Early Return to Work for Work Related Injuries

I treat many patients with work related injuries in my practice.  Below is the AAOS position statement on treating work injuries.

The American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons (AAOS) support safe early return to work programs that help injured workers improve their performance, regain functionality, and enhance their quality of life. The success of an early return to work program is dependent on appropriate planning, as well as attention to a host of physical, psychological, and environmental factors. As patient advocates, physicians realize that early return to work results in many benefits for the injured worker, including the prevention of de-conditioning and the psychological sequels of prolonged time off work. Employers also realize benefits through substantial reductions in disability payments, medical treatment costs, absence from work, insurance premiums, and overall workers’ compensation costs. However, improved outcomes are dependent on the communication between and the cooperation of the employee, employer, insurance company third party administrator, attorney, rehabilitation nurse, and treating physician.

Effective management of the injured worker can include the following:

Providing prompt access to medical care

• An injured employee should be seen for early medical evaluation and appropriately referred for specialty care as medically necessary.
• The employer should communicate with the insurance carrier to expedite care.
• Medical care should be based on a specific diagnosis, when possible.
• Treatment programs should include options for early return to work.

Support for the injured worker

• A case manager can help begin the process of considering the worker’s injury as it relates to such issues as work and home environment, personal skills, and education.
• The employer should make the injured worker feel valued and encourage the worker to return as soon as possible.
• The employer should maintain a list of modified or alternate work for injured employees.
• An injured worker should be educated about how the workers’ compensation system operates.
• An injured worker should be taught the value of being an integral part of his/her own recovery.
• An injured worker should receive prompt and adequate wage replacement.

Returning the employee to work

• The injured worker (patient) and the physician should discuss time frames for recovery, expected duration of pain, the potential need for medication, and options for returning to work.
• The worker should resume; if possible, some form of work that meets the restrictions and requirements outlined by the treating physician. Such modified work is the cornerstone of job rehabilitation.
• The treating physician should be included in determining if the physical demands of a modified job are appropriate for the recovering worker.
• Workplace guides should be written out and provided to the employee and employer.
• In all cases, the treating physician needs to understand the patient's work environment and occupational tasks. In difficult cases, a videotape of the job, formal job analysis, or an ergonomic report may be helpful to assist in establishing workplace guides.
• Workplace guides should be considered flexible and should be updated to reflect the improving medical condition.
• Work hardening, functional capacity evaluations, and other forms of Physical Therapy can be used to simulate specific job demands so that the worker can eventually resume previous work duties without re-injury during the return to work phase.
• An injured worker must be taught to recognize cause and effect related to symptoms and accept responsibility for symptom control through strategies such as pacing, energy conservation, and proper body mechanics.
• If the treating physician and employer believe there are no suitable duties in the present workplace, it may be necessary to refer the injured worker to a Vocational Rehabilitation Professional.

Preventing chronic pain

• Physicians recognize that pain is individually experienced and can sometimes be influenced by a number of issues, including emotions, cultural differences, family support, and social experiences. Early medical intervention can often limit the period of acute pain and frequently prevent chronic pain.
• Additional intervention may be warranted when a treating physician recognizes that pain is being modified by the psychological state of the patient.

Encouraging safety and prevention measures

• Workplace safety requires an understanding of how the physical factors often described as repetition, force, posture, vibration, contact stress, and temperature interact with the individual’s risk factors of age, gender, and inherited genetic characteristics.
• Employees should be encouraged to report potentially hazardous conditions or situations for review.
• Prevention requires a commitment from management, physician support, and employee understanding.
• Emphasis should be placed on accident reporting, investigation, and ergonomic interventions that are based on scientific data.

The AAOS believes that safe early return to work programs are in the best interest of patients. Studies have demonstrated that prolonged time away from work makes recovery and return to work progressively less likely. Return to work in light duty, part-time, or modified duty programs is important in preventing the deconditioning and psychological behavior patterns that inhibit successful return to work and in improving quality of life for the injured worker.

References

1. AAOS Position Statement. Managed Care in Workers’ Compensation. September, 1996.
2. IAIABC Rehabilitation Committee. Job Placement in Workers’ Compensation Rehabilitation: Techniques and Concepts. September, 1989.
3. Kinsley, Donald R., Esq., Joan Grossman, Esq., and Terri L. Danik, Esq. (Editors). 2000 Workers’ Compensation YearBook. LRP: 2000.
4. Krause, Niklas and Lisa K. Dasinger, and Frank Neuhauser. “Modified Work and Return to Work: A Review of the Literature.” Journal of Occupational Rehabilitation. 1998, Vol. 8, No. 2.
5. Melhorn, J. Mark, MD. “Return to Work Restrictions and Work Guides for Upper Extremity.” Workers’ Compensation Case Management: A Multidisciplinary Perspective. (AAOS Course Syllabus). November, 1999.461-463.
6. Melhorn, J. Mark, MD. “Workers' Compensation for Fractures and Dislocations.” Rockwood and Green's Fractures in Adults, edited by Heckman, J. D. and Bucholz, R. W. Philadelphia, PA. J B Lippincott Company, 2000.
7. Peters, Pamela, MSN, RN, CRRN. “Successful Return to Work Following a Musculoskeletal Injury”. AAOHN Journal. June 1990, Vol. 38, No. 6.

© September 2000 American Academy of Orthopaedic Surgeons

Thanks,

JTM, MD

 

The orthopedist and the workers’ compensation patient

A cautionary tale of patient care and professional liability

Orthopaedic surgeons are commonly asked to care for patients who have been injured in the course of their employment. Some of these injuries are employment-specific, such as a mangled hand from a punch-press injury; others are similar to those encountered in everyday practice, such as an ankle fracture from a “slip-and-fall” at work, acute or chronic back pain, or carpal tunnel syndrome. 

Yet caring for an injured worker poses special challenges that must be remembered. Indeed, many orthopaedic surgeons are so concerned about those challenges that they refuse to accept workers’ compensation patients. A better understanding of the workers’ compensation system and its operation may help alleviate some of those concerns.

The origins of workers’ compensation

The workers’ compensation system originated at the end of the 18th century as part of the progressive movement. In an era when factory safety standards didn’t exist, it was an attempt to ensure that factory workers injured at work received appropriate medical care and compensation for permanent crippling injuries.

In general, the worker’s compensation is a “no-fault” system that is designed to benefit both employer and employee. The benefit for employees is that they do not have to prove negligence to have a claim; it is sufficient that the injury occurred at work. The benefit for the employer is that damages are typically limited to an amount defined in the statute.

Today, each state has its own workers’ compensation system, with its own rules and processes. In Illinois, for example, the patient can choose his or her treating physician, while in Missouri, the employer can determine who treats the patient. If you accept workers’ compensation cases, you must be familiar with applicable laws; if you practice in a border region, you need to be aware of the differences between various state laws. Treating workers’ compensation patients requires interaction with multiple entities—the exam room can get crowded!

The workers’ compensation patient

The first person you deal with—and the person to whom you owe primary responsibility—is the patient. The workers’ compensation patient deserves the same level of diligent care you provide to any other patient. 

 

Do not allow an employer or insurer to dictate care; as the physician, you must decide and advise your patient on what you believe is the proper care for the injury. As in all claims for damages, there may be a tendency for a workers’ compensation patient to exaggerate injuries or not comply with rehabilitation, because the greater the permanent disability, the larger the eventual settlement. This tendency may be unconscious, making it different than malingering, which is intentional, fraudulent behavior.

Orthopedic surgeons may fear that injured employees are litigious and prone to file medical liability lawsuits. Little evidence exists to support this concern. Most employers require employees to file workers’ compensation claims for any work injury and employees’ medical insurance typically will not cover work-related injuries. While the injured worker is involved in a legal process, it is directed at the employer/insurer, not at the physician. 

The employer and the insurer

In the workers’ compensation system, the employer is typically required by statute to maintain workers’ compensation insurance and the insurer is usually responsible for paying for the injured worker’s medical care, rehabilitation, and other expenses.

Most insurance companies that sell workers’ compensation coverage specialize in this kind of insurance. Their intermediaries—nurse case managers or nurse rehabilitation specialists—will usually interface with you. The titles imply a level of expertise that these people may not, in fact, possess. I’ve worked with some who have been very valuable in coordinating rehabilitation services, facilitating a return to work on a limited basis, and generally serving as a mediator on the patient’s behalf. Unfortunately, I’ve also known others who took a very confrontational role and actively interfered with patient care. 

If the employer is a small firm, the owner may be directly involved and attempt to interfere in the medical care. At other times, the employee may be dealing with a personnel office or an immediate supervisor, who may be less sophisticated about the process and less willing to take the worker back on limited duty. 

The lawyers

Although the workers’ compensation system was designed to relieve the injured worker of the responsibility of proving in court that his or her injury resulted from an employer’s negligence, it didn’t eliminate the role of lawyers. Many law firms specialize in representing either patients or employers in workers’ compensation cases. 

Sometimes the worker may already have retained a lawyer before seeing an orthopaedic surgeon; other times, the patient may need to be advised that representation may be helpful. The first determination is whether the employee was injured on the job, and what is the extent of the short-term and permanent disability. The dilemma that both the patient and the patient’s attorney face is that because the attorney’s fee is usually a percentage of the patient’s recovery for permanent disability, the worse the patient does, the better the lawyer does!

An extended battle over “compensability” to determine whether or not the injury occurred during employment may delay treatment. A patient who has to wait 3 years for a rotator cuff repair while the system decides who will pay for it will certainly not have an optimal result. In these cases, if you are called to give testimony, answer truthfully and succinctly. If you don’t know, say so. Although you are the patient’s advocate as far as getting appropriate treatment, when it comes to deposition testimony, it’s best if you are a neutral servant of the truth.

One question that is often asked is whether the patient’s problem is work-related. This can be a difficult question to answer for back pain or “repetitive trauma disorders.” Be aware of current literature on causation, and do not be afraid to say, “There’s no way to know for sure” if that’s what you think. 

The industrial commission

The state agency that administers workers’ compensation programs may be called the industrial commission or have another name. This agency holds hearings on disputed claims and adjudicates compensability and final disability. Commissioners will rely on your deposition testimony and your office notes for the facts of the case (so you should make sure you know what’s in your records before you testify, and be ready to explain any contradictions).

In many states, either the employer or employee will present an independent medical examination (IME) as evidence. If you are asked to do an IME, you should act as if you’ve been retained as a neutral consultant to the judge and provide an objective opinion. Many physicians will perform IMEs; some physicians develop reputations for being consistently favorable to the employee or to the employer. 

If you are threatened by an attorney with a malpractice suit solely because you wrote a report that is not favorable to the patient, report the threat to the attorney’s state licensing board as unethical behavior. 

Employees who are injured on the job deserve good medical care, rehabilitation, and compensation for permanent injury. Many of these injuries will be orthopaedic in nature. Orthopedic surgeons should not shy away from treating patients in the workers’ compensation system, but they should be aware of how the system works.

AAOS Now
April 2008 Issue
http://www.aaos.org/news/aaosnow/apr08/managing8.asp

Thanks,

JTM, MD 

Cigarette smoking impedes tendon-to-bone healing

Orthopedic surgery researchers at Washington University School of Medicine in St. Louis have identified yet another reason not to smoke. Studying rotator cuff injury in rats, the research team found exposure to nicotine delays tendon-to-bone healing, suggesting this could cause failure of rotator cuff repair following surgery in human patients.
Smoking is implicated in a host of physical problems, from cardiovascular disease to lung disorders. Many of us probably don't think about smoking's effects on orthopedic conditions, but several studies have shown that nicotine interferes with healing of bone fractures and also inhibits bone fusion processes — many spine surgeons, for example, won't do certain operations on people who smoke because of the risk of failure. But little is known about the effects of cigarettes on tendon and ligament healing.


There also are some gaps in medical knowledge about the prevalence of rotator cuff injuries. The rotator cuff is a group of four muscles and their tendons in the shoulder that provide rotation, elevate the arm and stabilize the shoulder joint. Rotator cuff tears involve one or more of the tendons. The injuries are more common as people age and more common in the dominant arm. The true incidence of the injuries is hard to determine because between 5 percent and 40 percent of people who may have a torn rotator cuff have no accompanying shoulder pain.


What surgeons do know is that rotator cuff repairs can fail in the days and weeks after surgery. Some studies have reported short- to intermediate-term recurrence rates from 30 percent to 90 percent, depending on the size of the tear, chronic nature of the injury and the age of the patient, among other factors. 

During the first six weeks after surgery, tissue may be vulnerable to re-injury.  Those early weeks are a time when there's a lot of tissue healing and remodeling occurring.
This study, published in the Journal of Bone and Joint Surgery in 2006, was the first to evaluate the effects of nicotine on rotator cuff repair, found that when rats were exposed to nicotine following rotator cuff repair, inflammation persisted for a longer time in the shoulder joint. That's detrimental to healing. The researchers also noted that there was less cellular proliferation in the rats' surgically repaired shoulders and decreased collagen production, leading to inferior healing.


When you have an injury and a repair, new cells come in and start to facilitate healing. When the new cells arrive, they make proteins such as collagen to form the junction between tendon and bone. In the rats exposed to nicotine, there was lower cellular proliferation.


The rats also made less type-I collagen and had different biomechanical properties in their shoulders following rotator cuff repair. Measuring properties called maximum stress and maximum force, the researchers found that shoulder joints in the nicotine-exposed rats were weaker.


Those changes were most apparent at earlier time points, and shoulder strength tended to equalize between the two groups about 8 weeks after surgery. But certainly, the tissue was weaker early on and more vulnerable to re-injury.



The study also may underestimate the harmful effects of smoking because rats tend to be better healers than humans and because they were exposed to nicotine for only a few weeks following surgery, whereas people may smoke for many years before surgery, as well as continue smoking following rotator cuff repair.


Based on this study there is now enough evidence to state that nicotine has a negative impact on healing in tendons as well as in bone.


Nicotine and cigarette smoking inhibit the formation of new blood vessels, and basically, all healing and all repair processes are aided by the formation of new blood vessels that bring in new cells. That process is assisted by increases in blood supply that may not happen as efficiently in smokers.


Galatz LM, Silva MJ, Rothermich SY, Zaegel MA, Havlioglu N, Thomopoulos S. Nicotine delays tendon-to-bone healing in a rat shoulder model. The Journal of Bone & Joint Surgery 2006 Sept;88:2027-2034.


Thanks,
 
JTM, MD

Interesting Shoulder X-rays

After almost 20 years in practice, I tend to see a lot of interesting patients and x-rays.  Below are some x-rays from patients who have come to me from "another surgeon". 

Each patient has had an arthroscopic rotator cuff repair by another surgeon.  The first set of films demonstrate that the metal anchors have pulled out of the very soft bone and as a result the tendon has retorn after a rotator cuff repair.  This failure was within the first year.  This patient was in therapy for many months and could never lift her arm after the repair.  Her pain was considerable and she became very unhappy with the situation and eventually came to me for help.  A simple x-rays tells the whole story.  No MRI needed here.  The only set of post operative x-rays done were those done in my office about a year after surgery.

The fact that the anchors are now out of the bone, floating in the joint, indicate that this mechanism of failure.  Rotator cuff tendon quality also affects the success of a tendon repair.  Poor quality tendon in more likely to retear.  Larger tears involving more than one of the 4 rotator cuff tendons will have a higher failure rate as well.  Patients over 65 years of age and chronic tendon tears will also have higher rates of failure.

Notice the metal anchors above that seem to be floating in the joint.  This foreign body in the joint is very painful.  I did surgery on the above patient to remove the anchors arthroscopically.  Her pain improved, but her function never recovered.  Although I thought she would have done well with a reverse total shoulder replacement, she said that she had enough surgery.  I advised her about the limits of surgery under these conditions and, after surgery, she was happy that her pain was improved. 

The x-rays below are from a different patient but the operation was by the same surgeon.  In this patient, there is moderate pain because the anchors remain in the bone.  The repair has failed.  If you look carefully, you can see that the head of the humerus (the bone with the metal anchors) has moved upwards and now is touching the bone above it (the acromion).  This can only happen when there is a massive rotator cuff tear. Once again, no MRI needed.  This patient cannot lift her arm at all and has what we call a pseudoparalyitc shoulder. 



This patient is considering a reverse should arthroplasy.  She is the same age as the first patient but much more active.  I suspect she would do well with the new shoulder. 

Every surgeon who does rotator cuff surgery will have some failures of their repairs.    It is just the nature of this type of surgery.  Sometime we know at the time of surgery that the repair is tenuous and is at risk for retearing.  These patients came to me because their surgeon did not pay much attention to them when they said they were in pain and could not lift their arm.  The lesson here is that you should listen to your patient.  Pain is normal in the recovery period after any surgery, but if a longer than usual period of time has passed, and the patient cannot lift their arm or has pain, there is usually a reason.  It is our job as orthopedic surgeons to try to get that answer.  The problem may not always be fixable and the answer may not always be what the patient wants to hear, but we should try to find the answer and recommend a treatment if appropriate.

Here is a excerpt from an article in the Journal of Bone and Joint Surgery, 2001.

Revision Rotator Cuff Repair:  Factors Influencing Results by M. DJURASOVIC, MD, et. al.

The causes of clinical failure of rotator cuff repair in any particular case are often multifactorial, but failure of tendon-healing is frequently a factor. The most common causes of failure of tendon-healing include the size of the tear (which is determined by both its anterior-posterior dimension and the degree of retraction), the quality of the tissue, the chronicity of the tear, and the degree of muscle atrophy. These specific factors may be interrelated as they often occur concomitantly in many patients with failed primary rotator cuff repairs. Surgically related reasons for the clinical failure of primary rotator cuff repair include inadequate subacromial decompression, severe subacromial scarring, and untreated symptomatic acromioclavicular arthritis.

Thanks,

JTM, MD 

Glucosamine and/or Chondroitin May Not Be Helpful for Osteoarthritis

Glucosamine and/or chondroitin may not be helpful for patients with osteoarthritis of the hip or knee, according to the results of a network meta-analysis reported in the September 17 issue of the BMJ.

 

Osteoarthritis of the hip or knee is a chronic condition mostly treated with analgesics and non-steroidal anti-inflammatory drugs, but these drugs can cause serious gastrointestinal and cardiovascular adverse events, especially with long term use.  Disease modifying agents that not only reduce joint pain but also slow the progression of the condition would be desirable. Throughout the world for the past 10 years, the cartilage constituents chondroitin and glucosamine have been increasingly recommended in guidelines, prescribed by general practitioners and rheumatologists, and used by patients as over the counter medications to modify the clinical and radiological course of the condition.

The goal of the study was to assess the impact of supplementation with glucosamine and/or chondroitin on joint pain and on radiologic progression in patients with osteoarthritis of the hip or knee. 

The primary study endpoint was pain intensity, and change in minimal width of the joint space was the secondary endpoint. When a 10-cm visual analog scale was used, the prespecified, minimal clinically important difference between preparations and placebo was −0.9 cm.

The investigators searched electronic databases and conference proceedings from their beginnings to June 2009, and they also contacted appropriate experts and searched relevant Web sites. Inclusion criteria were large-scale, randomized controlled trials enrolling more than 200 patients with knee or hip osteoarthritis and comparing glucosamine, chondroitin, or their combination vs placebo or head to head.

Ten trials meeting eligibility criteria were identified, enrolling a total of 3803 patients. The overall difference in pain intensity vs placebo was −0.4 cm (95% credible interval, −0.7 to −0.1 cm) on the 10-cm visual analog scale for glucosamine, −0.3 cm (95% credible interval, −0.7 to 0.0 cm) for chondroitin, and −0.5 cm (95% credible interval, −0.9 to 0.0 cm) for the combination. The 95% credible intervals crossed the boundary of the prespecified, minimal clinically important difference for none of the estimates. Compared with commercially funded trials, industry-independent trials showed smaller effects (P = .02 for interaction).

For changes in minimal width of joint space, the differences were all very small, with 95% credible intervals overlapping zero.

The study found that compared with placebo, glucosamine, chondroitin, and their combination do not reduce joint pain or have an impact on narrowing of joint space.  Health authorities and health insurers should not cover the costs of these preparations, and new prescriptions to patients who have not received treatment should be discouraged.

Study Limitations

Limitations of this study include use of different instruments to measure joint pain, which made it necessary to calculate effect sizes as a common measure of effectiveness so that outcomes assessed with different instruments would be comparable. Differences in responsiveness of different instruments could potentially threaten the validity of results. In addition, many patients included in the trials may have had radiologic disease too severe to benefit from supplementation or pain too minimal to benefit from analgesic effects.

Conclusion

The study found that glucosamine, chondroitin, and their combination do not result in a relevant reduction of joint pain nor affect joint space narrowing compared with placebo.  

Some patients, however, are convinced that these preparations are beneficial, which might be because of the natural course of osteoarthritis, regression to the mean, or the placebo effect.

The study authors are confident that neither of the preparations is dangerous.  Therefore, we see no harm in having patients continue these preparations as long as they perceive a benefit and cover the costs of treatment themselves.

Thanks,

JTM, MD

The Swiss National Science Foundation's National Research Program 53 on musculoskeletal health supported this study. Some of the study authors were supported by the Swiss National Science Foundation and/or the Janggen-Poehn-Foundation. The other study authors have disclosed no relevant financial relationships.

BMJ. 2010;341:c4675.

This article was adapted from Medscape Medical News © WebMD, LLC

 

Keys to Keeping Your Body and Golf Game on Par

Tips for golfers to avoid injury on the green and ways to get back on course after a joint replacement

Golf can be played competitively or just for leisure, and for professional players on the 2010 PGA Tour, the game is probably a combination of both. The game demands skill and physical discipline because improper technique can lead to discomfort, minor injury, or even joint replacement. Whether on the golf course or at the driving range, your swing and technique can make or break a game, and in many cases, help avoid or cause pain. The American Academy of Orthopaedic Surgeons (AAOS) recommends that golfers maintain proper form and take it slow when playing golf to avoid injury and to stay on par.

• According to the U.S. Consumer Product Safety Commission (CPSC), more than 115,000 Americans were treated for golf-related injuries in 2009.
• Golfers most often suffer from hand tenderness or numbness; shoulder, back and knee pain; golfer’s elbow; and wrist injuries, such as tendonitis or carpal tunnel syndrome.
• Over 360,000 men and women, ages 45 to 64 had a total hip replacement or total knee replacement in 2008, according to the Agency for Healthcare Research and Quality (AHRQ).

Golfers – especially beginners, who haven’t learned proper techniques yet – are more susceptible to injuries from overuse and poor mechanics.  It’s important for golfers to regularly participate in a muscle conditioning program to reduce the risk of common golf injuries.

In an effort to reduce golf injuries, many of which are treated by orthopaedic surgeons, the AAOS recommends the following golf injury-prevention tips:

• Dress for comfort and make sure to wear the appropriate golf shoes; short cleats are best on the course.
• Do not hunch your neck or shoulders over the ball; it may predispose you to neck strain and rotator cuff tendonitis.
• To avoid golfer’s elbow, caused by a strain of the muscles in the inside of the forearm -- perform wrist and forearm stretching exercises and try not to overemphasize your wrists when swinging.
• To avoid lower back pain caused by a poor swing -- try rowing and/or pull down exercises to improve flexibility and muscle strength.

Those who are recovering from a joint replacement should take additional precautions as they transition back into their golf game.

People who are trying to get back on the course after a joint replacement must listen to their body if they are experiencing any pain or discomfort. It’s so important for them to ease into the game until they are back to full strength.

To return to golf after hip or knee replacement, the AAOS suggests the following safety guidelines below:

• Always warm up and stretch well before playing, but avoid undue strain on your replaced joint.
• Get back into the game slowly. Begin with chipping and putting before hitting irons and then woods. Also, it is best to play just nine holes initially; once this can be done comfortably you can try a full 18.
• Use a riding cart initially. Those who like to walk while playing should wait until they can play comfortably with a cart and then try walking. It’s best to use a pull cart rather than carrying your bag.
• Be aware of weather conditions; wet weather can predispose you to falls, especially when the legs are still weak.
• Use “soft spikes” (required by most courses now) or even tennis shoes (if ground is not wet). This will reduce torque on the hip and knee.
• Don’t get frustrated when you resume playing. You may not hit the ball as far as you did prior to surgery because the leg will be weak; this will get better as strength returns.
• Be careful about squatting down to line up a putt. This can put too much pressure on the knee and could possibly cause a dislocation of a hip prosthesis.
• Continue a regular exercise program to maintain as much strength in the leg as possible.

Thanks, 

JTM, MD

Does Your Insurance Company Know Who the Good Doctors/Surgeons Are?

I usually do not include topics that are not clinical on the newsletter, but I thought this was interesting.  JTM, MD

New study finds that physician ratings do not help consumer decision-making

Several health plans have introduced physician rating systems to offer consumers more information when choosing their doctors. However, a recent study presented in the September issue of the Journal of Bone and Joint Surgery (JBJS) reveals that physician-tiering guidelines and results are not consistent across insurance companies, do not fully define quality; and could confuse consumers. 

Since affordable and more accessible health care is a critical national challenge, the use of rating systems will increase as one response to rising costs. Doctors receive notices from insurance companies about their ratings, although they do not fully understand how their tier was determined. When patients receive letters from insurers and see that their doctors are not in a top tier, their reactions may range from disappointment to confusion. This study is the first to analyze tiering system data as it applies in a specific setting.

“We examined data on 615 orthopaedic surgeons who had been accepted in one or more health plans in Massachusetts,” explains one of the authors, orthopedic surgeon Timothy Bhattacharyya, MD, Head, Clinical Investigative and Orthopaedic Surgery Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). “Tiering ranks physicians on the basis of cost efficiency and adherence to performance quality benchmarks. Thus, a higher physician rating could lead to lower co-pays and out-of-pocket costs for patients.” 

This study also reveals concerns that should be addressed:

• Study analysis showed that board certification, Medicaid acceptance, and practice in a suburban location were independent factors associated with a physician ranking in the top tier. However, more years in practice or fewer malpractice claims, important indicators of quality, did not influence or factor into tier rating. Dr. Bhattacharyya and his co-authors suggest that tiering data deserves more exploration and a clearer definition of quality.

• Insurance companies did not agree on physician inclusion in top tier. Since ratings are not consistent from one insurance company to another, a physician is often rated differently from one plan to another.

• Patients need more information about physician tiering. While health plans display a physician’s tier in online and printed directories, explanation of stratification methodology and its relation to quality of care is limited. Currently, for example, there is no evidence to suggest that physicians ranked in a second tier provide lower quality care.

The authors note that their study has limitations. Data was examined for one specialty, orthopedics, and in one state, and may not be applicable to other medical specialties or geographical areas. The lack of agreement between health plans may be the result of measuring different aspects of healthcare quality. A “gold-standard” consensus could serve as a benchmark and provide consistency across plans.

What should consumers do if they check a physician and discover that he/she is not in the top tier? Dr. Bhattacharyya explains that:

• Your physician’s rating may change from one plan to another, so compare his/her rating with another plan.

• When checking on a physician, ask about board certification and experience in this medical area or procedure. Seek referrals from people you trust, such as your doctor or someone who has had the same procedure or condition.

• Information about methodology and its relationship to quality of care is limited. Because this issue can misrepresent doctors and confuse patients, we should seek a universal definition of quality.

Thanks,

JTM, MD

Gender disparities in total joint arthroplasty

Two patients—one male, one female, both with osteoarthritis of the knee and with identical clinical scenarios of chronic knee pain—visit their primary care provider. The man is referred to an orthopedist for a possible arthroplasty. The woman is given prescriptions for an analgesic and physiotherapy. Is this appropriate care—or does it demonstrate a gender disparity?

Patient gender may influence the referral and recommendation process for total joint arthroplasty.

“Although age-adjusted rates of total joint arthroplasty (TJA) are higher for women than men, a Canadian population-based study found that underuse of TJA among willing and appropriate candidates is more than 3 times greater in women than men,” said Cornelia Borkhoff, PhD, of the Canadian Osteoarthritis Research Program at Women’s College Hospital in Toronto, Canada. Dr. Borkhoff was a featured speaker at the recent AAOS/Orthopaedic Research Society/American Bone and Joint Surgeons sponsored research symposium on Musculoskeletal Health Care Disparities.

What’s at the root of this disparity? Dr. Borkhoff believes that the answer may lie in subtle or overt bias and other factors related to a patient’s gender.

According to Dr. Borkhoff, patients go through eight steps from the initial recognition that something is wrong until the final decision to have surgery. At any point along the way, the patient’s gender may play a role in healthcare decisions. 

Primary care “gatekeepers”

The first step occurs when patients recognize they have a treatable medical condition, said Dr. Borkhoff.

“Women have been shown to be at least as willing as men to consider TJA, and women are more likely than men to seek treatment for osteoarthritis and other medical conditions,” said Dr. Borkhoff. “Thus, gender does not appear to have an important influence on this step.”

At the second step in the process, the patient obtains access to a healthcare provider. Although access to health care is frequently cited as a possible explanation for disparities based on race, access barriers are less relevant for gender disparities.

“Most people in the United States who have advanced osteoarthritis are 65 years or older and are therefore eligible for Medicare,” she said. “In Canada, patients of all ages have universal access to health care. So, it would appear that women’s access to health care is comparable to that of men.”

In step 3, the patient reports symptoms, and in step 4, the primary care physician, who acts as a “gatekeeper,” determines whether to refer the patient to an orthopaedic surgeon. Dr. Borkhoff noted that many primary care physicians lack sufficient musculoskeletal training and are therefore inconsistent about the level of pain and disability that warrants TJA.

“Primary care physicians also tend to overestimate the risks and underestimate the benefits of arthroplasty,” she said. “This is not surprising, because no guidelines currently exist, other than expert consensus reports, regarding which patients should be considered for TJA.”

Research indicates that primary care physicians refer women less often or later for specialty care.

“Primary care physicians do not refer women for surgical consultation until the degree of disability has progressed to a relatively serious level,” said Dr. Borkhoff.

Communication issues

Another factor that may affect a physician’s referral patterns is the way patients describe their symptoms.

“Women speak more openly and personally about their symptoms, describing them in a narrative style,” said Dr. Borkhoff. “As a result, the physician may perceive the woman as being reluctant to have surgery.”

Men may be perceived as more willing to undergo surgery, she said, “because they typically pre-sent their symptoms in a businesslike, factual manner.”

In step 5, the patient either accepts or does not accept the primary care physician’s treatment recommendation. The patient’s perception of the severity of his or her arthritis plays a significant role in this decision.

“There’s some evidence that women may perceive their arthritis to be less severe than men do,” she said.

Dr. Borkhoff also noted that female patients tend to receive less information about TJA than male patients. To illustrate this point, Dr. Borkhoff referred to the study she and her colleagues, including Gillian A. Hawker, MD, MSc; James G. Wright, MD, MPH; and Hans J. Kreder, MD MPH, conducted from August 2003 to October 2005 using two standardized patients—one male and one female patient with chronic, moderate knee osteoarthritis—who visited 71 physicians, including 38 family physicians and 33 orthopaedic surgeons.

“In our standardized patient study, we found that physicians were less likely to discuss the clinical issues of the decision, such as how long the hospital stay would be, with the female patient than with the male patient,” said Dr. Borkhoff. “Physicians seldom discussed the female patient’s role in the decision, assessed her understanding of the decision, or assessed her treatment preferences. As a result, the female patient had less information and less encouragement to participate in the decision to undergo TJA.

“We know that patients who get less information and less encouragement to participate in decision-making are less satisfied and are less likely to accept physicians’ treatment recommendations,” she added.

Referral to an orthopedist

At step 6, the patient reports symptoms of chronic knee pain or hip pain to the orthopedist, who determines whether the patient is a candidate for surgery.

“Based on the Canadian population-based study, among appropriate candidates for surgery, women were less likely than men to report having discussed TJA with an orthopedist,” said Dr. Borkhoff. “Women are therefore less likely than men to reach this step.”

Orthopedists—just like primary care physicians—may interpret the female’s communication style as expressing reluctance to undergo TJA.

“An orthopaedic surgeon who senses any reservation from a patient is not likely to consider that patient a good surgical candidate,” noted Dr. Borkhoff. “Subtle or overt gender bias may also inappropriately influence orthopaedists’ clinical decision-making.

“In our study, 93 percent of the orthopedists recommended TJA to the man, but only 38 percent recommended it to the woman,” she said. “The orthopaedic surgeon recommended TJA to the male patient 22 times more often than to the female patient.”

After a recommendation is made, the final step occurs—the patient either proceeds with or rejects the recommended surgery.

“In the Canadian population-based cohort, 9 percent of men and 13 percent of women were definitely willing to consider TJA,” said Dr. Borkhoff. “Despite the relatively equal willingness to have surgery, the most important predictor of definite willingness was having previously discussed TJA with a physician, and women are less likely to have done so.”

Other factors may keep women from accepting an orthopedist’s recommendation for surgery. Research has shown, said Dr. Borkhoff, that women perceive the risks of TJA to be higher than men do. In addition, compared to men, women are more concerned that the surgery will interfere with their caregiving roles and that they will be a burden on others during recovery.

Bridging the divide

According to Dr. Borkhoff, interventions to address the disparity in TJA usage among women are needed.

“Primary care physicians need tools to assist them in making decisions about referral for orthopaedic consultation,” she said.

In addition, Dr. Borkhoff noted physicians need to improve their shared decision-making skills and must receive more training in delivering culturally competent care.

“Good-quality decision aids focused on hip and knee osteoarthritis treatment, such as online resources, brochures, and DVDs, may improve patients’ informed decision-making and willingness to have TJA,” she asserted. “Decision aids are designed to help patients make an informed choice between two or more equally relevant treatment options. When patients arrive at their surgical consultation prepared and informed, the surgeon can focus on issues of concern to the individual patient, leading to a more efficient clinical encounter and care that is more patient-centered.”

Dr. Borkhoff and colleagues plan to perform a study to evaluate the effect of “patient preference reports,” resources that clearly specify the severity of the patient’s condition, that can be included as part of patient decision aids for hip and knee osteoarthritis treatment.

In addition, mass media campaigns may help the general public, healthcare providers, and patients learn about the indications for and expected outcomes of TJA and the potential benefits of early treatment.

“Even though the prevalence and severity of osteoarthritis disproportionately affects disadvantaged populations, few studies evaluate the effectiveness of interventions to improve healthcare quality in these populations,” said Dr. Borkhoff. “Studies evaluating interventions that target healthcare providers, such as shared decision-making skills or decision support tools, are also lacking.

“It’s time to evaluate whether potential interventions are effective in reducing disparities in access to care, healthcare utilization, and healthcare outcomes of disadvantaged populations with osteoarthritis,” she said.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom line

• Even though women are just as likely as men to seek treatment for osteoarthritis, physicians are less likely to recommend total joint arthroplasty (TJA) to a woman than to a man.
• How physicians respond to male and female patients during the referral and recommendation process may affect a woman’s odds of undergoing TJA.
• More training for physicians in culturally competent care and shared decision-making may reduce this disparity.

References

1. Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mahomed NN, Wright JG: The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. CMAJ, 2008;178(6):681-687.
2. Hawker GA, Wright JG, Coyte PC, et al: Differences between men and women in the rate of use of hip and knee arthroplasty. N Engl J Med, 2000;342(14):1016-1022.
3. Stacey D, Hawker G, Dervin G, et al: Management of chronic pain: Improving shared decision making in osteoarthritis. BMJ, 2008;336:954-955.

AAOS Now
July 2010 Issue
http://www.aaos.org/news/aaosnow/jul10/cover1.asp