160 Evidence-Based Orthopaedics
The American Academy of Orthopaedic Surgeons Appropriate Use Criteria on the Treatment of Distal Radius Fractures Members of the Writing, Review, and Voting Panels of the AUC on the Treatment of Distal Radius Fractures*, William C. Watters, MD, James O. Sanders, MD, Jayson Murray, MA and Nilay Patel, MA.
T
hese Appropriate Use Criteria (AUC) for the Treatment of Distal Radius Fractures (DRF) are based on a review of the available literature regarding the treatment of distal
TABLE I Indications and Classifications Indication
Classification
AO/OTA fracture type
A: Extra-articular fracture B: Partial articular fracture C: Complete articular fracture
Mechanism of injury
radius fractures and a list of clinical scenarios (i.e., criteria) constructed and voted on by three panels of experts in orthopaedic surgery and other relevant medical fields: the Writing, Review, and Voting Panels. The AUC development methods are adapted from the RAND/UCLA Appropriateness Method (RAM)1. The full Appropriate Use Criteria on the Treatment of Distal Radius Fractures with the Appropriate Use Criteria tables, final appropriateness ratings, and a list of panel members, can be accessed on the AAOS website at http://www.aaos.org/auc. The DRF AUC are also available as a web-based application; to access this application, please visit http://www.aaos.org/aucapp.
High energy Low energy
Functional demands
TABLE II Treatments
Homebound
ASA status (comorbidities) Associated injuries
Independent
1. Immobilization without reduction
Normal
2. Reduction and immobilization
High
3. Percutaneous pinning
ASA 1 to 3
4. Spanning external fixation
ASA 4
5. Nonspanning external fixation
No associated injuries
6. Distraction plate
Grade-I or II open fracture
7. Volar locking plate
Grade-III open fracture
8. Dorsal plate
Median nerve injury Other ipsilateral injury
9. Fragment-specific fixation 10. Intramedullary nail
Disclosure: The complete Disclosures of Potential Conflicts of Interest submitted by the authors of this AUC are provided on page 67 in Appendix C of the online version of the AUC document. *Authors: All of the members of the Writing, Review, and Voting Panel of the AUC on the Treatment of Distal Radius Fractures as well as the involved AAOS staff are listed on page i of the online version of the AUC document. Disclaimer: Volunteer physicians from multiple medical specialties created and categorized these Appropriate Use Criteria. These Appropriate Use Criteria are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These Appropriate Use Criteria represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician’s independent medical judgment, given the individual patient’s clinical circumstances, should always determine patient care and treatment.
J Bone Joint Surg Am. 2014;96:160-1
d
http://dx.doi.org/10.2106/JBJS.M.01314
161 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 2 J A N UA R Y 15, 2 014 d
d
d
T H E A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S A P P R O P R I AT E U S E C R I T E R I A O N T H E T R E AT M E N T O F D I S TA L R A D I U S F R A C T U R E S
TABLE III Appropriateness Ratings* Appropriateness Scale
Rating
Description
Rarely appropriate treatment
1 to 3
Median panel rating between 1 and 3 and no disagreement
May be appropriate treatment
4 to 6
Median panel rating between 4 and 6 OR medial panel rating 1 to 9 with disagreement
Appropriate treatment
7 to 9
Median panel rating between 7 and 9 with no disagreement
*Of 2160 total voting items (i.e., 216 patient scenarios · 10 treatments), 440 (20%) were rated as ‘‘Rarely Appropriate’’, 953 (44%) were rated as ‘‘May Be Appropriate’’, and 767 (36%) were rated as ‘‘Appropriate’’. Additionally, the voting panel members were in agreement on 730 voting items (34%) and were in disagreement on ten voting items (0.5%).
Fig. 1
Summary of appropriateness ratings.
Members of the Writing Panel developed a list of 240 patient scenarios based on the identified indications and defined classifications (Table I) along with ten treatments (Table II). The Review Panel reviewed these scenarios and treatments independently to ensure that they were representative of patients and scenarios clinicians are likely to encounter. Each independent reviewer could suggest potential modifications to the content or structure of the lists and literature review. The Writing Panel provided final determination of modifications to the indications, scenarios, assumptions, and literature review. The Voting Panel participated in two rounds of voting. During the first round, the Voting Panel was given approximately one month to independently rate the appropriateness of the ten treatments for the 240 patient scenarios as ‘‘Appropriate,’’ ‘‘May Be Appropriate,’’ or ’’Rarely Appropriate’’ via an electronic
ballot (Table III). After the first round of appropriateness ratings were submitted, AAOS staff calculated the median ratings for each patient scenario and specific treatment. Three 1.5-hour conference calls were held with participating Voting Panel members to address the scenarios/treatments that resulted in disagreement. After this discussion, members of the voting panel had the option to change their appropriateness ratings during the second round of electronic voting. There was no attempt to obtain consensus about appropriateness. Using the median value of the second-round ratings from the members of the Voting Panel, the final levels of appropriateness were determined. Disagreement among raters can affect the final rating. Agreement and disagreement were determined using the BIOMED definitions of Agreement and Disagreement as reported in the RAND/UCLA Appropriateness Method User’s Manual1 for a panel of eight to ten voting members. For this panel size, agreement was defined as when two or fewer panelists’ ratings were outside of the 3-point range containing the median. And, disagreement was defined as when at least three members’ appropriateness ratings fell within the Appropriate (7 to 9) and Rarely Appropriate (1 to 3) ranges for any scenario and its treatment. If there was still disagreement in the Voting Panel ratings after the second round of voting, that voting item was labeled as ‘‘5’’ regardless of the median score. In the final tally, 440 voting items (20%) were rated as ‘‘Rarely Appropriate’’, 953 voting items (44%) were rated as ‘‘May Be Appropriate’’, and 767 voting items (36%) were rated as ‘‘Appropriate’’ (Fig. 1). Additionally, the voting panel members were in disagreement on only ten voting items (0.5%). n
Reference 1. Fitch K, Bernstein SJ, Aguilar MS, Burnand B, LaCalle JR, Lazaro P, van het Loo M, McDonnell J, Vader J, Kahan JP. The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation; 2001.
Update This article was updated on March 27, 2014, because of a previous error. In Table III, the numerical values in the first and third rows of the ‘‘Description’’ column were reversed. The values have now been corrected.
The American Academy of Orthopaedic Surgeons Appropriate Use Criteria on the Treatment of Distal Radius Fractures Members of the Writing, Review, and Voting Panels of the AUC on the Treatment of Distal Radius Fractures*, William C. Watters, MD, James O. Sanders, MD, Jayson Murray, MA and Nilay Patel, MA.
T
hese Appropriate Use Criteria (AUC) for the Treatment of Distal Radius Fractures (DRF) are based on a review of the available literature regarding the treatment of distal
TABLE I Indications and Classifications Indication
Classification
AO/OTA fracture type
A: Extra-articular fracture B: Partial articular fracture C: Complete articular fracture
Mechanism of injury
radius fractures and a list of clinical scenarios (i.e., criteria) constructed and voted on by three panels of experts in orthopaedic surgery and other relevant medical fields: the Writing, Review, and Voting Panels. The AUC development methods are adapted from the RAND/UCLA Appropriateness Method (RAM)1. The full Appropriate Use Criteria on the Treatment of Distal Radius Fractures with the Appropriate Use Criteria tables, final appropriateness ratings, and a list of panel members, can be accessed on the AAOS website at http://www.aaos.org/auc. The DRF AUC are also available as a web-based application; to access this application, please visit http://www.aaos.org/aucapp.
High energy Low energy
Functional demands
TABLE II Treatments
Homebound
ASA status (comorbidities) Associated injuries
Independent
1. Immobilization without reduction
Normal
2. Reduction and immobilization
High
3. Percutaneous pinning
ASA 1 to 3
4. Spanning external fixation
ASA 4
5. Nonspanning external fixation
No associated injuries
6. Distraction plate
Grade-I or II open fracture
7. Volar locking plate
Grade-III open fracture
8. Dorsal plate
Median nerve injury Other ipsilateral injury
9. Fragment-specific fixation 10. Intramedullary nail
Disclosure: The complete Disclosures of Potential Conflicts of Interest submitted by the authors of this AUC are provided on page 67 in Appendix C of the online version of the AUC document. *Authors: All of the members of the Writing, Review, and Voting Panel of the AUC on the Treatment of Distal Radius Fractures as well as the involved AAOS staff are listed on page i of the online version of the AUC document. Disclaimer: Volunteer physicians from multiple medical specialties created and categorized these Appropriate Use Criteria. These Appropriate Use Criteria are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These Appropriate Use Criteria represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician’s independent medical judgment, given the individual patient’s clinical circumstances, should always determine patient care and treatment.
J Bone Joint Surg Am. 2014;96:160-1
d
http://dx.doi.org/10.2106/JBJS.M.01314
161 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 2 J A N UA R Y 15, 2 014 d
d
d
T H E A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S A P P R O P R I AT E U S E C R I T E R I A O N T H E T R E AT M E N T O F D I S TA L R A D I U S F R A C T U R E S
TABLE III Appropriateness Ratings* Appropriateness Scale
Rating
Description
Rarely appropriate treatment
1 to 3
Median panel rating between 1 and 3 and no disagreement
May be appropriate treatment
4 to 6
Median panel rating between 4 and 6 OR medial panel rating 1 to 9 with disagreement
Appropriate treatment
7 to 9
Median panel rating between 7 and 9 with no disagreement
*Of 2160 total voting items (i.e., 216 patient scenarios · 10 treatments), 440 (20%) were rated as ‘‘Rarely Appropriate’’, 953 (44%) were rated as ‘‘May Be Appropriate’’, and 767 (36%) were rated as ‘‘Appropriate’’. Additionally, the voting panel members were in agreement on 730 voting items (34%) and were in disagreement on ten voting items (0.5%).
Fig. 1
Summary of appropriateness ratings.
Members of the Writing Panel developed a list of 240 patient scenarios based on the identified indications and defined classifications (Table I) along with ten treatments (Table II). The Review Panel reviewed these scenarios and treatments independently to ensure that they were representative of patients and scenarios clinicians are likely to encounter. Each independent reviewer could suggest potential modifications to the content or structure of the lists and literature review. The Writing Panel provided final determination of modifications to the indications, scenarios, assumptions, and literature review. The Voting Panel participated in two rounds of voting. During the first round, the Voting Panel was given approximately one month to independently rate the appropriateness of the ten treatments for the 240 patient scenarios as ‘‘Appropriate,’’ ‘‘May Be Appropriate,’’ or ’’Rarely Appropriate’’ via an electronic
ballot (Table III). After the first round of appropriateness ratings were submitted, AAOS staff calculated the median ratings for each patient scenario and specific treatment. Three 1.5-hour conference calls were held with participating Voting Panel members to address the scenarios/treatments that resulted in disagreement. After this discussion, members of the voting panel had the option to change their appropriateness ratings during the second round of electronic voting. There was no attempt to obtain consensus about appropriateness. Using the median value of the second-round ratings from the members of the Voting Panel, the final levels of appropriateness were determined. Disagreement among raters can affect the final rating. Agreement and disagreement were determined using the BIOMED definitions of Agreement and Disagreement as reported in the RAND/UCLA Appropriateness Method User’s Manual1 for a panel of eight to ten voting members. For this panel size, agreement was defined as when two or fewer panelists’ ratings were outside of the 3-point range containing the median. And, disagreement was defined as when at least three members’ appropriateness ratings fell within the Appropriate (7 to 9) and Rarely Appropriate (1 to 3) ranges for any scenario and its treatment. If there was still disagreement in the Voting Panel ratings after the second round of voting, that voting item was labeled as ‘‘5’’ regardless of the median score. In the final tally, 440 voting items (20%) were rated as ‘‘Rarely Appropriate’’, 953 voting items (44%) were rated as ‘‘May Be Appropriate’’, and 767 voting items (36%) were rated as ‘‘Appropriate’’ (Fig. 1). Additionally, the voting panel members were in disagreement on only ten voting items (0.5%). n
Reference 1. Fitch K, Bernstein SJ, Aguilar MS, Burnand B, LaCalle JR, Lazaro P, van het Loo M, McDonnell J, Vader J, Kahan JP. The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation; 2001.
Update This article was updated on March 27, 2014, because of a previous error. In Table III, the numerical values in the first and third rows of the ‘‘Description’’ column were reversed. The values have now been corrected.
