This point-counterpoint discussion between Drs. Karl-André Lalonde and Hans Kreder regarding benchmarks for the management of hip fracture patients is timely. The dilemma faced by all of us providing clinical care in orthopaedic surgery is limited resource allocation in most public hospitals in Canada. Our two protagonists are both from Ontario and therefore their arguments may seem parochial to those of you reading from outside that province. However, I can assure you that the move by the Ontario government to define wait times for both elective and emergent orthopaedic surgery (hip fractures) is a trend that will soon be national.
Both Dr. Lalonde and Dr. Kreder make very legitimate points in their essays regarding the benefits of and problems with the establishment of benchmarks. Essential to the establishment and, more importantly, adoption of benchmarks is first, evidence that the benchmarks are appropriate and second, a data collection/monitoring system that not only confirms that the benchmarks are being utilized appropriately but that their utilization does not adversely impact care for other deserving patients.
Wait Time and Orthopaedic Procedures
The importance of accurate data collection is clearly demonstrated by the wait time information system (WTIS) implemented through the Ministry of Health and Long Term Care in Ontario (MOHLTC). When it was decided that Wait 2 for hip and knee replacement surgery should not exceed 182 days (from time of consultation to time of surgery), there was considerable fear that by implementing this type of benchmark, other patients awaiting elective orthopaedic surgery would be displaced, thus lengthening their wait time for surgery. With the implementation of obligatory wait time reporting for all surgical procedures in the province came specific directions that all incremental funding for additional hip and knee replacement surgery provide additional operating room time and additional implants, forbidding hospitals from directing resources away from other orthopaedic patients to the hip and knee program.
Analysis of wait time data over the past 3 years available on the MOHLTC web site clearly documents that the average wait time for non-hip and knee replacement patients for surgery is approximately the same as that for hip and knee replacement patients. There are exceptions – wait times for foot and ankle surgery in particular, as well as shoulder surgery in some jurisdictions and spine surgery in other jurisdictions, are unacceptably long.
The concept of establishing a benchmark for acute surgery is not new. The Ontario program has been modeled on programs established in England and Scotland some years ago, and analysis of data from those jurisdictions clearly demonstrate a decrease in morbidity and short-term mortality related to early hip fracture surgery but, unfortunately, no reduction in long-term mortality.
Research done by Dr. Nizar Mahomed (University of Toronto) and others through the Total Joint Network demonstrated that a comprehensive model of care for hip fracture patients could shorten the acute hospital length of stay for these patients as well as improve significantly the percentage of patients returning home as opposed to going to long-term care. Implementation of this model includes such initiatives as early surgery, a surgical procedure that permits immediate weight-bearing, a care plan for hip fracture acute care, and a care plan for postoperative rehabilitation. As part of the implementation of this comprehensive care plan, we have developed an algorithm for expediting early surgery in this often frail patient population, available on the BJHN web site.
Allocation of OR Resources
Just as we were able to demonstrate to government and hospital administration that additional resources were necessary to meet the demand for hip and knee replacement surgery (and hopefully the programs for foot and ankle surgery, spine surgery and shoulder surgery already developed), we should be able to demonstrate to hospital administration that additional operating room resources for hip fracture patients are important and achievable. This can be done without sacrificing access for other patients and has been demonstrated in many hospitals where the model has been adopted.
Dr. Lalonde is rightly concerned that giving additional resources to hip fracture patients might impede access to care for other acute orthopaedic problems and this should not be permitted. Rather, it is the obligation of the hospital to provide appropriate resources for all patients requiring urgent surgical care — not just orthopaedic patients — and hospitals should be asked to review priority ratings in their operating room for the classification of surgical emergencies. Furthermore the allocation of dedicated fracture room time should be revisited to ensure that hip fracture patients are given the same consideration as other fracture patients in terms of priority. The practice of discharging ambulatory fracture patients from the emergency department and re-admitting them semi-electively into dedicated fracture room time has become widespread and may limit access for hip fracture patients — this obviously must be discouraged.
There are approximately 30,000 hip fractures a year in Canada. The purpose of establishing guidelines is to ensure that these patients receive appropriate care not just from orthopaedic surgeons, but also from everyone involved in their care, including hospital administrators who are responsible for ensuring adequate access to appropriate care for everyone who is admitted to the hospital for which they are responsible.
Reprinted with permission from the Summer 2011 issue of COA Bulletin
Viewpoint 1: Karl-André Lalonde
Benchmarks in Orthopaedic Care - Not Without Pitfalls
Over the last few years, timely access to care has become a problematic issue for Canadian orthopaedic patients. In an effort to address this problem, payers and health care administrators have adopted “access to care” parameters so that waiting times do not exceed certain established benchmarks. In most cases these benchmarks are based on available evidence and have been established by surgeons who have then lobbied health organizations to adopt them.
It is generally accepted that articulating benchmarks can help us in improving quality of care for our patients. The pitfalls arise when government payers dedicate so many resources to these targeted patients that they become detrimental to other orthopaedic patients.
Managed care risks removing some of the decision-making from clinicians and placing it in the hands of administrators. In Ontario, for example, hip fracture patients are now prioritized based on benchmarks: All hip fracture patients are to undergo surgery within 2 days of presentation to the emergency department. Hospitals are assessed based on their ability to meet this benchmark. In response to imperatives imposed by the benchmarks, hospital administrators mobilize their finite resources so that the hip fracture patients can get their surgery within the prescribed time frame.
Who's Setting the Clinical Priorities?
The result of such a measure can be that hip fracture care is expedited, but often at the expense of other non-elective patients with tibial plateau fractures, femur fractures, or upper extremity fractures for whom no benchmarks exist. The patients who are not prioritized are therefore pushed down the surgical wait list to allow the hip fracture patients to jump the queue.
Cannibalization of resources for a specific subgroup of patients may be good for this subgroup, but implementation has to be done with respect to the rest of our patients. On the elective orthopaedic side, the experience over the last few years has given us a first hand look on how devoting resources to hip and knee arthroplasty has led to relative neglect of the rest of the orthopaedic patients (spine, shoulder, foot and ankle). When used indiscriminately, hip fracture benchmarks may lead to similar problems with the rest of our fracture patients.
Managing resources can also be a challenge for on-call surgeons. When administrators prioritize a hip fracture, they sometimes fail to appreciate the other imperatives the clinician is facing.They may be unaware of the necrotizing fasciitis case in the ICU, the young patient with displaced femoral neck being transferred, or the subspecialty case that needs to be done by the specific surgeon on call. Achieving the benchmark becomes the only priority, and while it may often be desirable, clinicians need to retain the ability to manage the resources available and set their own clinical priorities.
Prioritizing patients within the orthopaedic service should always be the surgeons’ role; each patient is unique, and hospital managers and nursing coordinators will never have the understanding of the clinical subtleties that influence our decisions on a daily basis.
The issue is not really with benchmarks themselves, but with the implementation of such goals. These types of goals have to be used with consideration to the resources available and the clinical imperatives facing the orthopaedic service. Some discretion needs to remain with the clinician and we cannot allow administrators to dictate our clinical priorities.
Reprinted with permission from the Summer 2011 issue of COA Bulletin
Viewpoint 2: Hans J. Kreder
Barriers to the Implementation of Best Practice Benchmarks
In 2002, the Canadian Orthopaedic Association formed the National Standards Committee with a mandate to formulate evidence-based policy recommendations with respect to acceptable national standards related to the practice of orthopaedic surgery. This work led to reports that highlighted the need for more operating time and other institutional and human resources to meet the musculoskeletal care needs of the Canadian population. The committee’s suggested benchmarks for time to treatment were adopted widely by Provincial Health Ministries for total hip and total knee replacement surgery.
However, the incremental resources that were meant to accompany these benchmarks were inadequate, and those that were made available were inconsistently distributed across the country. Moreover, accountability for adherence to suggested benchmarks was generally delegated to hospital CEOs, with the result that orthopaedic clinical practice patterns and recruitment was in some cases determined by hospital leadership anxious to participate in government financial incentive total joint quota-based programs, with little or no input from the orthopaedic surgeons.
In 2008, the Bone and Joint Health Network was created in Ontario through the Ministry of Health and Long-term Care. Led by a panel that included orthopaedic surgeon representatives, the mandate of this Network was to operationalize efforts to improve the orthopaedic care of the population through implementation of evidence-based guidelines. One of the issues tackled by the Network involved optimizing the care of hip fracture patients.
The panel recommended that all patients with hip fractures should undergo surgery within 48 hours.1,6 Toolkits were developed to assist in the implementation of best practice regarding patient optimization for surgery (eg, how to manage patients on Plavix or anticoagulants), best surgical practice to allow immediate weight-bearing as tolerated, rehabilitation strategies, and the prevention and management of delirium, depression, and dementia.
Evidence-Based Benchmark Is Not the Problem
Hospitals throughout the province have been monitored regarding implementation of the 48-hour access to surgery benchmark. However, strategies to implement this benchmark have varied widely across the province. In some hospitals, hip fracture patients have been assigned more urgent surgical status (type 1B) to ensure that they will be done within the recommended timeline. Where resources for urgent cases are available outside of orthopaedic scheduled surgical time, this has allowed patients with hip fractures to access these resources in competition with other urgent surgical cases (ie, urgent neurosurgical, general surgery, and other cases). In some cases, hospitals have recently created incremental type 1B operating resources to process these urgent cases, including hip fractures.
Unfortunately, it appears that in other institutions, the orthopaedic surgeons are being asked to implement the 48-hour hip fracture benchmark by displacing scheduled orthopaedic cases, without being given access to any additional resources. This latter strategy obviously pits the welfare of unquestionably deserving patients with hip fracture against those of scheduled patients displaced by the implementation of the guideline.
The problem is not the evidence-based benchmark, but the implementation of this benchmark within a given institution or even a local community or LHIN. In fact, the LHINs as initially conceived would have been the ideal vehicle for the implementation of these benchmarks by working with the local community to ensure the appropriate distribution or redistribution of resources to meet the needs of the population being served. This might involve regionalizing care of certain groups of patients, such as those with hip fractures, into one or more LHIN institutions that were appropriately resourced to comprehensively address the surgical, rehabilitation, and secondary prevention needs of this patient group. Unfortunately this never did materialize, and this LHIN function has been devolved to individual hospital leadership. Consequently, broad system changes such as regionalization and policies regarding resource allocation remain fragmented and inconsistent.
Orthopaedic Surgeons Must Take Action
Ideally, resource allocation of beds, operating time, human resource requirements, and subspecialty training mix should all be determined by the needs of the population. I believe it is the duty of the orthopaedic community to continue to work on generating the evidence that forms the basis of decisions with respect to the national and local needs for human and other resources, acceptable times for access to care, optimal treatment, and the development of new and better health care models and systems. Using this information to generate evidence-based benchmarks or guidelines for maximum wait times seems a logical strategy that would be expected to improve patient outcomes through timely access to care, although I know of no systematic research that compares benchmarking to other potential strategies in terms of achieving the goal of improved access to care and patient outcomes.
Given that orthopaedic surgeons do not directly control most of the resources required to deal with the musculoskeletal (MSK) needs of Canadians, we must continue to partner with others. We need to involve the public to advocate for their MSK needs using the information that we provide. We need to continue working with the provincial ministries of health to educate them regarding the resources, and the policies that they need to enact to achieve our vision of a healthy population with lifelong mobility. To succeed, our message must be clearly focused on patients and their needs. Finally, within our own communities and institutions, orthopaedic surgeons must continue to provide leadership regarding the ultimate allocation and distribution of resources.
Reprinted with permission from the Summer 2011 issue of COA Bulletin
- Weller, I., Wei, E.K., Jaglal, S.: The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J. Bone Joint Surg. 2005;87b:361?366.
- Pickett W., Hartling, L., Brison, R.J.: A population based study of hospitalized injuries in Kingston,Ontario, identified via the Canadian Hospitals injury Reporting and Prevention Program. Chron. Dis. Can. 1997;18:61-9.
- Adunsky, A., Fleissig, Y., Levenkrohn, S., et al: A comparative study of mini-mental test, clock drawing task and cognitive-FIM in evaluating functional outcome of elderly hip fracture patients. Clin. Rehabil. 2002;16:414-419.
- Hoenig, H., Rubenstein, L.V., Sloane, E., et al. What is the role of timing in the surgical and rehabilitation care of community-dwelling older persons with acute hip fracture? Arch. Phys. Med. 1997;157:513-520.
- Zuckerman, J.D., Skovron, M.L., Koval, K.J., et al: Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J. Bone Joint Surg Am. 1995;77:1551--?1556.
- Scottish Intercollegiate Guidelines Network (SIGN): Prevention and management of hip fracture in older people: A national clinical guideline. 2002;56.