Beat Shoulder Pain: Steps to Getting Back to What You Love

Join Dr. Jason Stanford with Covenant Clinic orthopedic surgery as he presents a seminar on Total Shoulder Replacement Surgery. Learn about managing your shoulder arthritis. The event starts at 11 am on November 25th at the NEI3A Healthy Lifestyle Center, 528 Main St., Cedar Falls, IA. Lunch will follow at 11:45 am for registered attendees only.

May is National Osteoporosis Month

Julia Bailey

Every year, only about 20 percent of the nearly 2 million Americans who sustain osteoporotic or fragility fractures are tested or treated for osteoporosis—despite the high risk of future fractures. This is a national health problem and, with a rapidly aging population, one that promises to grow in importance, as the following statistics show:

• The total number of fractures attributed to osteoporosis is expected to double by 2040.
• Osteoporotic fractures represent an estimated $17 billion in direct healthcare costs.

Kyle Jeray, MD, chairs the steering committee of the Own the Bone program, a quality improvement program launched by the American Orthopaedic Association (AOA) in 2009 to address the osteoporosis treatment gap. “Healthcare reform is making physicians, hospitals, and healthcare systems look at things differently,” he says. “There’s more focus on quality care, the patient’s quality of life, and actual outcomes as they affect day-to-day living. The other big picture item is keeping costs down.

“As orthopaedic surgeons, we need to practice integrated medicine,” continues Dr. Jeray. “If we don’t, we’re not going to be able to address the issues that are becoming huge problems.”

Beyond the fracture
“Orthopaedic surgeons can play a critical role in addressing the increasing burden of fragility fractures in our society, particularly given the demographic changes that we’re facing,” says Joshua J. Jacobs, MD, past president of the American Academy of Orthopaedic Surgeons (AAOS).

“One of the best predictors of a fragility fracture is a previous fragility fracture. The orthopaedic surgeon is in an ideal position to help manage that by referring those patients to the healthcare professionals who are experienced in managing osteoporosis,” he continues.

Dr. Jeray agrees. “We see the problem as it occurs, which gives us the opportunity to get involved.”

One way that orthopaedic surgeons can get involved is through the Own the Bone program. It is designed to build awareness about the postfracture care gap and to encourage orthopaedic surgeons, as treating physicians of fracture patients, to initiate care coordination for these individuals.

Own the Bone provides web-based tools to help healthcare organizations establish a fracture liaison service (FLS) that promotes compliance with postfracture quality measures, bone health evaluation, and appropriate pharmacologic treatment of patients with osteoporosis to prevent recurrent fractures.

“AOA established Own the Bone as a turnkey program that would be accessible for hospitals and practices to initiate a program to identify, screen, and treat patients to prevent future fractures,” says Debra Sietsema, PhD, RN, clinical research director at Orthopaedic Associates of Michigan and a member of the National Association of Orthopaedic Nurses (NAON), who sits on the Own the Bone steering committee. “It tracks key metrics, including patient counseling about nutrition, physical activity, and lifestyle factors.”

Emerging models 
Emerging models of coordinated, team-based musculoskeletal care include nurse coordinators or midlevel practitioners to coordinate the diagnosis, treatment, and support for patients presenting with fragility fractures. “The recommended model, which originated in Europe, is with a nurse coordinator,” says Dr. Sietsema.

At Orthopaedic Associates of Michigan, “We have had more than 6,000 follow-up visits per year to our clinic through the hospital’s,” says Dr. Sietsema. “We’re reporting nearly 90 percent compliance with medications and nearly 100 percent compliance for calcium and vitamin D. With a well-coordinated, comprehensive system that uses electronic health records for support in referral and follow-up, you can do very well.”

The drive toward team-based care makes NAON a logical partner in establishing the FLS model. “Own the Bone has partnered with the Orthopaedic Trauma Association (OTA), NAON, and AAOS to provide educational symposiums, instructional course lectures, and FLS presentations to keep orthopaedic surgeons, nurses, and physician assistants informed and current in the treatment and care of fragility fractures,” states Dr. Sietsema.

Other orthopaedic societies, including OTA, are also building awareness of the care gap among members. “Many OTA members are on the Own the Bone steering committee,” says Dr. Jeray. “Because they take care of fractures, they recognize the problem.”

According to Ross Leighton, MD, OTA president, the United States and Canada are adopting similar coordinated care models. “At the clinic level, the program is guided by a physician, with physician extenders looking after patients,” he says. “If you can start a patient on treatment with the first fracture, as many as half will not have a second fracture. That’s significant.”

Dr. Leighton acknowledges that the coordinated care model for postfracture care may require a paradigm shift for orthopaedics. “Some orthopaedic traumatologists are passionate about treating the patient after the fracture, others are more comfortable with identifying the patients and handing them off,” he says. “We have to fine-tune the system so that individuals can determine what works for them. If they don’t want to initiate treatment, the clinic needs to include a group that will do it for them.”

Own the Bone is also reaching out to other subspecialty groups, including hand and spine surgeons, who are front-line treaters of compression fractures. Already, healthcare institutions in 46 states have enrolled in the program. “The increased awareness will lead to a decrease in secondary fractures,” says Dr. Jeray. “Yet, it makes just a small dent in a huge problem.”

Awareness and standards
Recently, the National Quality Forum (NQF) Endocrine Standing Committee endorsed two new patient safety quality performance measures related to postfracture osteoporosis treatment. These measures acknowledge that “all fragility fracture patients should undergo assessment of future fracture risk and, where clinically appropriate, be considered for pharmacologic treatment for their underlying disease.”

“These measures tie in nicely with Own the Bone,” says Dr. Jeray. “If the Joint Commission adopts them as national standards, that will help Own the Bone expand and bring greater recognition to the problem.”

According to Dr. Jacobs, the AAOS is also drafting a clinical practice guideline on hip fractures that will bring more attention to the issue. “It is a wonderful collaboration between the Academy and 15 other organizations—including the International Bone and Joint Initiative—that are involved in patient care for fragility fractures,” he says. “Among the topics covered in the guidelines will be osteoporosis evaluation and treatment, the role of calcium and vitamin D, and other factors that are critical in addressing the challenge of fragility fractures.”

Julia Bailey is a contributing writer for the AOA.

Quoted from “www.aaos.org”

Measures would address antitrust, medical liability, research funding

Elizabeth Fassbender and Simit Pandya

Three bills recently introduced in Congress put national attention on the following issues that the American Association of Orthopaedic Surgeons (AAOS) has identified as critical:

• Creating a level playing field in physician insurer negotiations
• Extending protections to sports medicine professionals who travel with teams
• Adequately funding biomedical research

Antitrust exemptions for physicians
Antitrust laws are designed to foster competition in the marketplace. However, current antitrust enforcement policies and recent healthcare industry consolidations have created situations in which a select few health plans are able to dominate the healthcare market in various areas of the country.

These same antitrust enforcement policies prohibit healthcare providers from coming together to negotiate meaningful contracts for private reimbursement that enable them to deliver high-quality health services to their patients.

This imbalance in market power gives health plans an advantage in contract negotiations with physicians and other healthcare providers related to reimbursement. In some cases, the result might be a unilateral, nonnegotiable contract that gives insurers the power to deny patients access to optimal care and to impose costly administrative burdens on physicians that limit their ability to provide patient care.

To address this issue, Reps. John Conyers Jr. (D-Mich.), and Dan Benishek, MD (R-Mich.), introduced H.R. 4077, the “Quality Health Care Coalition Act of 2014.” This legislation provides an antitrust exemption for physicians engaged in negotiations for private reimbursement with insurance companies, thereby leveling the playing field between physicians and private insurers.

“The AAOS strongly applauds the introduction of H.R. 4077,” statedJoshua J. Jacobs, MD, AAOS past president. “More than 80 percent of U.S. health insurance markets today are considered ‘highly concentrated’ due to antitrust enforcement policies that enable select insurers to dominate the healthcare market. The antitrust relief provided in H.R. 4077 will not only protect physician practices from anticompetitive behavior—such as the unilateral, nonnegotiable contracts that result from this market power—but will ensure that patient access to care is not compromised as a result of insurer monopsony.”

“Over the last several decades, the health insurance market has become exceedingly concentrated, dominated by a few large insurers offering a limited number of health insurance plans,” Rep. Conyers stated in a release. “In contrast, our nation’s physicians and healthcare providers are afforded no comparable protections. Our legislation allows for physicians to negotiate with insurers on a level playing field, ensuring heightened quality standards for patient care.”

Rep. Benishek also commented on the bill’s introduction. “Having been a doctor for 30 years, I see this bipartisan bill as a way to help improve patient care and lower costs for Michigan families,” he stated. “With health care being such a big part of everyone’s lives, this is the kind of common-sense reform that will make it easier for doctors to provide patients with top-notch care.”

Liability for sports medicine professionals
Many states do not provide legal protection for sports medicine professionals who travel to other states with an athletic team solely to provide care for that team. Additionally, many medical liability insurance carriers will not provide medical liability insurance coverage to sports medicine providers who deliver care to their athletes at sporting events in a state where they are not licensed to practice medicine. Consequently, these sports medicine providers must choose either to treat injured athletes at their own professional risk or to see their athletes’ access to timely healthcare services limited.

The AAOS, together with the American Orthopaedic Society for Sports Medicine (AOSSM) and the American Medical Society for Sports Medicine (AMSSM), is pursuing federal legislation that addresses this issue.

In December 2013, Reps. Tom Latham (R-Iowa) and Cedric Richmond (D-La.) introduced H.R. 3722, a measure that would protect sports medicine professionals from civil and criminal malpractice liability when they provide care to athletes at sporting events in another state.

Furthermore, this bill will preserve sports medicine providers’ access to their medical liability insurance coverage when they provide care to their athletes at sporting events in a state where they are not licensed to practice medicine. Consequently, H.R. 3722 would allow sports team practitioners to provide timely, high-quality healthcare services to injured athletes during sporting events.

H.R. 3722 was referred to the Committee on Energy and Commerce and to the Judiciary Committee, and currently has seven additional cosponsors. Sens. John Thune (R-S.D.) and Amy Klobuchar (D-Minn.) have also introduced a Senate version of the bill.

“Sports medicine providers should not have to choose between either treating injured athletes at great professional risk or reducing athletes’ access to timely healthcare services,” stated AAOS President Frederick M. Azar, MD. “This bill will ensure injured athletes have timely access to the highest quality of care so they can return to their active lifestyle as soon as possible. The AAOS thanks Sens. Thune and Klobuchar for their leadership on this important issue.”

“Sports medicine providers take on great professional and financial risk to treat injured athletes on the road,” said Sen. Thune. “Although some states provide legal protection to shield these professionals from assuming the risk, many providers are still left with the decision of treating an injured athlete or accepting the risk. I look forward to working with the AAOS to move this common-sense legislation forward to ensure we deliver quality care for traveling athletes while providing legal protections for sports medicine professionals.”

Biomedical research
In 2011, more than half (53 percent) of all funding for basic medical research came from the federal government. But those dollars have been declining.

On March 11, 2014, Senate Assistant Majority Leader Dick Durbin (D-Ill.) introduced S. 2115, the “American Cures Act,” to address a recent decline in federal funding for biomedical research. The bill would provide for $150 billion in federal funding to support the future of research at the National Institutes of Health, the Centers for Disease Control and Prevention, the Department of Defense Health Program, and the Veterans Medical & Prosthetics Research Program.

Sen. Durbin announced his plans to introduce the legislation during a policy address before beneficiaries of biomedical research, stakeholder representatives, and the press at the Center for National Policy. “In the last two centuries, U.S. government support for scientific research has helped split the atom, defeat polio, conquer space, create the Internet, map the human genome, and much more,” he said. “No nation has ever made such a significant investment in science, and no nation’s scientists have ever done more to improve the quality of life on Earth. But America’s place as the world’s innovation leader is at risk as we are falling behind in our investment in biomedical research.”

In recent years, federal investment in biomedical research has sharply declined. As a percentage of the total federal budget, funding for research and development today is just a third of what it was in 1965. Additionally, over the past decade, the NIH has been able to fund fewer research grants every year.

The American Cures Act attempts to remedy this trend by supplementing federal appropriations for biomedical research with a mandatory trust fund dedicated to fostering a steady growth in federally funded research. The bill would provide an annual increase in funding for each agency and program at a rate of GDP-indexed inflation plus 5 percent. Sen. Durbin believes that this steady, long-term investment would enable the agencies to plan and manage strategic growth while maximizing efficiencies.

So far, the bill has attracted nine original cosponsors, as well as from several dozen patient and provider groups, including the American College of Rheumatology and the American Heart Association.

Elizabeth Fassbender is the communications specialist and Simit Pandya is the Orthopaedic Quality Institute specialist in the AAOS office of government relations.

Quoted from “www.aaos.org”

It may not be your decision

For many people, driving a car is a necessity of everyday life. In areas without public transportation (and even in cities with good public transportation), people drive everywhere. So when something happens—whether it’s a flat tire or a fractured tibia—drivers want it fixed quickly so they can get behind the wheel again.

As Geoffrey S. Marecek, MD, and Michael F. Schafer, MD, write in the November 2013 issue of the Journal of the AAOS, “The inability to drive presents a significant obstacle to patients. … The decision to resume driving after orthopaedic surgery is difficult for both patient and surgeon.”

Recently, AAOS Now spoke with Dr. Marecek about driving after orthopaedic surgery.

AAOS Now: What orthopaedic procedures or surgical sites are most likely to impair a patient’s ability to drive?

Dr. Marecek: All injuries and procedures have the potential to alter one’s ability to drive. Braking and accelerating require coordinated activity at the hip, knee, and ankle. Steering and shifting require use of the shoulder, elbow, and wrist. Sitting upright and watching the road require good spine function. In short, driving requires total body coordination.

Based on the available studies, patients who sustain major lower extremity fractures should delay driving the longest—up to 18 weeks in some cases—but nearly every orthopaedic procedure will have some impact on a patient’s ability to safely drive.

AAOS Now: Are there guidelines that orthopaedic surgeons can reference when patients ask about driving after a specific surgery or procedure?

Dr. Marecek: A number of studies have used driving simulators to determine when braking ability returns to normal after surgery. This provides a rough guideline for when a patient may begin to consider returning to drive. Although most studies have focused on lower extremity or spine procedures, some studies on the impact of upper extremity procedures are in the works.

The decision to resume driving should be individualized; patients and surgeons need to talk about how the recovery process is proceeding and what impact the procedure may have on driving skills.

However, these discussions should take place early on. For elective surgeries, driving discussions should take place when the decision to schedule the surgery is made. This will enable the patient to make accommodations well in advance. If it’s an urgent situation, such as a fracture, the discussion about driving should take place before the patient leaves the hospital or at the first postoperative visit.

AAOS Now: What challenges do orthopaedic patients face in returning to driving?

Dr. Marecek: Most studies have considered emergency braking to be the critical test that would allow a patient to return to driving without posing a risk to others. Due to the coordinated movements involved in driving, surgery around the hip, knee, ankle, and foot can impair braking function. Any splint, cast, knee immobilizer, or walking boot on the lower extremity impairs braking function, and patients should not drive while wearing any of them.

After a total hip replacement, the ability to sit in a car safely is a concern. If the car seat is low and depending on the surgical approach used, patients may be at risk for hip dislocation.

Taking evasive maneuvers to avoid an accident also causes delays in braking time. Immobilization of any part of the upper extremity for any reason can affect the ability to shift gears and turn the steering wheel. Even highly trained drivers do not drive well while wearing casts. As for removable wrist splints, there are conflicting reports, so patients should discuss their particular circumstances with the surgeon.

AAOS Now: Many orthopaedic patients may be on pain medications. What impact does that have on driving?

Dr. Marecek: Although some evidence suggests that chronic narcotic use under the supervision of a pain specialist may not affect braking ability, patients should avoid driving while taking any narcotics. Narcotics can impair cognitive function and reaction time and could be considered “driving under the influence.”

AAOS Now: Did anything surprise you in your research?

Dr. Marecek: One of the most striking findings was that insurance companies and law enforcement agencies generally consider the patient to be the only person responsible for determining when he or she is fit to drive. There is no “clearance” or “doctor’s note” that can help if a patient is in an accident or receives a ticket.

Despite this, lawsuits have been filed against the physician if a patient under care has an accident while driving.  Although these cases may not qualify as medical malpractice, they may be considered negligence. Orthopaedic surgeons should discuss the issue of returning to driving with patients and document that discussion in the medical record.

I advise my patients to think about the neighbor’s child—or their own grandchildren—running into the street. If they could avoid an accident, they may be ready to begin driving again.

Quoted from “www.aaos.org”