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Tuesday, March 17, 2015

Based on the Evidence-Cardiac and Orthopedic Procedures To Avoid

Here are the latest conclusions from the 2015 Road to Rightcare by the doctor-driven Lown Institute, which aims to prevent unnecessary and ineffective procedures and enhance patient health. To quote one of the conference speakers, America Bracho, M.D., "Health is more than the absence of disease." Become a more powerful practitioner and patient by signing-up for the Rightcare newsletter and to learn more about the practices this multi-disciplinary group is promoting.

 Cardiac Care
Percutaneous Coronary Intervention or Angioplasty
As incredible as it may seem there are thousands of unnecessary and non-beneficial cardiac procedures performed each year in the U.S. Here are the summary notes from the Lown Conference Cardiac Care presentation by Dr. William Boden, FACC, FAHA, Professor of Medicine, Albany Medical College and Chief of Medicine at Stratton VA Medical Center. For patients with chronic and stable angina, the benefits of percutaneous coronary intervention, which involves working a balloon up through the femoral artery to unblock the clogs in the heart, are unclear. In the past, PCI was done for patients who had high risk of death due to a heart attack. Because angioplasty is less invasive than coronary artery bypass  graft or CABG, it has become more popular.  A randomized trial of 1,018 patients comparing PCI or angioplasty to treatment with medication, was conducted in the United Kingdom and Ireland. Of the 504 patients whom underwent PCI, 11 died, compared to the 7 of the 514 randomized patients, whom were treated with medication. Additionally, 21 of the PCI patients had heart attacks compared to 10 of those on medication. These results are quite astounding, because the benefits of not having the surgery are almost twice (1.92 in relative risk variance) what the surgical intervention produced.
Orthopedic Surgery
There are 800,000 joint replacements done in the U.S. every year by the 20,000 orthopedic surgeons, who are the highest income earners of all clinicians, averaging $413,000 annually, as cited by Dr. Boniface, Clinical Professor and Chairman of Orthopedic Surgery at Northeastern Ohio Medical University. Here is the alphabetized list of commonly performed unnecessary and often ineffective orthopedic procedures as identified by James Rickert, M.D. President of The Society for Patient-Centered Orthopedics, Thomas J. Grogan, M.D. Orthopedic Surgeon, Thomas Boniface, M.D., NEOMED, and Rob Rutherford, M.D. Clinical Instructor, University of Washington:
Adolescent Clavicle Fractures and Surgical Repair
Traditionally family practitioners, which would be pediatricians for adolescents, treated clavicle fractures by deploying a sling to prevent stress on the bone while it healed. Why is surgery being done on so many clavicles which heal on their own?
Anterior Cruciate Ligament or ACL Tear Surgery
Most of us have heard of the "ACL injury" as it is the de rigueur for weekend warriors. However, clinically, many more people are having this surgery than for whom it was intended to treat. In 2008, there were 100,000 ACL surgical repairs and now there are 200,000. In Unraveling U.S. Healthcare-A Personal Guide, I devote a chapter to surgical tips for consumers and why I chose non-surgical treatment for my ACL tear. In fact, a 2013 article published in the American Journal of Sports Medicine demonstrates that patients who opted for a nonsurgical treatment had the same rate of return to sports activities. The Scandinavian  Journal of Medicine and Science in Sports published a study in 2009, which found that 51% of the patients which did not have the ACL repair operation performed better on two of the four, single-legged hop tests. And for those of you who need more evidence, the British Journal of Medicine also published a study in 2013, which showed that ACL reconstruction and rehabilitation did not produce better results than initial rehabilitation and postponement of surgery, after five years of observation.
Partial Meniscectomy for Arthritic Knees
Meniscectomy was studied in a randomized controlled trial of 351 patients,  where physical therapy was compared to the surgical repair technique of the meniscectomy and found equal results for pain relief and functional status were achieved with physical therapy. The randomized controlled trial means that patients were chosen at random and followed for the same period of time, using the same measures to assess the effectiveness of the treatment. Conclusion-if you have arthritis this procedure won't help you.
Rotator Cuff Tears and Surgical Intervention
Rotator cuff tears are often asymptomatic, which means the patient is not aware there is a problem and is not experiencing any restrictions. A 2010 article in the Journal of Shoulder and Elbow Surgery found that 20.7% of the general population had rotator cuff tears and asymtomatic tears were twice as common as those in patients with symptoms. This condition, which is an aspect of normal aging is found via the ubiquitous MRI. Despite this evidence, there are 600,000 of these surgeries in the U.S. each year. To put it bluntly, medical evidence shows that physical therapy can be just as effective to treat this problem, and should only be provided to patients who actually have symptoms.Risks of a surgical repair to the rotator cuff include; bleeding, infection, stiffness, re-rupture of the tear, neurovascular injury, and unrelieved pain. For patients whom are 60+ years, a non invasive treatment is preferential to a surgical repair. As the gold-standard randomized controlled trial showed, the results are the same with our without surgery.
Vertebroplasty-A Spinal Treatment
Vertebroplasty is a heavily marketed orthopedic procedure which involves injecting cement into the center of a fractured vertebra. It is used for compression fractures of the spine. The British Medical Journal did a large randomized controlled trial and found there was no evidence this procedure provided any medical benefit. One fourth of women over age 50 have one or more fractures. The rate of vertebroplasty has increased from 45 to 87 cases per 100,000 patients in the Medicare population. Though this treatment is marketed as providing quick pain relief, scientific studies show there is a risk of increased compression fracture, dural tears, infections, cement migration, and the need for additional surgery due to radiculopathy. In a 2009 study published in the New England Journal of Medicine, pain cessation for patients treated with vertebroplasty were similar to those in the control group who did not have the surgery. No commercial entity paid for any of the materials in this study and the costs of the surgery were billed to insurance companies. In the industry funded studies, the cementing procedures is typically compared to sham procedures and not to nonsurgical interventions.Conclusion-This is yet another back surgery which has elusive results-Medicare needs to review this.
How Changes in Health Policy at the Centers for Medicare and Medicaid Can Improve Care
In the three days I spent at the Lown Care Conference it was obvious the physicians all had ideas on how changes in our national health care policy could drive health care practices and result in better patient care and a reduction in ineffective treatments. Here are their observations on ways to improve health care quality in the nation:
  1. United States healthcare is being pushed toward a "risk-based" model which means identifying the most efficacious treatments and creating cost savings is critical. One way to achieve this is through bundling payments or reimbursements for clinicians and health care facilities. This would create less of a financial impetus to perform the highest reimbursement surgery as opposed to the treatment most appropriate for the patient. 
  2. CMS needs to make coding changes for cardiac procedures which would not punish the doctor for doing the cost-effective treatment. For example, a doctor's fee should not be linked to the cost of the cardiac catheter.
  3. We build over capacity at the medical school level by encouraging more specialists and increasing the supply of highly trained surgeons, which also means we have to generate  demand for services through scope creep, marketing directly to patients, and the ever expansion of facilities to be filled with patients who have the money to pay for the procedures.
  4. Consumer or patient-driven health care is not the same as market driven medicine because patients are not commodities, hospitals are not factories, and money should not be the driving force of health care decisions. Education of patients is the key to providing the right care for each patient, with a much stronger emphasis on prevention. We need to collaborate more effectively so that patients can make informed decisions. Health outcomes need to be patient based, not based on Relative Value Units. We need to figure out the health treatments with the most impact and CMS needs to reward those. Patients need to be informed and accountable.
  5. Nonoperative treatment needs to be valued more by CMS and insurance companies, because the Journal of Patient Safety cites 440,000 patients are still harmed in U.S. hospitals annually. If doctors are paid for providing preventive care they will do more of it. But as it stands right now, primary care clinicians make the least amount of money in the medical field.  More procedures does not necessarily mean more health. 
State Initiatives
 Rhode Island has sparked a unique health effort to meet community needs in under-served areas by creating community centers which incorporate fitness centers, achieve critical mass in community enrollment through representation of community members, provide urgent care services at the center, offer home health visits, and deploy school-based health programs. They plan to fund it through taxation of health services. University of Minnesota professor, Bill Doherty has co-authored the Citizen Health Care Initiative, which  aims to engage communities, families, and individual patients to participate and generate health improvements. This community model attempts to instill healthier perspectives and behaviors instead of waiting for major medical interventions at the hospital. Washington State has Healthier Washington, a grant funded project, which is exploring everything from reimbursement and design changes to the state Medicaid plan, to community assessment, and resourcing of health care needs.The real question is whether any of these ambitious programs will be able to improve health. My money is on the Rhode Island community center model.

Have I met all of my health goals since I returned from the conference-no, but I am making progress and just remember Winston Churchill's quote, "You can always count on Americans to do the right thing, after they have tried everything else." And this is the healthpolicymaven signing off encouraging you to think about your health and ask questions before you pursue health treatments.

This article was written by Roberta E. Winter, MHA, MPA, an independent health care analyst and writer and may be shared with others. It is not meant to give medical advice, but to highlight what the experts and the medical evidence show for common surgical procedures which are over utilized in the United States. The article is not a comprehensive review of unnecessary surgeries, especially in cardiac care, because it was written for the layperson.