"one of the worst offenders" orthopedic surgery overuse . . .

Orthopedists' Financial Conflicts Can Hurt Patients, Surgeon Says

Cheryl Clark, for HealthLeaders Media , March 17, 2015  FiDA highlight added

It is financially compelling for many doctors to do things that aren't really going to help their patients, says an orthopedist who is leading a campaign against surgical overuse.

Financial conflicts of interest often drive physicians to perform worthless surgeries, but the field of orthopedics "is one of the worst offenders," says an Indiana orthopedist who has launched a "moral persuasion" campaign to persuade his colleagues to stop.

"It's really hard for doctors to acknowledge this and change their ways," says James Rickert, MD, who years ago founded the Society for Patient Centered Orthopedic Surgery to address the problem.

It's especially tough for doctors who own related businesses that depend on surgical volume, which puts even more pressure on them to "be more like businessmen instead of doctors," he says.

A lot of orthopedic surgeons "own part of the distributorships that sell the total hip or knee implants to the hospital, and they'll make a ton of money on that. Or they own the imaging center they send their patients to. They own a piece of the surgical center. They know if they're not doing a lot of surgery, they may lose money on their overhead," Rickert says.

A series of four reports from the Government Accountability Office documents greater numbers of procedures referred by physicians who own providing businesses, compared to referrals from non-owners.

"That makes it really compelling for doctors to do things that aren't really going to help their patients. They become more like salesmen, saying things like, 'Well, it might help.' Or, 'We don't have much to lose, let's try it,' knowing full well the data shows there's very little chance the procedure will help and some evidence the patient could be hurt."

Rickert has long been aware of surgical overuse, including his own. But he didn't work hard to stop it until he himself got sick. He was diagnosed with non-Hodgkin Lymphoma at age 42, underwent chemotherapy, bone marrow, and stem cell transplants, recurrences, and foul-ups in his care. Now 54, he's been cancer free for five years. 

"I was accessing the system every day for months as a very sick person, having a lot of problems. I started to think about patient-centered care expectations and how different that is from reality."

As he got better and returned to his Bloomington practice, he founded the society to appeal to surgeons' consciences. So far, 14 fellow orthopedists have joined his effort.

Performing unnecessary surgeries, he says, "is not [necessarily] below the standard of care. For example, the doctor can usually say, 'Hey, he had a torn medial meniscus and here's an MRI that proves it,' even though it was not the right thing for a severely arthritic patient."

"I certainly have a lot of patients referred to me from nearby. And when I look at the surgery and pathology they had, I just know that there was no way that doctor really thought that was going to help them."

At the Lown Institute conference in San Diego last week Rickert described one of many sad cases. Two decades after performing a successful knee scope on a patient, the now severely arthritic patient returned, seeking another scope. Rickert advised that it would not help and could cause problems.

The patient went to another orthopedist and had the procedure. This surgeon thought the worst that would happen would be the patient wouldn't be any better, but would at least be satisfied that the doctor had tried to help. "Instead, the patient gets a deep vein thrombosis that turns into a pulmonary embolism, and two days later he's dead," Rickert says.   

For doctors, it's like an inside secret, he says. "We know about these risks, but the patients don't."

Rickert and some of his colleagues also criticize the American Academy of Orthopedic Surgeons' Choosing Wisely list of five procedures doctors and patients should avoid. None on the academy's current list is especially common or very important, Rickert says. 

Kevin Bozic, MD, chair of the AAOS Council on Research and Quality, said via email that the Choosing Wisely list was created from systematic reviews of the literature and is limited to available evidence that various treatment options for musculoskeletal conditions are effective, "which we are seeking to improve." AAOS is working to define appropriateness criteria incorporating patient preferences and values into medical decision-making, he said. Since it submitted its list of five practice guidelines in 2012, AAOS has published four more to be reviewed for possible inclusion in a second Choosing Wisely list.

At the conference, Rickert and Rob Rutherford, MD, an orthopedic surgeon from Coeur d'Alene, ID, presented what they say is a more relevant list of procedures that are frequently performed, usually unnecessary, high cost, and sometimes harmful:

1. Vertebroplasty
Cost: $10,000 

The percutaneous injection of cement into a fractured vertebra. The procedure, done in about 100,000 patients a year, is falsely marketed as relieving pain quickly. But in clinical trials, pain relief was similar to that seen in patients who underwent sham surgery. The procedure's risks include compression fractures in adjacent vertebrae, dural tears, infections, cement migration, and nerve pain that requires subsequent surgery.

2. Rotator Cuff Repairs in Elderly Patients

Cost: $15,000

About 600,000 such surgeries are performed in the U.S. each year. The number of surgeries increased by 141% between 1996 and 2006. This surgery is vastly overused on patients who are asymptomatic. Complications include infection, bleeding, re-rupture of the rotator cuff, nerve damage, blood clots, and the need for repeat surgery to correct the first procedure.

3. Clavicle fracture repair or "plating" in adolescents
Cost: $13,000
This procedure is performed in a small percentage of adolescents each year to improve function. "I don't know of any good indication, especially with conservative care being so successful" and rarely does the surgery benefit, Rickert says.  

Regardless of patient age, type of sport, and final clavicle shortening, there's no differences in pain, strength, or range of motion. But there is a risk of deep infections, pneumothorax, and other complications. 

4. Anterior Cruciate Ligament Tear Repair in Low-Risk individuals
Cost: $10,000
ACL surgeries are performed in 100,000 patients a year and carry high risks but demonstrate no difference in rates of return to pivoting-activity sports one year later than conservative rehabilitation and activity modification. Complications include infection, instability, stiffness, pain, patellar fracture and growth plate injury in children.

5. Surgical Removal of Part of a Torn Meniscus 

Cost: $6,000
Annually, this surgery is performed in 700,000 patients with knee arthritis and no mechanical symptoms. But it does not provide significant benefit compared with sham surgery in patients with degenerative meniscal tears. There's equal pain relief and functional status.

Rickert, who is on the faculty of the Indiana University School of Medicine, emphasizes that IU Health has a policy forbidding its doctors from accepting money or gifts from the pharmaceutical or medical device industries.

He says his specific orthopedic group does not own an MRI or an orthopedic surgery center. And he acknowledges that he gets "e-mails and grouchy comments from doctors [at other organizations] who want me to not do this [campaign]."  

"There's still a lot of resistance from entrenched interests. But we have to show doctors the data, studies that show this doesn't work, and then ask, 'why are we still doing this?' We have to confront them with the data."

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists. 

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