Outcomes-based evaluations of our patients: A challenge for us all
MBChB(UCT), MMed(Orth), FCS(SA)Orth President: SA Orthopaedic Association
I think we would all agree that Orthopaedics is an extremely rewarding specialty, which often returns patients to a greatly improved quality of life and productive lifestyle. Huge advances have been made over the past years, which have enabled us to treat an increasing range of conditions more effectively, with reduced complications and a quicker return to function.
However we are faced with a significant increase in the cost of providing this service, a more informed and demanding patient population and an exponential increase in medical litigation, which further drives up the provider costs. On the other side of the equation, funders are under increasing pressure to contain costs and we are frequently being informed that the present practice of medicine is becoming unaffordable.1
Michael Porter, a health economist from the Harvard Business School, defined value in health care as the health outcome achieved per dollar spent.2 Over recent years a lot has been written about the definition of health care and what tools would be most appropriate to measure this outcome. There is no doubt that we need risk-adjusted patient-specific models and validated outcomes measures. The lack of reliable cost information remains a problem.3
One thing that has impressed me so far on my travels to our sister organisations, is how far they have progressed down the road of outcomes assessment, how much it is integrated into their practices and how far we have fallen behind in this regard. You only have to look at the programme for the forth-coming COMOC congress and our international journals to see this growing international trend.
I have no doubt that the vast majority of us practise cost-effective medicine with appropriate indications and patient-centred care. However, and I include myself when I say this, we may overstate our successes and understate our complications without some objective measurement of our work. The implementation of outcomes measurements into our practices obviously adds time and expense to our already busy schedules. This is but one of the many challenges associated with this introduction. There are legal and regulatory challenges and the question of funding of the registries is another. However, unless we are able to critically evaluate our results objectively and compare them with our peers both locally and internationally, we won't know how effective we really are. The whole process should lead to better patient outcomes, which must be our primary goal.
It is obviously not practical at this time to evaluate all surgical procedures in this way. I would therefore like to make a plea that we all start by contributing data to the National Joint Registry. As with any registry, it becomes more accurate when more events are captured. The Knee Society and Shoulder Society are probably going to roll out software for outcomes studies appropriate to their areas, through the Surgical Outcomes Solutions programme. There are additional modules, which pertain to our other special interest groups and if the roll-out is beneficial to the membership, the South African Orthopaedic Association will consider partnering in the extension of this.
While the primary reason for engaging in this exercise should be to objectively assess our patient outcomes and thereby improve our management, we may in the foreseeable future have to justify our expertise to the funders in an increasingly competitive environment. We would then need data to justify our position. One can already see a trend of linking funding to improved patient outcomes. Whether we are in private or State practice, the central tenets of outcomes measurement still apply, as does practising cost-effective medicine.
There are many challenges involved in implementing outcomes-based evaluations into our practices; however, I don't foresee that we are going to be able to avoid it. I think it is something to which we will have to give increasing attention. We should take the initiative in introducing systems which are beneficial to our practices and patients.
1. Lansky D, Milstein A. Quality measurement in orthopaedics. Clin Orthop Relat Res. 2009;467:2548-55. [ Links ]
2. Porter M. What is value in health care? N Engl J Med 2010;363:2477-81. [ Links ]
3. Andrawis JP, Chenok KE, Bozic KJ. Health policy implications of outcomes measurement in orthopaedics. Clin Orthop Relat Res. 2013;471:3475-81. [ Links ]