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POLICY: An Outcomes Primer by Eric Novack

THCB welcomes back regular contributor Dr. Eric Novack, who has something to say about outcomes as well as some recent snide comments made about orthopedic surgeons by a certain other poster on the site. In addition to blogging for THCB in his (oh so rare) free time, Eric is also the host of The Eric Novack show, which airs every Sunday on KKNT 960 AM in Phoenix. You can find an archive of his recent shows here.   

An Outcomes Primer

By ERIC NOVACK M.D.

Many in medicine view those of us in orthopedics as the ‘dumb bone doctors’Sd2 (or, according to the IV, much worse than that). Much of this stems from the basic idea that fracture care, or broken bone treatment, seems very straight-forward. Oh, but wait…

So here is a brief sense of how difficult it can be to evaluate outcomes even in the ‘simple’ area of a broken wrist. And, how it can be absurd to make the surgeon completely responsible?

The first question we need to ask is, “what outcome are we measuring”? Are
we going to look at (a) has the bone healed? (b) how ‘good’ does the
xray look- i.e. how close to ‘perfect’ are the bones lined up? (c) how
is the patient’s function, and at what point after injury do you
measure- months, years?

THCB is big on functional outcomes, so let’s just say that we care about wrist function 1 year after injury. But what kind of function? Range of motion? Return to work? Return to sports?

I’ll
make it easy and say we’ll leave that to the patient and simply ask
about satisfaction with ability to return to pre-injury functioning.

Stick
with me- I know we are looking at the easy area of a broken bone. So,
we are trying to determine functional outcomes 1 year after a wrist
fracture.

Here is one way to look at the factors impacting the outcome:

1. Patient
factors – age, motivation to get better, willingness to listen to
medical advice and follow recommendations, nutritional status, other
medical conditions, previous injuries, secondary gain issues (workers’
comp, lawsuits), body’s response to injury (i.e. inflammatory response
to trauma)

2. Injury factors—severity of injury force (e.g. trip
over dog vs. 60mph motorcycle crash), location of fracture (e.g.
involving joint cartilage), degree of displacement (i.e. how ‘bad’ the
xray looks), associated soft tissue injuries, associated injuries
impacting treatment and rehab decisions

3. Surgeon
factors—appropriate decision making, surgical technical skill,
doctor-patient communication (discussing injury, options, risks, and
expectations)

Rhetorically (and not), I ask- how much of the outcome can the surgeon possibly control?

The
answer, of course, is only the ‘surgeon factors’, which I will claim
generally make up a relatively small piece of the total outcome pie.

So
I say again (and again)- until I can get some converts… the future of
quality improvement lies not in just trying to identify ‘best
practices’ that can be difficult to prove and identify and can change
every few years—but rather in identifying what are the WRONG approaches
for conditions (much easier to get agreement here), and emphasizing the
importance of communicating appropriate expectations to patients.

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Maggie MaharEric NovackTom Leith Recent comment authors
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Tom Leith
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Tom Leith

> hope this explanation helps.
It does help.
This sounds like what every UR or pre-auth clinician at an insurance company does.
Have I got it about right?
t

Maggie Mahar
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Maggie Mahar

Eric– In an earlier post you asked if I agreed with you that trying to eliminate the worst practices on the right side of the bell curve is extremely important. I do. And I’d add that those worst praactices often involve “doing something” rather than failing to do something — like surgery after a few weeks of tennis elbow. My own orthopod complains about the many patients who demand an MRI–or want knee surgery– when all they realy need is a course of physical therapy. The fact that she is a young woman and many of her patients are impatient… Read more »

Eric Novack
Guest

Tom- actually, no. Let’s be reasonable about the issue. While the list of wrong issues is technically endless, the wrong answers in many cases were never superseded since they have almost always been believed to be wrong. (The Elements of Style police will find me for that sentence…) Here’s are some straightforward orthopedic examples- (1) failing to check and document a neurologic exam after fractures (2) failing to evaluate for and document same about compartment syndrome after lower extremity (especially tibia) fractures (3) recommending surgery after only a few months of symptoms for tennis elbow (4) fixing displaced femoral neck… Read more »

Tom Leith
Guest
Tom Leith

Dr. Novak writes:
> identifying what are the WRONG
> approaches for conditions
Well, isn’t this list infinite?
Do you mean “identify approaches in fairly common use that are also widely agreed to have been superseded”?
t