology (CEHRT). “We are deeply concerned with the lack of flexibility that the rule provided for 2015,” the authors write. They note that an HHS decision to require a full year of reporting using 2014 edition CEHRT in 2015 puts many eligible hospitals at risk of not meeting meaningful use requirements for 2015. “Under current regulation, [eligible hospitals] must use 2014 CEHRT in less than one month,” the authors continue. “If they do not, they become ineligible for incentive payments and they are subject to downward 2017 Medicare payment adjustments.” The organization requests that providers who are not in their first year be allowed to achieve meaningful use with 2014 CEHRT for any one 3-month quarter in 2015, rather than a full year.   Read more…
Read the letter (PDF)…

4. Study: Reducing readmissions after TKA may increase institutional profits.
According to evidence published in the October CORR, although associated with a positive contribution margin, unplanned TKA readmissions may reduce an institution’s total profit—an effect that will likely increase as the U.S. Centers for Medicare & Medicaid Services increases penalties for readmissions. The researchers conducted a retrospective review of 3,218 primary TKAs performed at a single, academic hospital network. For TKA visit with readmission, the median profit and contribution margins were $2,855 and $13,901, respectively; for TKA visit without readmission, they were $5,300 and $11,652. The researchers estimate that readmission penalties could reach $6.21 million per year for their hospital network.
Read the abstract…

5. Reminder: Increased restrictions on prescribing of hydrocodone combination products will take effect Oct. 6.
The Massachusetts Medical Society is reminding healthcare providers that, beginning Oct. 6, 2014, hydrocodone combination products will be rescheduled from schedule III to schedule II of the Controlled Substances Act. As a schedule II substance, prescriptions will not be refillable and patients will be limited to a single, 90-day supply of any hydrocodone combination product. Prescriptions for HCPs with authorized refills and issued before Oct. 6, 2014 may be dispensed until April 8, 2015 in accordance with U.S. Drug Enforcement Administration rules for refilling, partial filling, transferring, and central filling Schedule III-V controlled substances.   Read more…
Read the rule rescheduling hydrocodone combination products…

6. Florida.
An article in the Miami Herald looks at the issue of price transparency in health care. The writer notes that proprietary contracts, in which insurers and healthcare providers agree to keep payment rates confidential, prevent employers from knowing the prices their own insurance plan administrators negotiate with healthcare providers, even when the plans are self-insured and the claims are paid with taxpayer money. The writer notes that several states have adopted legislation to require insurance companies and healthcare providers to report reimbursement rates and payments for use in an all-payer claims database.   Read more…

7. Washington.
The Associated Press reports that the Washington State University board of regents has approved the startup of a new medical school in Spokane. The move is part of an effort to address a shortage of providers in the state, with nearly half of the state’s physicians practicing in the Seattle area and 18 of 39 counties having 10 or fewer physicians per 10,000 people. Establishment of the new school is opposed by the University of Washington, which operates the state’s only publicly funded medical school.   Read more…

8. Call for volunteers: Evaluation Committees.
Sept. 29 is the last day to submit your application for an opening on an Evaluation Committee. Members of Evaluation Committees write questions for orthopaedic self-assessment examinations. The following positions are available:

  • Anatomy-Imaging (chair; two members—hand and wrist; two members—tumors)
  • Hand & Wrist (chair, nine members)

Applicants for chair openings must be active fellows. Applicants for member openings must be active fellows, candidate members, candidate member applicants for fellowship, or emeritus fellows with a practice emphasis in the relevant topic.
Learn more and submit your application…(member login required)


September 17, 2014

Today’s Top Story
1. Meta-analysis suggests no significant difference in efficacy or safety among various VTE treatment strategies.
A study published in the Sept. 17 issue of The Journal of the American Medical Association compares various strategies for the treatment of acute venous thromboembolism (VTE). The research team conducted a meta-analysis of 45 trials covering 44,989 patients comparing eight 8 anticoagulation options for treatment of VTE—unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux in combination with vitamin K antagonists; LMWH with dabigatran or edoxaban; rivaroxaban; apixaban; and LMWH alone. They found no statistically significant differences for efficacy and safety associated with most treatment strategies compared against the LMWH–vitamin K antagonist combination. However, the research team noted that the UFH–vitamin K antagonist combination was associated with the least effective strategy, and that rivaroxaban and apixaban were associated with the lowest risk for bleeding.   Read more…
Read the complete study…

Other News
2. CMS Open Payments data correction period opens.
The U.S. Centers for Medicare & Medicaid Services (CMS) is reminding healthcare stakeholders that the Open Payments (Sunshine Act) data correction period is now open. At this time, applicable manufacturers and group purchasing organizations (GPOs) have the opportunity to acknowledge and resolve disputes initiated by physicians and teaching hospitals. CMS states that it will not be responsible for mediating disputes; it is up to the applicable manufacturer or GPO to work directly with physicians or teaching hospitals. Open Payments data will be released to the public on Sept. 30, 2014.   Read more…
View the Open Payments user guide (PDF)…

3. How much does “defensive medicine” affect healthcare costs?
A research letter published in the Sept. 15 issue of the journal JAMA Internal Medicine looks at factors related to the practice of so-called defensive medicine. The researchers surveyed 36 hospital-employed physicians regarding demographics and attitudes toward defensive medicine, then asked participants to review their orders from the previous day and rate them according to the degree to which each was perceived to be defensive. They found that overall, 28 percent of orders and 13 percent of costs were considered to be at least partly defensive. However, compared with physicians with fewer defensive orders, physicians with defensive orders of 10 percent or more placed a similar number of orders and generated similar costs per patient. Physician factors such as sex, training, and litigation were not associated with an increase in defensive orders or costs.
Read the abstract…

4. Study: TKA for working population may produce societal value in excess of cost.
Data from a study published online in the journal Value in Health suggest a net societal benefit to the use of total knee arthroplasty (TKA) procedures. The authors examined the impact of an Oregon policy for public employees that required additional cost-sharing for high-cost procedures such as TKA. They used a Markov model to estimate the societal impact in terms of quality of life, direct costs, and indirect costs of higher co-pays for TKA, and found that TKA for a working population can generate societal benefits that offset its costs. The authors note that delay in receiving surgical care reduced the societal savings from TKA.
Read the abstract…

5. FDA releases list of recent drug safety labeling changes.
The U.S. Food and Drug Administration (FDA) has released a list of safety labeling changes in August. The posting comprises 32 products with changes to the following sections: boxed warnings, contraindications, warnings, precautions, adverse reactions, and patient package insert. Drugs that saw modifications include:

  • Eliquis (apixaban) tablets for oral use
  • Pradaxa (dabigatran etexilate mesylate) capsules for oral use
  • Zohydro ER (hydrocodone bitartrate) extended-release capsules
  • Zorvolex (diclofenac) capsules

Read more…
On a related note, the American Medical Association has released a list of six key points for healthcare providers should keep in mind regarding the recent decision to reschedule hydrocodone combination products from schedule III to schedule II of the Controlled Substances Act.   Read more…

6. CMS: ACOs improved quality, reduced overall costs.
According to information from CMS, accountable care organizations (ACOs) participating in the second year of the Pioneer ACO Model have demonstrated a 0.45 percent lower per capita growth in spending for the Medicare program compared with fee-for-service providers. Overall, the mean quality score among Pioneer ACOs increased by 19 percent, from 71.8 percent in 2012 to 85.2 percent in 2013, and the organizations displayed improvement in 28 of 33 quality measures. In addition, of ACOs participating in the Shared Savings Program, 53 held spending $652 million below their targets and earned performance payments of more than $300 million. One ACO overspent its target by $10 million and owed shared losses of $4 million, and an additional 52 ACOs reduced healthcare costs compared to their benchmark, but did not qualify for shared savings.   Read more…
Read the statement from CMS…

7. Are ASCs less appropriate for some patients?
An article in Modern Healthcare looks at calls by some physicians and safety advocates to carefully consider which patients may be most appropriate for treatment in ambulatory surgery centers (ASCs). A spokesperson for the American Geriatrics Society states that risk may be greater for older patients treated at ASCs, as compared to hospitals, where emergency teams can respond more rapidly. The Ambulatory Surgery Center Association advises that all ASCs should be prepared to routinely cater to the needs of older patients. The author notes that four organizations currently accredit ASCs: The Joint Commission, the American Association for Accreditation of Ambulatory Surgery Facilities, the Accreditation Association for Ambulatory Health Care, and the Healthcare Facilities Accreditation Program. In addition, ASCs that provide care to Medicare beneficiaries must meet CMS certification requirements.   Read more…

8. Call for volunteers: Central Evaluation Committee.
Oct. 3 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 annually and the Orthopaedic Self-Assessment Examination triennially. The following openings are available:

  • Adult Reconstruction Hip and Knee (one member opening)
  • Basic Science (one member)
  • Foot and Ankle (one member)
  • Oncology (one member)
  • Trauma (two members)

Applicants for these positions must be active fellows, emeritus fellows, candidate member applicants for fellowship, candidate member applicants for fellowship osteopathic, or associate members osteopathic with a practice emphasis in the relevant area.
Learn more and submit your application…(member login required)

September 19, 2014

Today’s Top Story
1. Study: Definition of infection may affect SSI rates and factors.
Data published online in the journal Clinical Orthopaedics and Related Research suggest that how infection is defined may affect the findings of clinical studies addressing surgical site infection (SSI). The authors conducted a retrospective study of 5,761 adult patients who underwent orthopaedic spine surgery at a single center. They applied three different definitions of infection: ICD-9 code for SSI, U.S. Centers for Disease Control and Prevention (CDC) criteria for deep infection, and incision and debridement for infection. Based on the ICD-9 code definition, the authors found that 361 patients had SSIs within 90 days of surgery. Of those, 216 met CDC criteria for deep infection, and 189 underwent irrigation and debridement within 180 days of surgery. The authors noted that Charlson Comorbidity Index, duration of operation, obesity, and posterior surgical approach were independently associated with a higher risk of infection for each of the three definitions of SSI. However, the influence of malnutrition, smoking, specific procedures, and specific surgeons varied by definition of infection, and accounted for approximately 6 percent of the variability in the risk of developing an infection.
Read the abstract…

Other News
2. TJC issues Sentinel Event Alert on misuse of single-dose/single-use and multiple-dose vials.
The Joint Commission (TJC) has issued a Sentinel Event Alert regarding the misuse of single-dose/single-use and multiple-dose vials. The organization states that the CDC is aware of at least 19 infection outbreaks since 2007 associated with the misuse of single-dose/single-use vials. TJC has outlined a series of recommendations and potential strategies to help prevent the misuse of such vials, including:

  • Implementation of evidence-based, standardized policy and procedures for the prevention of the misuse of vials.
  • Regular quality checks on clinical units to look for open vials.
  • Annual education on injection safety and on preventing the misuse of vials for all staff who administer injections—including new or temporary staff.
  • Pre-discharge injection safety education for patients and caregivers who will use injectable medical products as part of a home health regimen.
  • Emphasizing that all staff are responsible for reporting risks, errors (including near misses), and adverse events.
  • Reporting of clusters of infections or other adverse events to the appropriate local and state public health authorities.
  • When unsafe injection and infection control practices are identified, assess potential harm to patients and, if warranted, notify patients and test for bloodborne pathogens.

Read more…
Read the Alert…

3. AOFAS issues list of recommendations under Choosing Wisely© campaign.
The American Orthopaedic Foot & Ankle Society (AOFAS) has joined a large group of medical societies, including AAOS, in releasing its own list of commonly ordered tests and procedures that may not be always be necessary, under the Choosing Wisely© campaign. The list identifies five things physicians and patients should question. The AOFAS recommendations are as follows:

  • Don’t perform surgery for a bunion or hammertoes without symptoms.
  • Don’t use shoe inserts for symmetric flat feet or high arches in patients without symptoms.
  • Don’t perform surgery for plantar fasciitis before trying 6 months of non-operative care.
  • Avoid X-ray evaluation of the foot and ankle without standing (weight bearing) in the absence of injury.
  • Don’t use alcohol injections for Morton’s neuromas.

Nearly 100 medical specialty societies and other stakeholders have joined the campaign since it was launched in 2012. The AOFAS list builds on a library of more than 300 tests and procedures that have been identified as potentially harmful and should be discussed with patients and physicians.   Read more…
View the AOFAS list…

4. Study: Lower economic status associated with increased musculoskeletal pain after trauma.
According to data presented online in the journal Pain, patients of lower economic status who have musculoskeletal pain after trauma may be at increased risk of poorer outcomes. The research team conducted a multicenter, prospective study of 948 European-American participants who had experienced a motor vehicle collision and who were discharged home after emergency department evaluation. At 6-week, 6-month, and 1-year follow-up, the investigators surveyed study participants and found that living in more disadvantaged neighborhoods was associated with increased musculoskeletal pain and increased pain interference with daily function.   Read more…
Read the abstract…

5. AMA offers outline to improve EHR systems.
The American Medical Association (AMA) has released a proposed framework for improving the usability of electronic health records (EHRs). The authors note that current EHR systems have presented challenges to many physicians, and they outline eight usability priorities that they argue should be “urgently addressed,” including:

  • Enhancement of physicians’ ability to provide high-quality patient care
  • Support of team-based care
  • Promotion of care coordination
  • Improved product modularity and configurability
  • Reduction of cognitive workload
  • Promotion of data liquidity
  • Facilitation of digital and mobile patient engagement
  • Incorporating user input into product design and post-implementation feedback

The organization states that additional research may be needed to determine how EHR use may promote or inhibit high-quality care. “It is essential to better understand the cognitive needs of physicians and how EHR products can meet them, identify evidence that outlines the benefit tools that support decision-making, and explore how EHRs influence the patient encounter,” the authors write.
Read the framework…

6. CMS to host MLN Connects™ National Provider Call on transitioning to ICD-10.
The U.S. Department of Health and Human Services has issued a rule finalizing Oct. 1, 2015, as the new compliance date for healthcare providers, health plans, and healthcare clearinghouses to transition to ICD-10. During this Provider Call, CMS subject matter experts will discuss ICD-10 implementation issues, opportunities for testing, and resources. Topics will include:

  • Final rule and national implementation
  • Medicare Fee-For-Service testing
  • Medicare Severity Diagnosis Related Grouper Conversion Project
  • Partial code freeze and annual code updates
  • Plans for National Coverage Determinations and Local Coverage Determinations
  • Claims that span the implementation date

The call will take place from 1:30 p.m. to 3 p.m. ET, Wednesday, Nov. 5, 2014. Space is limited and registration is required.
Register for the call…

7. Call for volunteers: AUC for Management of Hip Fractures in the Elderly.
The Appropriate Use Criteria (AUC) Section seeks AAOS fellows to participate on the writing panel of the Management of Hip Fractures in the Elderly AUC. The writing panel is responsible for constructing a comprehensive patient indications list and a treatment list for patients presenting with hip fractures. Writing panel members will be required to construct and review materials, correspond with AAOS staff electronically, and participate in approximately five to 10 conference calls, spanning 1 to 3 months, to produce the AUC materials. Members should have experience in treating patients with hip fractures. Nominees for the writing panel may have relevant conflicts and will be required to complete the AAOS conflict of interest enhanced disclosure form online. If you are interested in participating on the writing panel for this AUC topic, please contact Erica Di Salvo by Monday, Oct. 6, 2014, at disalvo@aaos.org.
Learn more about the AUC process (PDF)…

8. Call for volunteers: Spanish Translation Review Work Group.
Oct. 3 is the last day to submit your application for a position on the Spanish Translation Review Work Group (10 member openings). The Spanish Translation Review Work Group will review the Spanish translation of an AAOS publication. The translation is being performed by a medical translation company, and Work Group members will be asked to review the translated text only for accuracy against the original English text. Applicants for this position must be active fellows, resident members, international affiliate members, or international resident members who are native Spanish speakers.
Learn more and submit your application…(member login required)

September 22, 2014

Today’s Top Story
1. Study: Many ED patients may be undertriaged.
Findings from a study published in the September issue of The American Journal of Emergency Medicine suggest that more than one third of major trauma patients in U.S. emergency departments (EDs) may be undertriaged. The authors drew data on 197,702 major trauma discharges from the 2010 Nationwide Emergency Department Sample and found that 34.0 percent were undertriaged in EDs. Traumatic brain injury was the most common diagnosis for undertriaged patients, accounting for 40.2 percent of undertriaged cases. In addition, the authors found that elderly patients were at significantly greater risk of undertriage. To accommodate all undertriaged patients, the authors estimate that level I and level II trauma centers in the United States would have to increase their capacity by 51.5 percent—a level they admit may not be feasible.   Read more…
Read the abstract…

Other News
2. Study: Morbid obesity may increase risk of subsequent revision following two-stage revision TKA for infection.
According to data published in The Journal of Bone & Joint Surgery, patients who are morbidly obese may be at increased risk of subsequent revision, reoperation, and reinfection following two-stage revision total knee arthroplasty (TKA) for infection. The research team conducted a two-to-one matched cohort study to compare outcomes patients who who underwent two-stage revision TKA for periprosthetic joint infection following primary TKA; 37 morbidly obese patients (body mass index [BMI] =40 kg/m2) were matched against 74 non-obese patients (BMI <30 kg/m>2). Researchers found that, compared to the control cohort, patients in the morbidly obese cohort were at significantly increased risk for revision surgery, reinfection, and reoperation. In addition, the research team found that 5-year implant survival rates were 80 percent for the morbidly obese group and 97 percent for controls, and 10-year implant survival rates were 55 percent for the morbidly obese group and 82 percent for controls.
Read the abstract…

3. Oct. 1 deadline looms for EHR compliance, but CMS systems may not be ready in time.
A report in Politico states that a technical glitch in U.S. Centers for Medicare & Medicaid Services (CMS) computer systems may result in some physicians being unfairly penalized for noncompliance with CMS rules regarding the adoption of electronic health records (EHRs). Physicians who accept Medicare are required to demonstrate that they are meeting program goals by Oct. 1. However, CMS will not be ready to officially register providers who adopted EHR systems during 2014 until after the Oct. 1 deadline. Under current rules, CMS will withhold 1 percent of 2015 Medicare payments to providers who do not demonstrate compliance by Oct. 1.   Read more…

4. Transparency tool may help steer consumers to more efficient and higher quality physicians.
Information from a report released by UnitedHealthcare suggests that price and quality transparency tools may effectively engage consumers seeking quality and cost-effective treatments. The authors of the report conducted a cross-sectional analysis comparing users and nonusers of the company’s proprietary online cost estimator 1 year after implementation. They found that users of the system were more likely to enroll in a consumer-drive healthcare plan, had an increased likelihood of choosing so-called “quality and efficient” (Q&E) physicians, and were more likely to choose Q&E orthopaedists and primary care physicians. The authors note that the study design did not take into account baseline differences in Q&E usage that may have existed between users and nonusers.   Read more…
Read the report (PDF)…

5. Neurosurgery supplement offers in-depth look at sports-related concussion.
A supplement published in the journal Neurosurgery looks at the history, current concepts, and future of treatment for sports-related concussion. Articles in the supplement include:

  • The New Neurometabolic Cascade of Concussion
  • Imaging Concussion: A Review
  • Current Concepts in the Treatment of Sports Concussions
  • Sideline Assessment Tools for the Evaluation of Concussion in Athletes: A Review
  • Emergent Treatment of Athletes With Brain Injury

Read more…
View the table of contents…

6. Colorado.
An article in Coloradoan looks at the issue of sepsis and argues that both healthcare providers and the public lack awareness of the gravity of the condition. The writer states that 12,000 people are expected to get sepsis in the state this year, and an estimated 3,000 will die. However, some observers suggest that sepsis may be underdiagnosed and underreported. A pediatrician who advocates for sepsis awareness notes that most ED physicians will see only one or two cases of pediatric sepsis over the course of a career, and points out that the symptoms of sepsis—low or high temperature and elevated heart rate—aren’t always good indicators of the condition in children.   Read more…

7. Call for volunteers: AUC for Osteochondritis Dissecans of the Knee.
The Appropriate Use Criteria (AUC) Section seeks AAOS fellows to participate on the review panel of the Osteochondritis Dissecans (OCD) of the Knee AUC. Members of the review panel will be responsible for reviewing the materials created by the writing panel. Review panel members will be given 2 weeks to submit any comments or suggestions for improvement of the writing panel materials via an electronic survey. Members of the review panel should have experience in treating or referring patients with OCD of the knee. If you are interested in participating on the review panel for this AUC topic, please contact Erica Di Salvo by Monday, Oct. 6, 2014, at disalvo@aaos.org.
Learn more about the AUC process (PDF)…

8. Call for volunteers: AMA House of Delegates.
AAOS seeks one delegate representative to join the American Medical Association (AMA) House of Delegates. Members of the AMA House of Delegates serve as an important communications, policy, and membership link between the AMA and grassroots physicians. The delegate/alternate delegate is a key source of information on activities, programs, and policies of the AMA. The delegate/alternate delegate is also a direct contact for the individual member to communicate with and contribute to the formulation of AMA policy positions, the identification of situations that might be addressed through policy implementation efforts, and the implementation of AMA policies. Applicants for this position must be AMA members as well as AAOS 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 (no longer than 20 pages) with complete contact information, a letter of interest, highlighting his or her expertise in subject area and a statement that he or she is able to participate in full capacity and a 100-word maximum biography. All supporting materials should be submitted by Oct. 1, 2014 at 11:59 p.m. CT, to Kyle Shah, clinical quality and medical affairs coordinator, at shah@aaos.org.
Learn more and submit your application…(member login required)

September 24, 2014

Today’s Top Story
1. Court tosses ACA “employer mandate” suit.
Politico reports that a federal appeals court has rejected a lawsuit challenging a delay of a key part of the Affordable Care Act (ACA). The so-called “employer mandate” requires that businesses with more than 50 full-time equivalent employees provide health insurance or pay a penalty. ACA calls for the mandate to have taken effect Jan. 1, 2014, but the Obama administration has delayed enforcement until 2015. A suit filed by the Association of American Physicians and Surgeons argued that the delay could negatively affect physician reimbursement, but the 7th Circuit Court of Appeals determined that the plaintiffs did not have standing to sue over the issue. In July, the U.S. House of Representatives voted to similarly sue President Obama on the grounds that he exceeded his authority when the administration delayed penalizing companies for not following the employer mandate. That suit has not yet been filed.   Read more…

Other News
2. AMA argues that Supreme Court ruling on case could affect medical “false claims” suits.
Information on the American Medical Association (AMA) website suggests that a lawsuit being brought before the U.S. Supreme Court could potentially extend the length of time available for plaintiffs to file “false claims” cases against physicians, and allow repeat lawsuits to be filed. Plaintiffs in KBR v. United States of America Ex Relator Benjamin Carter are seeking to eliminate an existing 6-year limit on pursuing “false claims” under the federal False Claims Act. In a friend-of-the-court brief filed by AMA, the organization argues that, depending how the case is ruled, the combined effect could “invite private plaintiffs and the government to pursue indefinitely and repeatedly any claim involving alleged fraud against the government. This elimination of all repose is not only contrary to law but would impose significant burdens on businesses, hospitals and other healthcare providers.” The case is expected to be argued during the upcoming Supreme Court session.   Read more…

3. Study: Many elite college athletes return to play after ACL reconstruction.
Findings from a study published online in The American Journal of Sports Medicine suggest that many elite college athletes are able to return to play after anterior cruciate ligament (ACL) reconstruction. The researchers conducted a retrospective review of 35 athletes who underwent precollegiate ACL reconstruction and 54 who underwent intracollegiate reconstruction. They found that patients in the precollegiate reconstruction group had a 17.1 percent injury rate with the original graft and a 20.0 percent rate of a contralateral ACL injury. Among patients in the intracollegiate reconstruction group, reinjury rates were 1.9 percent with an ACL graft, and there was an 11.1 percent rate of contralateral ACL injury after ACL reconstruction. Overall, 88.3 percent of patients in the intracollegiate reconstruction group played an additional non-redshirt year after their injury.   Read more…
Read the abstract…

4. What causes geographical variation in elective surgeries?
An article on The Pew Charitable Trusts website looks at the issue of geographical variation in elective surgeries, including some orthopaedic procedures. A recent report from The Dartmouth Institute for Health Policy & Clinical Practice finds that differing surgical rates did not always reflect variations in prevalence of the associated diseases. The article looks at factors that may contribute to geographical variations, such as physician training, shared decision-making, and poor communication among healthcare providers.  Read more…
Read the report (PDF)…

5. Report: Quality evidence lacking on long-term effects of opioid therapy.
According to information released by the U.S. Agency for Healthcare Research and Quality, evidence on long-term opioid therapy for chronic pain is very limited, but available information suggests that such therapy may be associated with increased risk of serious harm. The research team conducted a retrospective review of 38 randomized trials and comparative observational studies of patients with chronic pain. They found that in general, strength of evidence was rated no better than low, due to imprecision and methodological shortcomings, and no study evaluated the effects of long-term opioid therapy versus no opioid therapy. Study data suggested rates of aberrant drug-related behaviors ranging from 5.7 percent to 37.1 percent. In addition, compared with nonuse, long-term opioid therapy was associated with increased risk of overdose, fracture, myocardial infarction, and markers of sexual dysfunction, with several studies showing a dose-dependent association. The research team writes that “more research is needed to understand long-term benefits, risk of abuse and related outcomes, and effectiveness of different opioid prescribing methods and risk mitigation strategies.”
Read the report (PDF)…

6. FDA initiative advises providers to know the source of purchased drugs.
An initiative by the U.S. Food and Drug Administration (FDA) is designed to encourage awareness among healthcare providers regarding illegitimate drug distributors. “While the U.S. healthcare supply chain is one of the most secure and sophisticated in the world,” the agency states, “there is a growing network of rogue wholesale drug distributors selling potentially unsafe drugs in the U.S. market.” FDA recommends that providers only buy drugs from wholesale distributors licensed in their states, and to that end is offering a state-by-state search engine that providers can use to determine whether their distributors are properly licensed.   Read more…
Access the search engine…

7. Massachusetts.
A report released by the Massachusetts Medical Society finds a slight but ongoing decline in the state’s physician practice environment. The MMS Physician Practice Environment Index—a statistical compilation of nine factors that influence the practice climate for physicians—displayed a decline of 0.3 percent for 2013. MMS states that since 2006, the Massachusetts index has remained relatively unchanged, while the U.S. index has increased every year in that 7-year period. The Massachusetts index now stands at 8 percent below the U.S. index, representing the largest gap between the two since 1992.
Read the report (PDF)…

8. Call for volunteers: Committee on Evidence-Based Quality and Value.
Oct. 2 is the last day to submit your application for a position on the Committee on Evidence-Based Quality and Value (five member openings). This committee oversees evidence-based initiatives such as Clinical Practice Guidelines, Appropriate Use Criteria, and related educational and implementation products. Applicants for this position must be active or emeritus fellows with understanding of evidence-based practice principles and methodologies in either a private practice or academic setting.
Learn more and submit your application…(member login required)

September 26, 2014
Today’s Top Story
1. Study: NSAID use may be linked to increased risk of VTE.
Other News
2. Study: Integrated orthotic and rehabilitation protocol may improve outcomes for patients with lower extremity trauma.
3. Study: Exercise therapy may reduce pain for patients with hip OA.
4. Study: Pin spread associated with increased risk of loss of reduction after percutaneous fixation of supracondylar fractures.
5. CMS: Register now to participate in 2014 PQRS GPRO.
6. 2013 PQRS incentive payments now available.
7. ACOs cite cost and interoperability as primary challenges to leveraging HIT.
8. Call for volunteers: Practice Management Instructional Course Committee.
Today’s Top Story
1. Study: NSAID use may be linked to increased risk of VTE.
Findings from a study published online in the journal Rheumatology suggest that use of NSAIDs may be linked to a statistically significant increase in the likelihood of venous thromboembolism (VTE). The authors conducted a meta-analysis of six studies covering 21,401 VTE events. They found a 1.80 pooled risk ratio for VTE among NSAID users compared to non-users. The authors note that the study is limited in that it evaluated all NSAIDs as one group and did not granulate among various NSAIDs.   Read more…
Read the abstract…

Other News

2. Study: Integrated orthotic and rehabilitation protocol may improve outcomes for patients with lower extremity trauma.

According to a study published in the October issue of the journal Clinical Orthopaedics and Related Research, use of an integrated orthotic and rehabilitation protocol may improve outcomes for patients with severe, traumatic lower extremity deficits. The research team conducted a prospective study of 84 service members with lower extremity trauma, including sustained fractures, sustained nerve injuries with weakness, and/or arthritis. Overall, 53 participants were less than 2 years since injury, and 31 patients were greater than 2 years since injury. All patients underwent a 4-week physical therapy program without orthosis, followed by 4 weeks with orthosis. At 8 weeks, patients overall improved in all physical performance measures and all relevant patient-reported outcomes, and 41 of 50 patients who had initially considered amputation favored limb salvage.   Read more…

3. Study: Exercise therapy may reduce pain for patients with hip OA.
Findings from a German study published in the journal Deutsches Ärzteblatt suggest that 12 weeks of exercise therapy may reduce pain and improve physical function for patients of normal vitality who have hip osteoarthritis (OA). The authors conducted a randomized, controlled trial of 218 patients with hip OA. Patients underwent no treatment (n = 68), 12 weeks of exercise therapy (n = 71), or placebo ultrasound treatment (n = 70). Researchers found that pain reduction based on WOMAC index was significantly greater in the exercise group compared to the control and placebo groups. However, the authors noted no significant difference in SF-36 score among cohorts.   Read more…
Read the complete study (PDF)…

4. Study: Pin spread associated with increased risk of loss of reduction after percutaneous fixation of supracondylar fractures.
A study published in the October/November issue of the Journal of Pediatric Orthopaedics looks at factors associated with loss of reduction after percutaneous fixation of supracondylar fractures. The researchers evaluated 192 patients with displaced supracondylar fractures and found that age, sex, fracture characteristics (type, comminution, and location), and treatment with lateral-entry pins were not associated with loss of reduction. However, pin spread at the fracture site was linked to loss of reduction, with less spread increasing the likelihood of failure. Fractures that lost reduction had an average pin spread of 9.7 mm or 28 percent of the humerus width, compared against 13.7 mm or 36 percent of the humerus width for those that remained aligned. Overall, 94 patients had type II fractures, and 98 had type III fractures.
Read the abstract…

5. CMS: Register now to participate in 2014 PQRS GPRO.
The U.S. Centers for Medicare & Medicaid Services (CMS) is reminding eligible professionals who wish to participate in the 2014 Physician Quality Reporting System (PQRS) program as a group practice to register for the group practice reporting option (GPRO) by Sept. 30. GPRO-participating group practices that satisfactorily report data on PQRS measures during the 2014 reporting period (Jan. 1 – Dec. 31) are eligible to earn the 0.5 percent incentive payment and will avoid the -2 percent 2016 PQRS payment adjustment. To earn an incentive for the 2014 PQRS program year and avoid the 2016 PQRS payment adjustment, group practices with two or more eligible professionals may register to participate in GPRO in the following ways:

  • Qualified PQRS registry
  • Directly from electronic health records (EHR) systems using certified EHR technology
  • Certified EHR technology via data submission vendor

Groups with between 10 and 99 eligible professionals that satisfactorily report PQRS could qualify for an upward or neutral payment adjustment in 2016 under the Value Modifier based on their performance on quality and cost measures in 2014; for groups of 100 or more eligible professionals that satisfactorily report PQRS in 2014, the Value Modifier could provide an upward, neutral, or downward payment adjustment based on performance on quality and cost measures in 2016.   Read more…

6. 2013 PQRS incentive payments now available.
CMS has announced that the 2013 PQRS incentive payments are now available for eligible professionals and group practices who submitted data for Medicare Physician Fee Schedule Part B services between Jan. 1, 2013 and Dec. 31, 2013. The PQRS incentive payments are for eligible professionals and groups practices who met the PQRS reporting criteria, regardless of participation in another program (i.e., Medicare Shared Savings Program Accountable Care Organization, Comprehensive Primary Care Initiative, etc.).
View the CMS analysis and payment webpage…

7. ACOs cite cost and interoperability as primary challenges to leveraging HIT.
According to a survey conducted by Premier, Inc., and the non-profit eHealth Initiative, cost and poor interoperability across systems and providers are barriers to effective use of health information technology (HIT) among accountable care organizations (ACOs). The research team surveyed 62 ACOs and found that 95 percent cited cost and interoperability concerns as challenges to leveraging HIT infrastructure. Other factors include:

  • Lack of funding or return on investment: 90 percent
  • Workflow integration: 88 percent
  • Lack of provider engagement: 73 percent
  • Lack of trained staff: 69 percent
  • Lack of consensus on quality benchmarks and measures: 67 percent
  • Privacy and confidentiality: 43 percent

The research team states that nearly all responding ACOs were medium to large in size, with 39 percent having 101-500 participating physicians and 41 percent having more than 500 participating physicians.
Read more, with related links…

8. Call for volunteers: Practice Management Instructional Course Committee.
Oct. 2 is the last day to submit your application for a position on the Practice Management Instructional Course Committee (two member openings). Members of this committee grade Instructional Course Lecture applications in May, provide input to the Central Instructional Courses Committee, and evaluate courses at the AAOS Annual Meeting. Applicants for this position must be active fellows with an emphasis in practice management.
Learn more and submit your application…(member login required)

September 29, 2014

Today’s Top Story
1.Study: Anti-inflammatory treatment may be effective in preventing HO after burns or traumatic injuries.
A study published in the journal Science Translational Medicine (Sept. 24) asserts that an anti-inflammatory treatment may help prevent heterotopic ossification (HO), a condition in which bone develops in places it should not—such as outside the skeleton and in joints, tendons, and muscles—following burns or trauma, such as car accidents or blast injuries. When researchers at the University of Michigan Health System used tissue from burn patients and a mouse model of trauma-induced HO to evaluate the body’s response to burn injury, they confirmed the connection between burn injuries and the activity of adenosine triphosphate (ATP), a cell energy source that, at elevated levels, can lead to the development of abnormal bone. Investigators found they were able to reduce HO through ATP hydrolysis at the burn site using apyrase, a compound that can break down ATP. In addition to affecting more than half of wartime orthopaedic casualties during the Afghanistan and Iraqi conflicts, HO may develop in approximately one in five joint replacement patients in the United States. An accompanying editorial suggests that apyrase treatment should go beyond high-risk burn patients.  Read more…
Read the abstract…

Other News
2. As Open Payments goes live, physicians voice concern about accuracy of data.
On the eve of the live implementation of the Open Payments (Sunshine Act) provision of the Affordable Care Act, many physicians are expressing apprehension about the accuracy of information about payments to providers as revealed by the Centers for Medicare & Medicaid Services (CMS). Specifically, physician leaders say that CMS has provided too short a window for correcting payment information submitted by drug companies and others, and that technical snafus have prevented physicians from identifying errors in their payment profiles. Release of inaccurate or misleading data on the Open Payments website could “cause patients to question their trust in their physicians… [and] discourage research and care delivery improvements that benefit patients,” said Robert M. Wah, MD, president of the American Medical Association, reported HealthLeaders Media. Physicians faced frustration in dealing with a balky website and a “non–user-friendly and cumbersome registration process to review data and request corrections of any inaccuracies,” he said. CMS has already said that it will hold back releasing approximately one-third of the data submitted by industry due to suspected inaccuracies.   Read more…
Read more information from the AAOS…
Learn more about the CMS Open Payments Program…

3. CDC probes limb paralysis in children.
The U.S. Centers for Disease Control and Prevention (CDC) is investigating whether cases of acute neurologic illness in Colorado children are associated with enterovirus D68, Forbes reports. Acute focal limb weakness and spinal cord lesions have developed in nine children; most of the patients had a recent respiratory illness and four patients tested positive for enterovirus D68. Tests for viruses that could cause similar reactions, including the West Nile and polio viruses, were negative. Physicians who see patients aged 21 years and younger with acute onset of focal limb weakness that began on or after Aug. 1, 2014, and who have a spinal cord lesion largely limited to gray matter confirmed by magnetic resonance imaging are urged by the CDC to report these cases to their local health departments.   Read more…
Read the CDC health advisory…

4. Study: Researchers examine outcomes after simultaneous arthroscopic repair of the RC and a Bankart lesion.
Patients who underwent simultaneous arthroscopic repair of the rotator cuff (RC) and a Bankart lesion after an acute shoulder dislocation had similar outcomes in the affected extremity compared to the asymptomatic, contralateral side at a mean of 3 years after surgery, according to a study in The American Journal of Sports Medicine. The investigators recruited 13 patients (mean age, 58.8 ± 11.2 years; mean follow-up, 38.5 ± 12.3 months) who had undergone simultaneous arthroscopic RC and Bankart repairs. When comparing the affected side to the contralateral side, investigators found no significant differences in mean American Shoulder and Elbow Surgeons (ASES) score, mean Constant score, or mean abduction strength. The mean SF-36 physical component summary for the cohort was 48.4. Ultrasound imaging revealed that four patients had persistent/recurrent full-thickness tears, and one patient had sustained a new full-thickness tear. At follow-up, researchers found that patients with full-thickness tears in the affected shoulder had similar abduction strength, as well as ASES and mean Constant scores, in the unaffected shoulder. The investigators noted that “persistent or recurrent RC tears involving the operative extremity were common, but they did not significantly affect functional outcomes in this small study.”
Read the abstract…

5. CMS seeks volunteers for ICD-10 end-to-end testing.
Oct. 3 is the deadline for providers to apply to participate in end-to-end testing of ICD-10. Testing will be conducted Jan. 26–30, 2015. Approximately 850 volunteer submitters will be selected to participate in this round. CMS intends to select volunteers representing a broad cross-section of provider, claim, and submitter types, including claims clearinghouses that submit claims for large numbers of providers. Additional opportunities for end-to-end testing will be available in 2015. Any issues identified during testing will be addressed prior to ICD-10 implementation. Educational materials will be developed for providers and submitters based on the testing results.   Read more (PDF)…
AAOS has a variety of materials available to help practices make the transition to ICD-10…

6. South Carolina.
Some struggling rural hospitals in South Carolina may find a lifeline in a state plan that provides incentives for them to forge partnerships with larger, non-rural facilities, The Post and Courier (Charleston, S.C.) reports. The $15 million Hospital Transformation Plan could help about a dozen small-town hospitals stay viable through various financial and operating arrangements with non-rural facilities, possibly including mergers. South Carolina is among states that opted not to expand Medicaid under the Affordable Care Act. The state does provide rural hospitals with an advantageous 100 percent Medicaid reimbursement, but the small facilities grapple with mounting costs and dwindling in-patient numbers. Although administrators and advocates of small hospitals welcome new resources to solidify the future of their facilities, they say that any initiatives undertaken with large operators must serve the long-term interests of rural healthcare and caution against quick-fix cash infusions.   Read more…

7. OKOJ October 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: “Contemporary Management of the Pediatric Patient with Achondroplasia,” “The Direct Posterior Approach for Treatment of Posteromedial Fractures of the Tibial Plateau,” and “Use of Bone Graft Extenders in Spinal Surgery.” In addition, a new video, “The Direct Posterior Lobenhoffer Approach for Posteromedial Tibial Plateau Fractures,” is now available, as are full-text, downloadable PDFs for articles in both the September and October issues, with more full-text PDFs on the way for all future OKOJ articles.
View these topics and more…(member login required)

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:

  • AMA Alternate Representative to The Joint Commission Professional and Technical Advisory Committee for the Home Care Accreditation Program (closes Oct. 5; one liaison opening)
  • AMA House of Delegates (Oct. 1; one member)
  • Anatomy-Imaging Evaluation Committee (Sept. 29)
    • Chair
    • Hand and Wrist (two members)
    • Tumors (two members)
  • Biomedical Engineering Committee (Oct. 5; one member)
  • Central Evaluation Committee (Oct. 3)
    • Adult Reconstruction Hip and Knee (one member)
    • Basic Science (one member)
    • Foot and Ankle (one member)
    • Oncology (one member)
    • Trauma (two members)
  • Committee on Evidence-Based Quality and Value (Oct. 2; five members)
  • Education Enhancement Fund Governance Committee (Oct. 2; one member)
  • Hand & Wrist Evaluation Committee (Sept. 29; chair, nine members)
  • Orthopaedic Video Theater Committee (Oct. 5)
    • Foot and Ankle (one member)
    • Hand and Wrist (one member)
    • Pediatrics (one member)
  • Practice Management Instructional Course Committee (Oct. 2; two members)
  • Spanish Translation Review Work Group (Oct. 3; 10 members)

Learn more and submit your application…(member login required)

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