“VALUE” in Health Care Delivery

1. “VALUE” inHealth Care Delivery AAOS ETHICS COMMITTEE Paul Levin, MD 1

2. Objectives • Define “value” • Understand the ethical imperative of controlling health care spending • Learn the principles of evidence- based medicine (EBM) and shared decision making • Learn strategies to control cost and deliver quality care • Gain an understanding of the balance between patient autonomy and clinical decision making 2

3. Value “An assessment of the benefit of an intervention relative to the expenditure” 1 American College of Physicians (ACP) Clinical Guidelines Committee 3

4. Case 1 Ms. Izhar is a healthy 28-year-old woman who presents to Dr. Young’s office with a 10-day history of minor LBP associated with moderate right buttock pain, posterior thigh pain, lateral leg pain, and numbness and tingling along the lateral border of her foot. She is working full time in a New York iStockphoto/Thinkstock law firm. 4

5. Ms. Izhar works out five days a week in the gym. She has normal bladder and bowel function, and her PMH and ROS are completely normal. Despite her pain she continues to work 60 hours a week, and she has not altered her exercise regimen. She uses ibuprofen on occasion. iStockphoto/Thinkstock 5

6. . The physical examination demonstrates that Ms. Izhar appears uncomfortable while sitting in the chair in the consultation room and discussing her symptoms. She is able to stand up from a sitting position, walk without a limp, and walk on her toes and heels. The neurologic examination demonstrates decreased sensation in the S1 distribution and a diminished achilles reflex on the right leg. No weakness is identified in the lower extremities. The right SLR is positive as well as the contralateral SLR. 6

7. . Ms. Izharadvises Dr. Young that she really needs to know what the problem is. She adds that a senior partner in her firm had the same problem. An MRI was performed and physical therapy was prescribed. Ms. Izhar believes that she has to have an MRI because she would like iStockphoto/Thinkstock to keep exercising at the same intensity and would also like to continue working. 7

8. How should Dr. Young proceed with the care of Ms. Izhar?Are any ethical issues involved in the initial treatment recommendations?8

9. After he completes his initial evaluation of Ms. Izhar, Dr. Young sits down in his consultation room with her to discuss his findings. He explains that her history and physical findings are typical for lumbar radiculopathy. He assures her that the symptoms usually resolve spontaneously, and he advises observation and a continued activity level within tolerance of symptoms. 9

10. The patient is uncomfortable with this advice, and inquires if Dr. Young can be 100% sure. After attempting to assure the patient that he is confident in his diagnosis and recommendations, he agrees to obtain an x-ray and to order an MRI. Ms. Izhar undergoes a iStockphoto/Thinkstock lumbar spine x-ray which is completely normal. She is scheduled for an MRI so she can “know for sure” what is causing the problem. 10

11. Are Dr. Young’s initial recommendations consistent with current practice standards related to patient autonomy and shared decision making?What is the role of evidence-based medicine (EBM) in the management of Ms. Izhar’s condition?Explain how the four basic principals of modern biomedical ethics impact the management of Ms. Izhar’s condition. 11

12. Case concluded Ms. Izhar returns to the office one week later. Her symptoms have partially improved (8/10 to 5/10) and are well controlled with an occasional ibuprofen. She is working full time and exercising five days per week. Dr. Young re-examines Ms. Izhar. The exam is Paul Levin, MD unchanged with a markedly positive SLR on the right. The MRI demonstrates a large right-sided L5/S1 disc herniation. 12

13. . Dr. Young recommends that Ms. Izhar undergo an epidural steroid injection to help relieve her symptomatology. The patient reports that she is afraid to have needles placed in her spine and doesn’t want to undergo that procedure. She reports that recently she heard on the news that a number of people died after this procedure. 13

14. Is Dr. Young’s recommendation for an epidural steroid injection appropriate?Does Ms. Izhar’s reaction to the recommendation raise any ethical concerns? 14

15. Case 2 Mr. Cerutti is a 62-year-old gentleman with well-controlled HTN and a BMI of 33.3. He has a long history of bilateral knee pain secondary to OA. A few years ago x-rays demonstrated advanced osteoarthritis of the knees, and he was treated with visco-supplementation. Image Source/Thinkstock 15

16. These injections afforded three months of relief. He has had numerous cortisone injections, most recently three months ago, and reports two weeks of improved symptomatology. He reports constant pain, limited walking ability, and buckling episodes. He is consulting with Dr. Smithian about further treatment options. Mr. Cerutti reports that another orthopaedic surgeon recommended TKA, but he does not wish to undergo major surgery. 16

17. . Dr. Smithian examines Mr. Cerruti and obtains new x-rays. He explains to Mr. Cerutti that he has severe OA and discusses available treatment options. He recommends an MRI to determine if a torn meniscus is causing the current problems. Paul Levin Mr. Cerutti undergoes an MRI of both his knees that afternoon. 17

18. . The MRI’s demonstrate complex degenerate tears of the medial and lateral menisci in both knees. Dr. Smithian explains that he believes that some of Mr. Cerruti’s symptoms are from arthritis and some are from the torn menisci. He reports that in his experience patients like iStockphoto/Thinkstock Mr. Cerruti can benefit from knee arthroscopy and avoid TKA. He recommends bilateral arthroscopic surgery of the knees. 18

19. Do you believe that Dr. Smithian’s recommendations meet the three basic requirements of EBM?Are Dr. Smithian’s recommendations ethically sound?What competing ethical principals are involved in understanding the care of Mr. Cerrutti?19

20. Summary • The biomedical principal of justice obligates physicians to consider “value” in their evaluation and treatment of their patients. • The practice of evidence-based medicine incorporates the best available medical evidence, the surgeon’s personal experience, and patient preferences. 20

21. Maintaining value in health care obligates orthopaedic surgeons to adequately, appropriately, and objectively educate their patients. • Orthopaedic surgeons have an obligation to maintain professional integrity. Respecting a patient’s autonomy does not override this obligation nor does it require the physician to render all the care that the patient believes is necessary. 21

22. The successful practice of evidence-based medicine and value-based medicine requires that the surgeon develop appropriate communication skills and have a complete understanding of the principals of shared decision making. 22

23. Recommendations • Establish personal professional practices that allow you to remain current and knowledgeable of AAOS and other professional clinical practice guidelines and appropriate use criteria. • Integrate the concept of value-based medicine in your practice while adhering to the four basic biomedical principals of autonomy, beneficence, non-maleficence, and justice. 23

24. Maintain an ongoing critical analysis of your professional practice and regularly reassess your patient care approach and recommendations. • Examine and refine your communication skills and ambulatory office practice style using available educational resources in a fashion similar to utilizing CME to maintain your operative skills. 24

25. References • 1Owens DK, Qaseem A, Chou R, Shekelle P: High-value, cost-conscious health care: Concepts for clinicians to evaluate the benefits, harms and costs for medical interventions. Ann Intern Med 2011;154(3):174-180. • 2Young P, Olsen L, McGinnis J: Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes and Innovation; Workshop Summary; Institute of Medicine Roundtable on Evidence-Based Medicine. Washington, DC, The National Academies Press, 2010. • 3Brett AS and McCullough LB: Addressing requests by patients for nonbeneficial interventions. JAMA 2012;307(2):149-150. • 4Lantos J, Matlock AM, Wendler D: Clinician Integrity and Limits to Patient Autonomy. JAMA 2011; • 305(5):495-499. • 25

26. Oshima Lee E and Emanuel EJ: Shared decision making to improve care and reduce costs. N Engl J Med 2013;368:6-8. Beauchamp T and Childress J: Principles of Biomedical Ethics, ed 6. New York, NY, Oxford University Press, 2009. Chou R, Qaseem A, Snow V, Casey D, Cross J, Shekelle P, Owens D: Diagnosis and treatment of low back pain: A Joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern MedOctober 2007;147(7):478-491. (Contains the American College of Physicians, American Pain Society and American Academy of Orthopaedic Surgeons guidelines for initial evaluation and treatment of acute low back pain) http://annals.org/article.aspx?articleid=736814 Fenton JJ, Jerant AF, Bertakis KD and Franks P: The cost of satisfaction. A national study of patient satisfaction, health care utilization, expenditures and mortality. Arch Intern Med 2012; 172(5): 405-411. 26

27. Levin PE: Professionalism and Ethics in Orthopaedic Surgery, Orthopaedic Knowledge Update (OKU) 11, 2013. Under publication. Lo B: Resolving Ethical Dilemmas – A Guide for Clinicians, ed 4. Philadelphia, PA, Lippincott Williams & Wilkens, 2009. Reuben DB and Cassel CK: Physician stewardship of health care in an era of finite resources. JAMA 2011;306(4):430-431. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS: Evidence based medicine: What it is and what it isn’t. BMJ 1996;312(7023):71-72. Straus SE and Sackett DL: Using research findings in clinical practice. BMJ 1998;317(7154):339-342. 27

28. American Academy of Orthopaedic Surgeons: Code of Ethics and Professionalism for Orthopaedic Surgeons, I.A., I.F., IV.A. Adopted October 1988, revised 2011. http://www.aaos.org/about/papers/ethics/code.asp Council on Ethical and Judicial Affairs: Code of Medical Ethics, Opinions 2.09. Chicago, IL, American Medical Association, ed 2012 – 2013. 28