Re: Orthopaedic surgery assessment tool

Interior Health has introduced a form to be filled out in combination with booking patients for surgery. This form has a pain and disability scale and contains other parameters. Our staff have had an in-service in this, and were invited to a clinical session to educate us in its use.

We were of course interested in anything used in this regard. The individuals we spoke with could not tell us how it would be used or how it would be to our benefit. I recently traveled to Vancouver for the Orthopaedic Collaborative. The form again was discussed. Once more there was no indication of how this was to be used or how it would help us.

We are all interested in expediting care. We are very aware of the concerns with wait lists. We understand that it has come to consciousness of our politicians. We hope that all of this is of some benefit.

Unfortunately, the number of forms we are filling out is steadily increasing. Each comes with a significant cost. None to date are electronic. For total joints alone we are now filling out 20 different sheets of paper. All of this is associated with costs. Our overhead cost is steadily climbing. Our remuneration is not. Faced with an increasing number of forms, the physician will simply breeze through them. The data as a result are biased and corrupt. Further compromise of the data is incurred when this duty is handed off to the staff. If physicians feel that their practice is being judged or the priority of the patient is compromised, there will be a bias toward more severe scores for pain, disability, and deformity This then is in no one’s interest. Alternatively the responsibility for the form may be shed to the clerical staff. This results in a further compromise of the data.

I believe that it is most unlikely that this data will be of any value other than perhaps to those people in those offices who wish to bandy about figures to suggest that there has been some influence to care produced by some maneuver or other. This is bad science. It is bad medicine. Is it politics?

The question of indications for joint arthroplasty has been raised by those responsible for costs. This has resulted in similar processes in various countries, even continents. The same procedure has been introduced in New Zealand, the United States, and Britain. Unfortunately, this is a question that taxes the faculties of Solomon. A recent article in Clinical Orthopaedics and Related Research[1] (one of the four major orthopaedic journals) found virtually no agreement between orthopaedic surgeons, rheumatologists, and primary caregivers regarding the indications for contraindications for joint replacement. Curiously, it showed that those surgeons with the highest volume were most likely to perform the surgery with good result.

The question reminds us of our national gun registry. A seemingly simple cheap process has turned out to be extremely expensive. If we had simply reviewed the results of similar processes in Europe, we could have anticipated the costs. The benefit is dubious. The same, I would suggest, applies to this process. Do we have any proof that it has been of value in improving the quality of care to total joint replacement patients and the quality of care to the general orthopaedic population? We must not forgot that any time we streamline the care of one patient, we are delaying that to another.

The process needs to be held in serious question. The surgeons need to buy into the process for it to be effective. Strong consideration should be given to remuneration for the forms. (If we look at the BCMA schedule of fees for forms (A00060—$31.20) and mention these to those who generate them, perhaps they will reconsider the effective costs of such a measure before instituting it.)

—Bernhard E. Driedger, MD
Cranbrook

References

1. Cross WW 3rd, Saleh KJ, Wilt TJ, et al. Agreement about indications for total knee arthroplasty. Clin Orthop 2006;446:34-39. PubMed Abstract Full Text