525568
research-article2014
FAIXXX10.1177/1071100714525568Foot & Ankle InternationalPinzur
FootForum Foot & Ankle International® 2014, Vol. 35(7) 740 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714525568 fai.sagepub.com
Appropriate Use Criteria Michael S. Pinzur, MD1
I read 2 articles from the Journal of Shoulder and Elbow Surgery recently that have given me good cause for reflection. The first article was an interesting example of the database mining from the New York State Department of Health database. The investigators learned that the incidence of rotator cuff repair in the state of New York went from 23.5 per hundred thousand in 1995 to 83.1 per hundred thousand citizens, an increase of 238%.1 The second article was even more interesting. A total of 452 patients with MRI documented atraumatic full-thickness rotator cuff tears were prescribed a structured physical therapy program. At the end of twelve weeks of therapy, the patients could choose 1 of 3 courses: (1) cured with no follow-up, (2) improved (continued physical therapy and reevaluation in 6 weeks), or no better (surgery offered). How many of these patients visiting your shoulder surgeon colleagues would be advised to have immediate surgery? It turns out that at 2 years of follow-up, fewer than 25% of the patients underwent surgery.2 During the period of the first investigation, the rate of shoulder surgery tripled. Are patients today with rotator cuff disease 3 times better than they were 20 years ago? We can ask the same questions of our spine colleagues who have astronomically increased the rate of spine surgery over the past 2 decades. Our health care system is imploding. There is not enough money or resources to support the increases in resourceconsuming interventions that are being performed today. Data from investigations like these give good cause for those responsible for providing health care to ask whether they are getting a fair return on their investment. For the readers of this journal, does every ankle sprain require an MRI following by acute repair of a ruptured anterior talofibular ligament? Does every flatfoot require surgical reconstruction? As we go forward, not only are we going to be required to provide the payers evidence that our
interventions benefit patients, we are also going to be required to demonstrate that our resource-consuming interventions are actually better than nonsurgical options. Even with 90% favorable outcomes with surgery, 10% fail and require more resource consumption. What is the cost of an infected total ankle as compared with an ankle-foot orthoses? The payers have this datum. It is up to us to justify our interventions. The Appropriate Use Criteria (AUC) model is the first attempt of the American Academy of Orthopaedic Surgeons to use evidence-based criteria to define indications for resource-consuming treatment. It is incumbent on us to provide the evidence that our resource-consuming interventions are superior to the cost of simple accommodative methods. Rather than complain that the insurance company is denying services for our patients, we have to demonstrate to them that we primum non nocere. For comments, please contact the FootForum at [email protected]. References 1. Ensor KL, Kwon YW, DiBeneditto BA, Zuckerman JD, Rokito AS. The rising incidence of rotator cuff repairs. J Shoulder Elbow Surg. 2013;22:1628-1632. 2. Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22:1371-1379.
1
Loyola University Health System, Orthopaedic Surgery, Maywood, IL, USA Corresponding Author: Michael S. Pinzur, MD, Loyola University Health System, Orthopaedic Surgery, 2160 S First Ave, Maywood, IL 60153, USA. Email: [email protected]
Downloaded from fai.sagepub.com at UCSF LIBRARY & CKM on March 23, 2015
research-article2014
FAIXXX10.1177/1071100714525568Foot & Ankle InternationalPinzur
FootForum Foot & Ankle International® 2014, Vol. 35(7) 740 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714525568 fai.sagepub.com
Appropriate Use Criteria Michael S. Pinzur, MD1
I read 2 articles from the Journal of Shoulder and Elbow Surgery recently that have given me good cause for reflection. The first article was an interesting example of the database mining from the New York State Department of Health database. The investigators learned that the incidence of rotator cuff repair in the state of New York went from 23.5 per hundred thousand in 1995 to 83.1 per hundred thousand citizens, an increase of 238%.1 The second article was even more interesting. A total of 452 patients with MRI documented atraumatic full-thickness rotator cuff tears were prescribed a structured physical therapy program. At the end of twelve weeks of therapy, the patients could choose 1 of 3 courses: (1) cured with no follow-up, (2) improved (continued physical therapy and reevaluation in 6 weeks), or no better (surgery offered). How many of these patients visiting your shoulder surgeon colleagues would be advised to have immediate surgery? It turns out that at 2 years of follow-up, fewer than 25% of the patients underwent surgery.2 During the period of the first investigation, the rate of shoulder surgery tripled. Are patients today with rotator cuff disease 3 times better than they were 20 years ago? We can ask the same questions of our spine colleagues who have astronomically increased the rate of spine surgery over the past 2 decades. Our health care system is imploding. There is not enough money or resources to support the increases in resourceconsuming interventions that are being performed today. Data from investigations like these give good cause for those responsible for providing health care to ask whether they are getting a fair return on their investment. For the readers of this journal, does every ankle sprain require an MRI following by acute repair of a ruptured anterior talofibular ligament? Does every flatfoot require surgical reconstruction? As we go forward, not only are we going to be required to provide the payers evidence that our
interventions benefit patients, we are also going to be required to demonstrate that our resource-consuming interventions are actually better than nonsurgical options. Even with 90% favorable outcomes with surgery, 10% fail and require more resource consumption. What is the cost of an infected total ankle as compared with an ankle-foot orthoses? The payers have this datum. It is up to us to justify our interventions. The Appropriate Use Criteria (AUC) model is the first attempt of the American Academy of Orthopaedic Surgeons to use evidence-based criteria to define indications for resource-consuming treatment. It is incumbent on us to provide the evidence that our resource-consuming interventions are superior to the cost of simple accommodative methods. Rather than complain that the insurance company is denying services for our patients, we have to demonstrate to them that we primum non nocere. For comments, please contact the FootForum at [email protected]. References 1. Ensor KL, Kwon YW, DiBeneditto BA, Zuckerman JD, Rokito AS. The rising incidence of rotator cuff repairs. J Shoulder Elbow Surg. 2013;22:1628-1632. 2. Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22:1371-1379.
1
Loyola University Health System, Orthopaedic Surgery, Maywood, IL, USA Corresponding Author: Michael S. Pinzur, MD, Loyola University Health System, Orthopaedic Surgery, 2160 S First Ave, Maywood, IL 60153, USA. Email: [email protected]
Downloaded from fai.sagepub.com at UCSF LIBRARY & CKM on March 23, 2015
