Three Reasons Surgeons Make Poor Decisions // New Study: Academic Medical Centers Discriminate Against Medicaid Patients // and More!

Three Reasons Surgeons Make Poor Decisions

James G. Wright, M.D., M.P.H., surgeon-in-chief at the Hospital for Sick Children in Toronto, is responsible for six surgical divisions. He has had ample opportunity to study and closely observe how surgeons come to a decision. His conclusion? There is a lot happening at the subconscious level. Dr. Wright, an orthopedic surgeon, tells OTW, “Most of us assume that because we are doing evidence-based medicine that the evidence will actually be used. This is not necessarily so, however, because the surgeon’s decision making process intervenes.”

“There appear to be three issues which come to bear when surgeons are trying to make a decision. The first is that surgeons come to relatively firm decisions and aren’t good at integrating new information. We are rather entrenched in our ways of thinking and despite new information/variations on what we know, we have trouble changing mindsets. Let’s say someone comes up with a great answer to an issue—something that should solve a controversy. The researcher publishes his or her work and promotes it through talks. We still see a slow uptake in the actual use of that information. I am pleased with what we are doing with evidence based orthopedics, but I don’t think we have considered the logical outplay of that, which is behavior change.”

“The second issue involves decision making at work. We did a ‘secret shopper’ study where we sent blinded total knee replacement patients into surgeons and family physicians’ offices. The result? Both types of doctors were more likely to recommend knee replacement to men than to women. The most likely explanation is that doctors form unconscious biases. When we asked these physicians if they treat men and women differently, they answered ‘No!’ But we know from employment research that when people go to job interviews those who are tall, more physically attractive, etc., fare better. These ubiquitous biases subtly influence behavior…and this is highly underappreciated.”

“The unconscious thought process likely went something like this: ‘Women come to arthroplasty later in the course of the disease and people who have arthroplasty later don’t bounce back to normal.’ Surely doctors would prefer having someone come in saying, ‘I feel fantastic’ versus, ‘I’m not sure that surgery helped so much.’”

“The third issue involves ‘confirmation bias’ wherein people grasp onto information that substantiates their views and discount any evidence that isn’t consistent with their views. For example, we looked at two forms of spinal instrumentation for idiopathic scoliosis. The surgeons had an explicit preference for one form of instrumentation (both before and after the trial). Afterwards we found no difference between the two forms of instrumentation in any aspect of what we thought should be affecting surgeons’ decision making. The surgeons found many reasons to discount the information we shared with them and persisted in using the instrumentation despite the neutral finding.”

“In another study we surveyed orthopedic surgeons and asked, ‘How do you make decisions involving a total knee surgery?’ We found a significant difference between the surgeons; when we repeated the survey 10 years later we found no difference in the variations in opinions of orthopedic surgeons. The upshot is that they actually disagreed with themselves!”

“We really need strategies to minimize these variations. On the grand horizon is the issue of behavior change. For that, we will be working with psychologists.”

Study: Academic Medical Centers Put Medicaid Patients Behind Private Pay Patients

Does it matter how crowded of an area a Medicaid patient lives in? Does the service they are rendered differ if they are near an academic medical center? Reid Draeger, M.D. and colleagues set out to find answers to these questions. Dr. Draeger, an assistant professor at the University of North Carolina Chapel Hill School of Medicine, told OTW, “We conducted a series of research projects on this topic. Initially we looked at whether an appointment was offered to Medicaid versus privately-insured patients for acute rotator cuff tears, acute lumbar disk herniations, and flexor tendon lacerations. We found that Medicaid patients were less likely to get a timely appointment than privately insured patients for these scenarios.”

“In our latest study, just published in the Journal of Bone and Joint Surgery, we wanted to see the effect of geography and population density on whether or not a Medicaid patient was offered an outpatient orthopedic appointment. Our state, North Carolina, is similar in population density to many other states; there are only a couple of academic medical centers and they are in high population density areas. Using the ‘secret shopper’ model from previous studies by our group, we called 203 orthopedic practices to see whether or not they would offer an appointment to a hypothetical patient using various patient scenarios—acute flexor tendon lacerations, acute rotator cuff tears, and acute lumbar disk herniations. We found that 119 practices offered the Medicaid patient an appointment within two weeks, and 160 offered the privately-insured patient an appointment within that same time period.”

“Patients with Medicaid were more likely to get an appointment if they were further away from an academic medical center or in a less-populated area. This result is in line with the literature coming out of the primary care field, but at odds with limited data that has been published in surgical subspecialty fields. We’re not entirely sure why we got this result, but we hypothesize that around these densely populated areas (where academic medical centers are located) there are more patients vying for appointments. So perhaps, the clinics can have stricter insurance profile guidelines as to whom they accept.”

“We were expecting the converse, i.e., that clinics further away from densely populated areas would have less expertise to care for some of these problems and would refer them to academic medical centers. There is likely an ethical issue here: are you going to make a patient drive four hours for something that could be done in their neighborhood simply based on insurance status?”

“Going forward we would like to look at this issue after the full implementation of the Affordable Care Act and compare our current results to those obtained in a similar fashion in five years. That would allow us to see if the patterns of appointment offerings change. My guess is that with a much larger patient volume being insured by Medicaid through its expansion by the Affordable Care Act, more practices will offer Medicaid patients appointments in the future.”

“Studies like ours are important to hopefully help to establish baseline data on access to orthopedic care for Medicaid patients. These data could be used on a policy level to help ensure that future policies do not further impede access to orthopedic care for these patients.”

Most New Devices Not Better After All?

In reviewing 118 studies and 15, 384 implants, researchers from the Netherlands found that none of five new devices reviewed improved functional or patient reported outcomes and that existing devices may be safer to use. What are we doing wrong as a field? Marc Nieuwenhuijse, M.D., an orthopedic resident at the Leiden University Medical Center and ICOR research fellow, tells OTW, “Changes in the way of introduction of new orthopedic implants into the commercial market are necessary. The introduction of new orthopedic implants and related technologies has been the focus of major scientific and policy discussions since the failures of articular surface replacement and large head size metal-on-metal articulations in total hip replacement were brought to light. However, scientists and policy makers seem to ‘run out of steam, ’ and the momentum for change generated by these recent high profile failures is waning.”

“The consequences of uncontrolled device introduction worldwide may not be fully recognized by the scientific community and there is a high likelihood that current practice regarding device innovations will not change much. As such, there is a need to investigate whether the problems associated with the articular surface replacement and large head size metal-on-metal articulation are isolated events or if there is a systemic problem affecting the introduction of a much wider range of implantable devices.”

“In this study, we evaluate the evidence concerning the introduction of five substantial, innovative, relatively recent, and already widely implemented device technologies used in major total joint replacement to determine the evidence of effectiveness and safety for introduction of five recent and ostensibly high value implantable devices in major joint replacement to illustrate the need for change and inform guidance on evidence-based introduction of new implants into healthcare.”

“I was surprised at the widespread usage of these innovations without either substantial research or convincing evidence of their benefit over existing alternative device solutions for the same conditions. Recent large scale failures of the articular surface replacement and large head size metal-on-metal articulations in total hip replacement have taught us that incremental device innovations can have a large impact on implant survival and patient safety. Since none of the five selected device innovations were safer than earlier alternative devices, we believe improved regulation and professional society oversight are necessary to prevent patients from being further exposed to these and future innovations introduced without proper evidence of improved clinical efficacy and safety. The clinical introduction of implants should follow a stepwise and controlled model preventing exposure of large numbers of patients to potentially inferior new devices.”

“Improved regulation and professional society oversight are necessary to prevent adverse events. We need to find a balance between being too careful and waiting until all of the results are available. The way to do this would be to focus our research on new methods for early evaluation of implant performance. For example, I did research on radiostereometry that allowed for measurement with a high degree of accuracy (to a few tenths of a millimeter). This has predictive value for future loosening of implants. Additionally, improved surveillance through the International Consortium of Orthopedic Registries should be undertaken. Their goal of combining all registries worldwide would lead to more accurate information. For now, we suggest adherence to the IDEAL recommendations and a critical point of view regarding evidence for efficacy and safety when considering adopting new implants.”