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High Imaging Costs a Result of Defensive Medicine, Study Claims

Nearly 35 percent of all the imaging costs ordered for 2,068 orthopedic patient encounters in Pennsylvania were ordered for defensive purposes, according to a new study presented during the recent Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego, Calif.


For many years, some physicians have ordered specific diagnostic procedures that are of little or no benefit to a patient, largely to protect themselves from a lawsuit. Until now, however, efforts to actually measure defensive medicine practices have been limited primarily to surveys sent to physicians. Such surveys simply would ask if an individual actually practiced defensive medicine.


“This is the first study we know of that looked at the actual practice decisions of physicians regarding defensive imaging in real time—prospectively done,” said John Flynn, M.D., associate chief of orthopaedic surgery at Children’s Hospital of Philadelphia, Pa. He said that many lawsuits hinge on the plaintiff’s lawyer’s claim that the doctor should have ordered extra diagnostic testing.


“And such a claim may be the driving force of so much of the defensive testordering,” Flynn added.


According to Flynn, 72 orthopaedic surgeons, who are members of the Pennsylvania Orthopaedic Society, voluntarily participated in the study, which included some 2,068 patient encounters throughout the state. Most of the patients participating this study were adults.


The study found that 19 percent of the imaging tests ordered were for defensive purposes.
Defensive imaging was responsible for $113,369 of $325,309 (34.8 percent) of total imaging charges for this patient cohort, based on Medicare dollars. The overall cost of these tests was 35 percent of all imaging ordered because the most common test was an MRI, an imaging test which costs more than a regular X-ray.


One piece of this problem to remember, Flynn explained, is that the legal environment that drives physicians to order additional tests has an effect on patients too, in a way that involves more than costs.


“Patients are sometimes put through tests that maybe otherwise would not be ordered,” he said.


The finding from this research that surprised Flynn the most was that surgeons were more likely to practice defensively if they had been in practice for more than 15 years.


“This was counterintuitive,” he said. “I thought that young doctors would come out of medical school immediately after training, be less confident because they weren’t experienced, and order more defensive tests. Then, as they become more comfortable and confident after 10 or 20 years in practice, they would order many fewer tests.


“In fact, the opposite was true. We found that—in Pennsylvania at least—a surgeon’s defensive nature gets worse over time. In this legal environment, orthopaedic surgeons order more imaging tests of a defensive nature, because over time they become more concerned that someone is going to second guess or sue them.”


Flynn said that medical liability awards typically are given because of the severity of a bad outcome, and not necessarily because of negligence. In fact, a May 2006 study published in the New England Journal of Medicine showed that 37 percent of claims did not involve medical errors, and in 3 percent of claims, no injury occurred at all.


Flynn identified various studies that show that defensive medicine, in general, is quite prevalent. One such study in the June 2005 Journal of the American Medical Association reported that almost 93 percent of 824 physicians in Pennsylvania responding to a survey practiced defensive medicine.


“Ideally, as a next step, we would hope to try to get a broader national picture using this prospective practice audit methodology, so we could get a better sense of the true costs of defensive imaging in orthopaedics,” Flynn said. “Ultimately, if you had doctors from multiple specialties, from OB/Gyn to neurosurgery to emergency medicine, do this type of practice audit, you could accurately quantify how much of our nation’s healthcare resources are wasted on defensive medicine.”


Stryker Rolls Out a Varied Mix of New Products


The Orthopaedics division of Kalamazoo, Mich.-based. Stryker Corporation recently received some news that would be music to most implant manufacturers’ ears.


A recently released report by the National Joint Registry for England and Wales noted that Stryker’s Trident Cup, its Accolade hip stem and the Triathlon knee system have better revision rates than the most frequently used brands.


“Stryker focuses on developing products that can address the clinical issues that are most critical to implant performance,” said Mike Mogul, group president of Stryker Orthopaedics.
“The National Joint Registry of England and Wales is incredibly important because it demonstrates the performance of implants on the market today and provides surgeon and hospital customers with valuable data, enabling them to make informed purchasing decisions to enhance clinical outcomes.”


According to the registry, Trident had the lowest revision rate (2.4 percent) among cementless cups at five years; Accolade had the lowest revision rate (2.8 percent) among cementless stems at five years, and Triathlon had the lowest revision rate (1 percent) among total knee replacement systems at three years for the second consecutive year.


“The registry results are a validation of everything we’ve studied and how we have engineered our products,” Patrick Treacy, vice president and general manager of Stryker’s Knee Reconstruction business in Mahwah, N.J., told Orthopedic Design & Technology. “It isn’t just material. It’s not just design. Our success in this area is a combination of both. This is one of the reasons we’ve had market-leading growth for the last 16-20 [financial] quarters.”


In addition to this recent registry news, the company also has released its latest

innovations in tissue-preserving hip arthroscopy. The company’s product is a comprehensive system of instrumentation and precision devices that play a role in restoring optimal hip biomechanics. The platform is designed to provide optimal joint preservation with minimal complication, company officials noted.


Recent advances in the knowledge of and treatment of femoroacetabular impingement have led to the development of minimally invasive techniques to restore the biomechanics of the hip and delay or obviate the need for a total hip replacement.


According to Stryker officials, the tissue-preserving system includes a high-definition visualization system called Ideal Eyes; a new cannulated access system, Serfas XL Ablation Probes; repair instrumentation and Formula XL blades featuring new angled cutter designs. The new instrumentation joins the Orthomap 3-D navigation package for CAM FAI and the TwinLoop FLEX labral repair system with a flexible drill and flexible suture anchor insertion handle for angled access to the acetabulum.


Another announcement by Stryker’s Orthopaedics division may not be on par with a new breakthrough implant or positive study results, but it’s a fun example of the crossover between the worlds of consumer electronics and medical devices.


The company has launched its first iPad applications for surgeons, available through Apple’s App Store, to help physicians enhance the patient education process and provide easy access to information about products and surgical techniques.


Several of Stryker’s other business units and divisions already are using iPads to enhance customers’ interactions with patients, including Craniomaxillofacial, Instruments, Endoscopy, Communications and Neurovascular. Stryker Orthopaedics also equipped its entire U.S. sales force with iPads, based on a successful 2010 pilot program. This shift to a digitally enabled sales strategy will enable Stryker Orthopaedics to achieve significant savings annually by reducing the amount of paper the company ships by hundreds of thousands of pounds.


Historically, medical device makers’ interactions with surgeons and hospitals were paper-based, which consumed a significant amount of time and resources. The company’s goal is to provide surgeons with digital access to educational tools that can support their dialogue with self-educated patients.


Two apps have been created so far to help support the evolving needs of healthcare practitioners and hospitals as well as Stryker’s sales and field operations in the United States.

Stryker Flipchart is a patient education tool designed to help orthopedic specialists explain a hip, knee or shoulder replacement procedure to patients who are either scheduled for surgery or contemplating total joint replacement. It contains overviews of a normal joint, arthritic joint and replaced joint, using graphics and X-rays. Surgeons also are able to customize and annotate the images to support patient discussions.


OpTech Live is a guide to Stryker’s surgical protocols with a touch-screen interface. The app includes information about Stryker products ranging from extremities to hip, knee, sports medicine and trauma.


“This is all part of a better, more efficient healthcare solution,” said Bill Huffnagle, vice president and general manager of Hip Reconstruction. “Our technology is more than one-sided—just about the implant and its efficacy. This—the iPad apps—is yet another way to help the patient population better understand their procedures, make the system more effective, healthcare providers more efficient, etc.”


What’s New in Hip Care?


They say knowledge is power. If that’s so, then orthopedic surgeons attending the recent annual meeting of the American Academy ofOrthopaedic Surgeons (AAOS) are a powerful lot.Three new studies unveiled during the meeting discussed some of the latestfindings in hip care.

The Need for Revision Surgery


“Who is More Likely to Need Revision Surgery 12 Years after Total Hip Replacement (THR)?” was the title of a first-of-its-kind study, which analyzed Medicare beneficiaries who had elective primary THR for osteoarthritis between July 1, 1995, and June 30, 1996. Study authors found the risk of revision was approximately 2 percent per year for the first 18 months post surgery and then approximately one percent per year for the remainder of the 12-year follow-up.


The risk of revision was higher in men than women and in patients 65-75 vs. patients older than 75. Patients operated on by surgeons who performed fewer than six THRs annually in the Medicare population had a higher risk of revision than those whose surgeons performed more than 12 hip replacements a year.


“These first national, population-based estimates of the rate of revision following THR over 12 years confirm the risk associated with younger age, male sex and low surgeon volume,” explained Dr. Jeffrey Katz, M.D., professor of medicine and orthopedic surgery at Harvard Medical School, Brigham and Women’s Hospital in Boston, Mass. “This research underscores the need to choose an experienced surgeon who commonly performs THR. The research also demonstrates that older THR recipients have a lower number of revisions than younger patients. Innovations to improve implant durability should be targeted to younger patients.”

Hip Revisions in Patients Older than 80?


Orthopedic surgeons commonly are faced with the decision whether or not to replace a total hip replacement in patients older than the age of 80. After several years of use, the joint may become painful or swollen due to loosening, wear or infection. Or the function of the implant may decline, resulting in a limp, stiffness or instability.


This new study evaluated two groups of patients who underwent revision surgery: 84 patients older than 80 and 241 patients younger than 80. All revision surgeries were performed between 1996 and 2008 at the Geneva University Hospitals, Geneva, Switzerland. Both age groups indicated general improvements following surgery.The study found that patients older than 80 reported substantial clinical improvement and satisfaction. In the older group, 84.2 percent reported no pain or only mild pain compared to 79.8 percent in the younger group.


However, more complications and higher mortality rates were seen with patients older than 80. Medical complications were significantly more common in the older patient group with 23.8 percent vs. 6.2 percent.


Overall, the older group experienced significantly more dislocations in the first year (14.4 percent) as compared to the younger group (6.6 percent). However, this risk was substantially reduced in recent years with use of specific devices.


Postoperative fractures were seen more in the older group with 9.5 percent as compared to 2.5 percent in the younger group.


Four patients from the older group died within 90 days of surgery.


“We encourage patients older than 80 to have revision surgery in terms of pain relief and function. But we also tell them they need very good medical preparation before the operation,” said Dr. Anne Lübbeke, M.D., DSc, division of orthopedics and trauma surgery, Geneva University Hospitals. “Patients should work with their primary physician to obtain a comprehensive checkup. And the anesthesiologist also will help evaluate their risk prior to surgery.”

Ceramic-on-Ceramic THR Squeaking: Patient Characteristics


Squeaking is somewhat common inceramic-on-ceramic total hip replacement. It is reported in less than 1 percent to 7 percent of ceramic procedures. Seventy-four squeaking hips were identified in 2,406 ceramic-on-ceramic THRs performed between June 1997 and December 2008 at the Mater Hospital in Sydney, Australia.


In this study—the largest to date according to its authors—researchers examined ceramic hip squeaking, finding that patients more likely to experience squeaking hips share similar qualities, such as:

• They’re taller (a mean height of approximately 5 feet 7 inches compared to 5 feet 6 inches with silent hips);


•They’re heavier (a mean weight of 176.8 pounds compared to 168.4 pounds with silent hips); and


• They’re younger seniors (a mean age of 60 vs. age 65 with silent hips).


Squeaking hips had a significantly higher range of internal and external rotation following surgery, and patients with squeaking hips were significantly moreactive, according to study results.


A squeaking hip was not associated with a significant difference in patientsatisfaction or Harris hip score.


“Fortunately, the majority of this squeaking is benign and has not led to revision or failure in large numbers,” saidWilliam L. Walter, MBBS, Ph.D., associate professor, University of Notre Dame and UNSW at the Mater Hospital in Sydney, Australia. “Ceramic-on-ceramic hip replacement remains a very successful procedure even with benign squeaking in some patients.”

High Performance Hips: More Durable Implants for Active Patients

Active patients of all ages currently are benefitting from improved functionalcapacity of current generation total hipreplacement. A teaching seminar presented at the AAOS meeting detailed high-performance hips, their advantages and how surgeons are working withpatients to implant them.


Dr. Thomas Schmalzried, M.D., medical director at the Joint Replacement Institute at the Saint Vincent Medical Center in Los Angeles, Calif., co-led the seminar. He described the four main characteristics of today’s high-performance hips:

1. Durable implant fixation: With these cementless implants, once the bone has grown into the device, it is unlikely the implant will ever loosen.


2. Improved biomechanics: There is a wider range of implant shapes and sizes which provide the individual patient better fit and function.


3. Larger diameter bearings provide greater stability: Increased impingement-free range of motion allows higher function and lower dislocation risk.


4. Lower-wear-bearing surfaces allowincreased longevity: Bearings with very low wear rates have a reduced risk of osteolysis (wear particles can trigger resorption of bone tissue and can lead to revision surgery).

“The greatest benefit of these higher performance hips for seniors is the improved biomechanics and increased stability,” said Schmalzried. “Further, these advances in total hip replacement allow for earlier intervention in patients with hip arthritis. There is no longer a need to wait so long before having a THR and patients can maintain an active lifestyle.”


In 2008, there were a total of 277,399 total hip replacements performed in the United States.
Most patients reportincreased functional improvement, pain relief and satisfaction. However, due to wear and tear, approximately 10 percent of implants will fail and require revision to remove the old implants and replace them with new components.




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