Maximizing Hip Care Capturing And Demonstrating Value Syllabus
2014-10-20
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10/20/2014
The Importance of Value in Healthcare
Kevin J. Bozic, MD, MBA
William R. Murray Professor and Vice Chair
UCSF Department of Orthopaedic Surgery
Core Faculty, Philip R. Lee Institute for Health Policy Studies
Visiting Scholar, Harvard Business School
Disclosures/Conflicts of Interest
Research Support:
AHRQ, NIH, RWJF, CHCF, UC CHQI, CMS
Consultant:
Institute for Healthcare Improvement, Pacific Business Group on Health
Visiting Scholar, Harvard Business School
Governance/Leadership Roles:
AAOS (Council on Research and Quality)
AAHKS (Health Policy, EBPC)
COA (Past-President)
OREF (Board of Trustees)
UCSF Medical Center (HTAP)
California Joint Replacement Registry (Chair)
Problems with US Healthcare System
Emphasis on
healthcare, not health
Fragmented delivery,
payment systems
Medical
error/defensive
medicine
‘Medical arms race’
Moral hazard
“Now we just have to sit
back and wait for the Fed
to bail us out.”
1
10/20/2014
Lack of Competition Based on Value
• Patient choice and competition for patients are powerful
forces to encourage continuous improvement in value
and restructuring of care
• Today’s competition in health care is not aligned with
value
Financial success of
system participants
Patient
success
• Creating positive-sum competition on value is
fundamental to health care reform
*Slide courtesy of Michael Porter, PhD
Primary Goal: Improve Value
Value = Outcome/* Cost
“Value in any field must be
defined around the customer
(e.g., patient), not the supplier
(e.g., providers)”
PatientCost
Costtoto
Centered
VALUE
Achieve
*Outcome=
Quality
(e.g.,
clinical
outcome,
Achieve
Outcomes
safety)
Service (e.g., satisfaction,Outcomes
Outcomes
of +
Care
convenience, communication)
Prerequisites for Value Based Healthcare
Empower patients, providers, payors/purchasers
with better information
Tools for efficient, real time data capture
Transparency of cost, quality
Reorganize delivery, payment system around
patient-centered value (not volume)
Align stakeholder incentives around value
Actionable, easy to understand/use, risk adjusted
Increased accountability for providers, patients
Leadership from the medical profession
2
10/20/2014
Physician Manner
Relative Importance on 5
point Likert Scale (n=243)
4.68
Physician Quality
4.64
Hospital Factors
4.01
Physician Reputation
4.00
Customer Service
3.98
Physician Qualifications
3.97
Non-Clinical Features
(convenience, cost)
3.50
Dimension
Average (5
point
Likert
Scale)
I believe that my choice of surgeon will have an
important impact on my outcome.
There are big differences in the quality of care among
different orthopaedic surgeons.
I had adequate information to choose the surgeon for
my procedure.
I found data that helped me understand how this
surgeon compares to other surgeons.
4.7
4.5
3.3
3.2
Who Will Define ‘Quality’ in Orthopaedics?
*Sinaiko and Rosenthal, AJMC, 2010
“Requires development of quality measures and
ensures close collaboration with physicians and
other stakeholders regarding the measures used
in the performance program.”
-SGR Repeal and Medicare Provider Payment
Modernization Act (HR 4015/S 2000)
3
10/20/2014
Empowering Patients, Providers with Data
10
Which Outcomes are Important to Measure?
Johnston et al., 2013, Patient-Reported outcomes in meta-analysis- Part 1: assessing
risk of bias and combining outcomes, Health and Quality of Life Outcomes,
Population Health Management: Appropriateness
4
10/20/2014
Population Health Management: ‘Downstreaming’
Population Health Management: Patient Engagement
Healthy
Behavior
Selfmanage
chronic
disease
Solicit input
on report card
measurements
Consumer
Engagement
Market
public
report cards
Shared
Decision
Making
Transitioning to Value Based Payment
Providers function in silos
Waste, inefficiency
Delivery, payment systems
don’t promote alignment,
accountability
Regulatory, legal barriers to
alignment
Stark, anti-kickback, CMP,
Tax Code
5
10/20/2014
Value Driven Payment
Readmissions
2%
Readmissions
2%
Cost Savings
9%
Post-Acute Care
27%
Post-Acute
Care
24%
Index Admission
- Physician
PaymentIndex
10%
Admission Physician
Payment
10%
Reduce/eliminate non
value-added care
Inappropriate care
Avoidable
complications/readm
issions/reoperations
Excess cost due to
variation in price
Standardization
Index
Admission Index Admission
Hospital
- Hospital
61% 55%
MeanDRG
DRG470
470Payment
Paymentper
Mean
Distribution
perCost
Episode
Episode
after 10%
Savings
Source: Brandeis Analysis of 2012 CMS Data
Providers Bear More Risk
The Choice is Ours…
“The first, critical step (in healthcare reform) is physician
leadership”-Mark McClellan, MD, PhD, testimony to Senate Finance Committee, May, 2010
Either we find ways to
stretch our healthcare
dollars by improving
quality and eliminating
waste, or…
Cost containment will be
imposed on us by limiting
access and cutting
provider reimbursement
6
10/20/2014
Leadership Opportunity for Orthopaedics
“Control your own destiny or someone else
will” – Jack Welch
Value is Agnostic to Practice Setting
Private practice
Solo/small group
Single specialty
Hospital-based
Multi-specialty group
Integrated delivery network
Academic practice
Are You Ready for Value Based Healthcare?
Focus on sustainable, patient-centric
value creation
Credible data!
Cost
Outcomes
Well-defined goals, performance
metrics
Leadership!!
7
10/20/2014
Thank You!!!
8
10/20/2014
Thomas G. Sampson M.D.
San Francisco, CA
Disclosure Information
The following relationships exist:
Consultant and Speaker:
Con Med; Smith and Nephew; Arthrex
Journal Review:
Journal of Bone and Joint Surgery - British; Arthroscopy; Clinical Orthopaedics
and Related Research; AJSM
International Society for Hip Arthroscopy:
Past President
1931 Cadaver Hip Arthroscopy
Peripheral Compartment Only
1
10/20/2014
Early Development 1970-1980
A different way of doing joint surgery with
minimally invasive techniques (Arthroscopy)
Central Compartment
Johnson
Distraction (Traction)
Errikson
Lateral Approach 1984 (Glick and Sampson)
Supine approach 1991 (Byrd)
Central Compartment-Long Scopes and Canulated Instruments
Hip Arthroscopy: The Next Evolution in Sports Medicine
Freddie H. Fu, MD, DSc,DPs (Editor)
Recognize Instability, Labral Repair, Research, Fellowships
2
10/20/2014
FAI(Femoro-acetabular Impingement)
Ganz
Arthroscopic Femoroplasty 2001
Treat the CAM with resection osteoplasty using
a specific reproducible technique
3
10/20/2014
Etiology of Hip Pain and DJD Explored
FAI
PVNS
AVN RA
OA
Trauma
Instability
Synovial
Chondromatosis
Available Procedures Hip
Pathology or Injury
Osteotomy
(PAO,
Femoral)
Hip At
Risk
Surgical
Dislocation
Arthroscopic
Correction
Both Open and Arthroscopic Evolve
Osteoplasty (Femoroplasty)
Open Surgical Dislocation
Arthroscopic
4
10/20/2014
OLC
Literature
Industry
( Stryker, Smith and Nephew, ConMed-Linvatec, Arthex, Wolfe, Stortz)
Company X
5
10/20/2014
Arthroscopic Treatment of FAI is
now Mainstream
Why should we be concerned
(Financial Healthcare)
6
10/20/2014
Is Hip Arthroscopy Cost-effective for
Femoroacetabular Impingement?
David W. Shearer MD, MPH, Jonathan Kramer BS,
Kevin J. Bozic MD, MBA, Brian T. Feeley MD
CORR 2012
If NO arthritis, may be cost effective or beneficial
With arthritis, probably NOT cost effective unless
there is a benefit delay to a THR for 16 years
The Patient
(Ideal compared to open surgery)
Day surgery
1.
2. Reduced pain and
disability
3. Reduced loss of
productivity (work)
4. Reduced limited
mobility
5. Quicker return to selfcare (reduced family
burden), ADLs and
sports
Clin Orthop Relat Res. Mar 2010; 468(3): 741–746.
Prospective Analysis of Hip Arthroscopy with 10-year Followup
J. W. Thomas Byrd, MD and Kay S. Jones, MSN, RN
50 patients (52 hips)
38 years (range, 14–84 years)
27 males and 23 females
Median improvement = 25 points (mHHS)
preoperative= 56 points
postoperative=81 points
14 patients converted to THA
2 died
Arthritis is an indicator of poor long-term outcomes
7
10/20/2014
Tissue damage
Surgical dislocation
Arthroscopic
The value of hip
arthroscopic surgery?
1. Define the goals of surgery
2. Optimizing cost per
outcome
3. Best practices advice
Define the goals of surgery
Relieve pain
Preserve cartilage and labrum
Restore ROM and function
8
10/20/2014
Optimizing cost per outcome
Direct costs Physician
Surgical
Therapy
Indirect costs Time away from work or
school
Time away from team
Family, etc.
Best practices advice for hip arthroscopy
Any non-arthritic hip
condition
Some with < Tönnis 1
Expectations match
outcomes
Surgeons expectations
= patients expectations
Reasonable and proven
procedures
Other tips to maximize value to patient, surgeon,
hospital, insurer, government (public health benefits)
1.
Correct indications, supported by H&P and imaging
2. Surgeon should know his abilities, and optimize the
surgical environment
3. Hospitals and surgical centers of excellence only
(avoid the occasional hip scope)
4. Insurers should pay a reasonable fee to support
centers of excellence
5. Insurers and Government should rely on members
(not bureaucrats) of AAOS and AANA to determine
appropriate hip surgical procedures
9
10/20/2014
10
10/20/2014
Maximizing Hip Care: Capturing and
Demonstrating Value in
TOTAL HIP REPLACEMENT
Ryan M. Nunley, M.D.
Associate Professor
Joint Preservation, Resurfacing, and Replacement Service
of Orthopaedic Surgery
Washington University in St. Louis
Disclosures
My disclosures are listed in the AAOS database.
• Consultant: Smith & Nephew, Wright Medical
Technology, Medtronic, CardioMEMS, Integra Life
Sciences, DePuy, Cardinal Health, Bluebelt,
Biocomposites, Mobile Compression Systems
• Research Support: Smith & Nephew, Wright Medical
Technology, Biomet, Stryker, Medical Compression
Systems, EOS Imaging, DePuy
The Problem: Uncontrolled health care costs
1
10/20/2014
International Healthcare
U.S. Health Care System in Crisis
US Insurers-all patients
2
10/20/2014
U.S. Total Joint Payer Mix
60%
Proportion of Patients
50%
40%
30%
20%
10%
0%
Medicare
HMO
PPO
Indemnity
Medicaid
% Total Discharges
Source: AHRQ, HCUPnet, 2002 Nationwide Inpatient Sample, http://hcup.ahrq.gov/HCUPnet.asp, site accessed on July 26, 2004. Total Hip Replacement is sum of ICD9CM Procedure Codes 81.51 and 81.53. 81.51 Total Hip Replacement, 81.53 Revise Hip Replacement. NIS data is collected for calendar years (January – December).
Routine discharge is discharge to home only. Discharge to another institution includes discharge to SNF and IRF.
DRG 209/471
7%
7%
6%
% Total Medicare Reimbursement
5%
% Total Discharges
6%
5.7%
4.4%
4%
3.4%
3.1%
3%
2%
1%
4.8%
5%
4.3%
4%
3.8%
3.5%
3%
2%
1%
0%
0%
209 & 471 (LE
Arthroplasty)
88 (COPD)
89 (Pneumonia)
% of Medicare Discharges
127 (Heart Failure)
116 (Implant
pacemaker, stent)
127 (Heart failure)
209 & 471 (LE
Arthroplasty)
483 (Tracheostomy )
% of Medicare Inpatient Charges
Incidence of Arthritis in U.S.
3
10/20/2014
The Problem:
• Number of patients needing TJA will continue to grow
600%
Kurtz et al JBJS 2007
Background
• Total hip replacement is
one of the most costeffective procedures in
all of medicine
•Cautioned against overutilization of THA in
young active patients
•Described those over 65 yrs as best suited
candidates
•By the 2nd decade, considered expanding THA
to much younger and more active pts
4
10/20/2014
• Primary goals
• Pain relief
• Restoration of Essential Functions
• One of the most cost-effective medical interventions for improving
quality of life
Total Hip Arthroplasty
• Implant Design
• Bearing Surfaces
• Surgical Techniques
• Lead to improved outcomes
• Increased patient satisfaction
• Enhanced Implant Durability
• Increased patient expectations and demand
Total Hip Arthroplasty
•# THAs in the United States
continues to steadily increase
Kurtz et al. JBJS-Am 2007
•Most rapid rate of growth is in
younger patients
Kurtz et al. J Arthroplasty 2009
5
10/20/2014
Rating scales for THA
•Harris, Merle d’Aubigne developed hip
scores in 1960’s
•Consistent with indications at that time,
excellent score required only pain relief,
normal walking, and successful basic
ADLs
•In spite of application of procedures
to younger, more active, more
demanding patient population, same
rating scales still utilized
•General outcomes, QOL measures
added; substantial ceiling effect
persists
•Evidence emerging that all patient
expectations are not being met
•43% of patients had ALL of their expectations
fulfilled completely
•Absence of any post-operative limp among most
important prognostic factors for satisfaction
6
10/20/2014
Specific values important to patients,
spouses, families, employers not
specifically addressed by current rating
scales:
•Return to employment at high level
•Return to high level recreation
•Return to normal sexual function
National Multi-Center Study Recently Completed
to:
•Establish current level of success/
function of modern implants in
returning high demand patients to
crucial activities
•Determine if there are any discernible
differences among currently utilized
implants (including THA vs. SRA)
Definitions
• Modern implants = uncemented stem + advanced bearing surface
• Advanced bearing surface:
• Highly cross-linked polyethylene against metal, ceramic, or Oxinium
• Ceramic-ceramic
• Metal-metal (monoblock, modular, SRA)
• High demand patients = age ≤ 60 + high activity level (premorbid UCLA
score ≥ 6)
7
10/20/2014
Multicenter Study: Methods
• Collected data through the administration of an unbiased and blinded
telephone questionnaire to evaluate functional outcomes of modern hip
implants at a minimum of one year after surgery.
• Included patients from 5 geographically diverse medical centers with
experience using different types of advanced bearing surfaces.
Investigational Centers
• Washington University School of Medicine
• St. Louis, MO
• Rush University Medical Center
• Chicago, IL
• Thomas Jefferson University/Rothman Institute
• Philadelphia, PA
• Anderson Orthopaedic Clinic
• Arlington, VA
• The Center for Hip and Knee Surgery
• Mooresville, IN
Survey Center Methodology
• University of Wisconsin Survey Center (UWSC)
was chosen as an independent third party
surveyor
• UWSC has long track record of administering
health questionnaires for state and federal
agencies
• No affiliation with any of the surgeons
• No knowledge or interest in bearing surfaces
8
10/20/2014
Overall Sample Disposition and
Response Rate
Sample Disposition
Total Cases
Completed Interview
943
Partial Interview
43
Eligible, Non-interview
361
Unknown Eligibility, Non-interview
33
Not Eligible
44
Total
1424
AAPOR Response Rate 1
68%
Demographics and UCLA
Demographics and
Pre-morbid UCLA
Activity Score
All Hips
Standard
Head THA
(≤32mm)
Big Head
THA
(>32mm)
SRA
806
359
323
124
n
Number Male
531 (65.88%) 195 (54.32%) 236 (73.07%) 100 (80.65%)
Number Female
275 (34.12%) 164 (45.68%) 87 (26.93%) 24 (19.35%)
Age at surgery (mean; years)
49.50
48.62
50.30
49.93
Length f/u (mean; years)
2.31
2.56
2.32
1.57
Number UCLA = 10
306 (38.01%) 109 (30.45%) 121 (37.46%) 76 (61.29%)
Number UCLA = 9
107 (13.29%)
Number UCLA = 8
98 (12.17%)
57 (15.92%) 31
(9.60%) 10
(8.06%)
Number UCLA = 7
61
34
(7.43%)
(2.42%)
Number UCLA = 6
UCLA frequency missing
(7.58%)
34
(9.50%) 52 (16.10%) 21 (16.94%)
(9.50%) 24
233 (28.94%) 124 (34.64%) 95 (29.41%)
1
1
3
14 (11.29%)
0
0
UCLA Activity Score
• In the year before your hip became painful, did you…
10
Regularly participate in impact sports such as jogging, tennis,
skiing, acrobatics, ballet, heavy labor, or backpacking.
9 Sometimes participate in impact sports.
8
Regularly participate in very active events, such as golf or
bowling.
7 Regularly participate in active events, such as bicycling.
6
Regularly participate in moderate activities, such as swimming
and unlimited housework or shopping.
• Regularly: 1 x week or more; Sometimes: 1 x month or less
9
10/20/2014
Employment
•THA is one of the most commonly performed
surgical procedure in the world
•Limited information in the literature to
provide to patients, employers, and insurance
companies about returning to work after THA
•Employment is vital component to overall
quality of life in young, active patients
Job Demand Classification
(U.S. Dept. of Labor)
•Sedentary:
• Sometimes stand or walk, but sit down most of the time.
• Occasionally, lift up to a 10 lb load.
•Light:
• Walk or stand more than one third of the time.
• Often lift up to 10 lbs.
•Medium: Often lift up to 20 lbs, sometimes up to 50 lbs.
•Heavy: Often lift up to 50 lbs, sometimes up to 100 lbs.
•Very Heavy: Often lift over 50 lbs, sometimes over 100 lbs.
Pre-op Job Demand Classification by Group
Job
Classification
All Hips
n
Sedentary
Light
Standard
Head THA
(≤32mm)
806
107 (13.54%)
68
(8.61%)
359
38 (12.10%)
34
28
(9.63%)
190 (24.05%)
91 (25.78%)
Heavy
188 (23.80%)
Very Heavy
237 (30.00%)
16
SRA
323
51 (14.45%)
Medium
Frequency missing
Big Head
THA (>32mm)
(8.92%)
124
18 (14.63%)
6
(4.88%)
66 (21.02%)
33 (26.83%)
80 (22.66%)
80 (25.48%)
28 (22.76%)
97 (27.48%)
102 (32.48%)
38 (30.89%)
6
9
1
10
10/20/2014
Return to Job Demand Classification Post-op?
• Return to the usual job you had before your hip operation either with
or without restrictions?
• Sedentary:
• Light:
• Medium:
• Heavy:
• Very Heavy:
97.98%
93.75%
95.95%
94.08%
90.91%
No difference based on type of implant
Nunley et al. J Arthroplasty 2011Rand Award
Working for Pay after Surgery
•90.4% worked after surgery
•1.6 % permanently disabled due to hip
•Mean time off work was 6.9 weeks
•94.1% returned to their usual job
•1.7% unable to return to usual job due to hip
•25.9% had some form of temporary work
restrictions when they first returned
• Temporary restrictions lasted mean 7.3 weeks
Symptoms; Function:
No difference in standard vs. large head THA
Standard THA
(< 32mm)
Large THA
(> 36mm)
NO limp last 30 days
46%
50%
Able to walk > 1 hour
52%
56%
Tried to run
74%
69%
Run > 1 mile
9%
14%
Run for exercise
27%
33%
11
10/20/2014
Patient Specific Index: The Most Important
Activity to the patient that they would like to
be able to return to
Top Activities
Walking
175
Running/Jogging
119
Golf
89
Biking
70
Basketball
59
Racquet Sports (tennis, squash, racquetball)
53
Baseball/Softball
38
Pt specific index: No difference seen between THA
cohorts
Return to Most Important Activity
Std THA
Large THA
UCLA 6/7/8
93%
91%
UCLA 9/10
86%
91%
Sexual Activity Results
Sexually active
after surgery?
Sexually Active
Not Sexually Active
10.5%
10 patients
(1.4%) stated
not sexually
active due to
hip
Favors males (p<0.0001) and
younger patients(p=0.0082)
89.5%
Frequency after
surgery?
More Frequent
43.5%
Same
52.0%
Less Frequent
4.5%
Favors females (p=0.0001) due to
less apprehension and greater
mobility
Quality after
surgery?
Better Quality
69.9%
Same
28.0%
Worse Quality
2.2%
Favors females (p=0.0011) due to
less pain and greater mobility
Hip Instability
during sex?
No Instability
96.7%
Sensation “slip out”
3.3%
No significant difference between
groups
12
10/20/2014
Sexual Activity Results
Sexually active
after surgery?
Sexually Active
Not Sexually Active
10.5%
10 patients
(1.4%) stated
not sexually
active due to
hip
Favors males (p<0.0001) and
younger patients(p=0.0082)
89.5%
Frequency after
surgery?
More Frequent
43.5%
Same
52.0%
Less Frequent
4.5%
Favors females (p=0.0001) due to
less apprehension and greater
mobility
Quality after
surgery?
Better Quality
69.9%
Same
28.0%
Worse Quality
2.2%
Favors females (p=0.0011) due to
less pain and greater mobility
Hip Instability
during sex?
No Instability
96.7%
Sensation “slip out”
3.3%
No significant difference between
groups
Sexual Activity Results
Sexually active
after surgery?
Sexually Active
Not Sexually Active
10.5%
10 patients
(1.4%) stated
not sexually
active due to
hip
Favors males (p<0.0001) and
younger patients(p=0.0082)
89.5%
Frequency after
surgery?
More Frequent
43.5%
Same
52.0%
Less Frequent
4.5%
Favors females (p=0.0001) due to
less apprehension and greater
mobility
Quality after
surgery?
Better Quality
69.9%
Same
28.0%
Worse Quality
2.2%
Favors females (p=0.0011) due to
less pain and greater mobility
Hip Instability
during sex?
No Instability
96.7%
Sensation “slip out”
3.3%
No significant difference between
groups
Sexual Activity Results
Sexually active
after surgery?
Sexually Active
Not Sexually Active
10.5%
10 patients
(1.4%) stated
not sexually
active due to
hip
Favors males (p<0.0001) and
younger patients(p=0.0082)
89.5%
Frequency after
surgery?
More Frequent
43.5%
Same
52.0%
Less Frequent
4.5%
Favors females (p=0.0001) due to
less apprehension and greater
mobility
Quality after
surgery?
Better Quality
69.9%
Same
28.0%
Worse Quality
2.2%
Favors females (p=0.0011) due to
less pain and greater mobility
Hip Instability
during sex?
No Instability
96.7%
Sensation “slip out”
3.3%
No significant difference between
groups
13
10/20/2014
Sexual Activity Results
Sexually active
after surgery?
Sexually Active
Not Sexually Active
10.5%
10 patients
(1.4%) stated
not sexually
active due to
hip
Favors males (p<0.0001) and
younger patients(p=0.0082)
89.5%
Frequency after
surgery?
More Frequent
43.5%
Same
52.0%
Less Frequent
4.5%
Favors females (p=0.0001) due to
less apprehension and greater
mobility
Quality after
surgery?
Better Quality
69.9%
Same
28.0%
Worse Quality
2.2%
Favors females (p=0.0011) due to
less pain and greater mobility
Hip Instability
during sex?
No Instability
96.7%
Sensation “slip out”
3.3%
No significant difference between
groups
Return to Sexual Function?
•Ability to Return to sex activity
•Quality of sexual activity
•Feeling of hip instability during sex
•Bearing surface
•Femoral head size
No difference based on type of implant
CCJR-OREF Award Paper
Shifts in Technology impact Surgeon “Value”
Source: Orthopedic Network News,
compiled from federal registers 1984-2011
14
10/20/2014
Who Will Define “Quality” in Orthopaedics?
*Sinaiko and Rosenthal, AJMC, 2010
Quality Reporting
•External / Internal Reporting
Systems
•HealthGrades / Vitals MD (External)
•Hospital Rating Systems
•Risk Adjusted Data
•Primarily Joints/Spine
Service Initiatives
Satisfaction
•HCAHPS (CMS)
•Insurance Companies
•Press Ganey
•HealthGrades
•Internally Generated Survey
15
10/20/2014
Cost Initiatives
•Practice (FTE’s; Malpractice;
Supplies)
•Hospital (LOS; OR; Implant Supplies,
etc.)
•Episode of Care / Bundled Payment
Total Hip Replacement
• One of the most cost effective procedures in all of medicine
• Expanding to younger and more active pt population
• Need for improved economic value by
• Increased efficiency to meet growing demand
• Reduction in cost of care
• Bundled Payments/ACOs are here to stay
THANK YOU
16
10/15/2014
Periacetabular Osteotomy for
Symptomatic Acetabular
Dysplasia
Young-Jo Kim, MD/PhD
Associate Professor of Orthopaedic Surgery
Acetabular Dysplasia
• Insufficient acetabular coverage leads to
mechanical instability
• Overloaded labrum and acetabular cartilage
at the acetabular edge degenerates and
results in hip PAIN with activity and
OSTEOARTHRITIS
• Periacetabular osteotomy reorients the
shallow acetabulum resulting in less PAIN
and POSSIBLE slowing of OA progression
Bernese Periacetabular Osteotomy
1
10/15/2014
Clinical Outcome after PAO
• Survival data using THA as end point
– 5-10 year
84-90%
Matheney, Kim, and Millis JBJS 2009 91:2113-2123
Troelsen, Elmengaard, Soballe JBJS 2009 91:2169-2179
– 20 year
60%
Steppacher, Tannast, Ganz, Siebenrock CORR 2008
466:1633-1644
Predictors of Failure
•
•
•
•
Higher age
More osteoarthritis, Tonnis grade>1
Poor joint congruency after osteotomy
Severe dysplasia
QOL in PAO patients older than 40
• Cohort comparison study
• WOMAC and SF-12
assessment
• Although PAO resulted in
good QOL, THA was
better.
Garbuz, et al. J Arthroplasty 2008 23:960
2
10/15/2014
Cost Effectiveness of PAO
• Cost effectiveness primarily a function of
pre-existing OA and longevity after surgery
• Tonnis grade I – PAO more cost effective
– Cost effectiveness of $7856 per quality adjusted life
year
• Tonnis grade II – PAO still more cost
effective, but
– Cost effectiveness of $824 per quality adjusted life
year
• Tonnis grade III – THA more cost effective
Sharifi, Sharifi, Morshed, Bozic, Diab JBJS 2008 90:2447
Proper patient selection is key!
Radiographic Assessment of Hip OA
• Plain radiographic features
– Joint space narrowing
– Osteophyte formation
– Subchondral cyst formation
• Radiographic views
– Standing vs supine AP pelvis views
– False profile view
– Functional view (abduction, flexion, internal rotation
view)
3
10/15/2014
Tönnis Grade of OA
• Subjective grading of radiographic OA on AP
pelvis
• Grade 0 – no arthritis
• Grade 1 – increased sclerosis of head and
acetabulum, slight narrowing of the joint
space, slight lipping at the joint margins
Tönnis Grade of OA
• Grade 2 – small cysts in the head or
acetabulum, increasing narrowing of the joint
space, moderate loss of sphericity of head
• Grade 3 – large cysts in the head or
acetabulum, severe narrowing or obliteration
of the joint space, severe deformity of the
head, necrosis
• Difficult to distinguish between grade 0 and 1
• Inter-rater reliability can be poor
Joint Space Width – Quantitative Measure of
Cartilage Loss
• Measure the minimum space between
acetabulum and femoral head in the weight
bearing zone
• Usually more reliable measure
• JSW > 3 mm considered normal
• JSW < 2.5 mm is considered arthritic
4
10/15/2014
Joint Space Width
JSW
delayed Gadolinium Enhanced MRI of Cartilage
-
+
-
+
-
+
+
-
+
+
-
+
+
+
+
+
-
-
+
+
Fluid
+
-
+
+ - - -+
-
+ +
+
+
- +
- +
- - +
LOW
Gd(DTPA)2- Image
+
+
+ +
+ + + + +
+
- - ++ + - +
+
+ +
+
+
+
- ++ + - +
+
+ Cartilage + +
+
+
T1 Image
[GAG] Image
HIGH
5
10/15/2014
Delayed Gadolinium-Enhanced
Magnetic Resonance Imaging
of Cartilage to Predict Early
Failure of Bernese Periacetabular
Osteotomy for Hip Dysplasia
TORIN CUNNINGHAM, REBECCA JESSEL,
DAVID ZURAKOWSKI,
MICHAEL B. MILLIS, YOUNG-JO KIM
JBJS 2006, 88A:1540-1548
Study Design
• Prospective cohort study looking at factors
affecting early failure of the joint after PAO
• Looked at pre-operative dGEMRIC, patient
factors, radiographic factors
• Looked at clinical and radiographic failure as
well as conversion to THR
Results
• Multiple stepwise logistic regression
confirmed that dGEMRIC and joint
subluxation are predictors of outcome
independent of age, center-edge angle of
Wiberg, Tönnis grade, and joint congruency.
• Final model:
– dGEMRIC: likelihood ratio test=9.91, p=0.002
– Subluxation: likelihood ratio test=6.33,
p=0.012
6
10/15/2014
Patient Selection for Pelvic Osteotomy
• 44 year old woman with chronic right hip
pain with activity
• Pain in the anterior groin
• Pain with activity and night pain
Cunningham, et al. JBJS-A 2006
10 % risk of early failure.
Patient decided to proceed
with surgery.
7
10/15/2014
7 years post-op
Conclusion
• PAO can be a cost effective solution in
young patients with minimal osteoarthritis
• Proper staging of cartilage damage is helpful
in improving the overall outcome after PAO
8
VuMedi
Maximizing Hip Care: Capturing and Demonstrating Value
Webinar
Managing the Hip at Risk
21st Century Paradigm
Allston J. Stubbs, M.D., M.B.A.
Medical Director Hip Arthroscopy & Associate Professor
Department of Orthopaedic Surgery
October 20, 2014
Allston J. Stubbs, M.D., M.B.A.
I have financial relationships with the following companies:
• Consultant: Smith & Nephew
• Stock: Johnson & Johnson
• Research Support: Bauerfeind
• Department Support: Smith & Nephew Endoscopy, DepuyMitek
• Boards/Committees: AOSSM, ISHA, AANA, Journal of
Arthroscopy
What is a “Hip at Risk”
Hip predisposed to OA
• Nature
– Genetics
– Acquired: LCP, SCFE, DDH
– Inflammatory
• Nurture
– Occupation
– Athletics
– Trauma
– Other: AVN
VCAM Biomarker
It’s more than FAI and dysplasia
1
“Why Do We Care?”
40 y/o Tae Kwon Do Olympian
6 months . . .
FAI CAM Impingement
Acetabular Surface Injury
Effect of Symptoms on CM
Stubbs et al. ISAKOS 2011
2
Why are the apparent #’s increasing?
• Improved recognition by MDs, PTs
• Better educated patient population
• MRI Arthrography
• Institutionalization of Sport
– Start at Age 3
– Formal
– Year Round
– Male and Female
Hip at Risk: OA Progression
21st Century Vision
Cartilage Condition
Pre-Arthritic
GOAL
2014
OA
Age
Why Does It Matter?
Patient & Provider
2.4 years of Hip Pain
3
Why Does It Matter?
Public and Government
Significant pressure for VALUE
How do we add VALUE?
• Reactive to Proactive Strategy
• Series to Parallel Team-Based Thinking
• Anticipating Future Paradigm Modifiers
STRATEGIC APPROACH
Proactive Strategy
• Patient Selection and Treatment
– What is our trigger for intervention: pain, MRI, other
• Diagnostic Capabilities and Tools
– Sensitivity & Specificity Optimization
• Automated Outcome Assessment
– Parallel background work-flow
4
Hip Screening Programs
• Scoliosis Model
• SCFE Model
Does prophylactic treatment make sense?
Nine Theories of Chondrolabral Dysfunction
Need “hip system” answers not silver bullet . . .
Age
Inflammatory
Neoplasm
Disease
(PVNS)
Trauma
s/p PAO
Instability
s/p Instrumentation
IPI
FAI
SCFE
States
Dysplasia
AVN
DDH
LT
Impingement
AIIS
s/p Osteotomy
LCP
IPI=Iliopsoas Impingement
Innovate with Existing Technology
until advancements are made
5
Functional Testing
Modified Dynamic Trendelenburg Test
NORMAL
ABNORMAL
Figure adapted from Limpisvasti et al. JAAOS 2007
Balance & Labral Tears
Stabilogram for Subject6-level65-trial2.txt mean COP distance = 6.38 mm
20
Anterior-Posterior distance (mm)
15
10
5
0
-5
-10
-15
-20
-25
-20
-15
-10
-5
0
5
10
Medial-Lateral distance (mm)
15
20
False Profile View:
Weight Bearing
A
C
B
Extract Maximum Information
1) Joint space
2) Joint shape
3) Extraarticular impingement
4) Other
6
Parallel Team-Based Thinking
• Hip-Based Team
• Coordinated Protocols
• Integrated Systems
Feagin Leadership Method
Prearthritic Hip Team
• Orthopaedic
• Radiographic
• Operative
• Rehabilitative
• Financial
• Patient & Patient Team
Coordinated message to patient, hospital, insurer
Anticipating Future Paradigm
Modifiers
• Biologics
– Stem cells & bioprinting
• Diagnostics
– Biomarkers & 4-D
• Surgical Techniques
– Outpatient & combination
• Certification
– Hip specialization
Don’t allow the impossibilities of the present limit the possibilities of the future
7
Performance Assessment
Easiest area for leadership
• Automated
• Background
• Accessible
Provider clinical care unaffected
Can we achieve Level 1 Evidence
• Patient enrollment
• Is non-treatment ethical
• Who is paying for it
Hip at Risk: OA Progression
21st Century Vision
1)
2)
3)
4)
Cartilage Condition
Pre-Arthritic
Hip at Risk
Genetic and Biomarker Assessment
Stem Cell Therapy
Early Correction of Mechanical Derangement
GOAL
2014
OA
Age
8
Thank You!
Cambridge, UK October 2015
www.isha.net
@ishanet
Bibliography
•
Byrd JWT. Hip Arthroscopy: patient assessment and indications. Instr Course Lect 2002; 52: 711‐719. Byrd
JWT: Physical Examination. In Byrd JWT (ed) Operative Hip Arthroscopy 2nd Edition, Springer
2005;36‐50.
•
Clohisy JC, Beaulé PE, O'Malley A, Safran MR, Schoenecker P. AOA symposium. Hip disease in the young
adult: current concepts of etiology and surgical treatment. J Bone Joint Surg‐Am 2008; 90(10): 2267‐2281.
•
Johnston TL, Schenker ML, Briggs KK, Philippon MJ. Relationship between offset angle alpha and hip
chondral injury in femoroacetabular impingement. Arthroscopy 2008; 24(6): 669‐675.
•
Martin RL, Irrgang JJ, Sekiya JK. The diagnostic accuracy of a clinical examination in determining intra‐
articular hip pain for potential hip arthroscopy candidates. Arthroscopy 2008; 24(9): 1013‐1018.
•
O'Leary JA, Berend K, Vail TP. The relationship between diagnosis and outcome in arthroscopy of the hip.
Arthroscopy 2001; 17(2): 181‐188.
•
Sierra RJ, Trousdale RT, Ganz R, Leunig M. Hip disease in the young, active patient: evaluation and
nonarthroplasty surgical options. J Am Acad Orthop Surg 2008; 16(8): 689‐703.
9
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