November 16, 2021
3 min read
November 16, 2021
3 min read
Romeo reports receiving royalties from, being on the speakers bureau and a consultant for, and doing contracted research for Arthrex.
Symptomatic osteoarthritis of the knee affects more than 14 million people in the United States, with more than half younger than 65 years. Orthopedic surgeons sit at the crossroads of nonoperative vs. operative treatment.
While technology and surgical education for knee replacement advances, an ageing population has increased the demand for knee replacement surgery. Evidence-based nonsurgical treatment should be offered to patients who present with knee OA, reserving knee replacement for patients who fail a well-designed nonoperative care program.
The American Academy of Orthopaedic Surgeons recently released a new clinical practice guideline (CPG) on the non-arthroplasty management of OA of the knee. The methodology for developing the guidelines was based on the Institute of Medicine standards and includes careful selection of experts representing various society memberships and other stakeholders, including representatives from non-orthopedic disciplines.
There remain some concerns with regard to the selection process, particularly when recognized experts have conflicts of interests. However, a formal management process mitigates potential bias, and every step is focused on analyzing and making group decisions based on the systematic review of the best information available. Hierarchy of evidence plays a role with level 1 studies receiving the highest consideration, although recommendations based on limited available information could lead to limited strength of a group consensus statement.
The CPG development process is transparent and open to third-party review. Despite the resources that went into the AAOS CPG program, some orthopedic surgeons do not formally incorporate CPGs into daily practice.
The CPG for non-arthroplasty treatment of OA of the knee is a valuable tool to create algorithms to manage one of the most common reasons patients seek orthopedic care. With the migration toward value-based care models with vertical integration of the management of specific diagnoses or episodes of care, the CPG forms the foundation for the algorithm to determine essential tools, such as specific radiographic studies, hierarchy of nonoperative treatment modalities and the threshold for surgical care.
Orthopedic surgeons should see the CPG as a reference to improve the consistency and value of care. When challenges or decisions arise that are not addressed in the 29 recommendations, opportunities for clinical trials and outcomes research should be recognized.
Significant effort is required to incorporate CPGs into the daily routine of providers as well as to implement methods that incentivize compliance among providers. Individual, experience-based or opinion-based decision-making is widely practiced in any group that does not have an administrative process in place to define best evidence-based practice. The process needs to have physician engagement and a strong guide for behavior modification, including incentives and consequences related to incorporating the guidelines into daily practice.
The resistance to understanding and incorporating CPGs into clinical practice is being eliminated with information management technology. OrthoGuidelines is a web-based app developed by AAOS that supports the use of CPGs in daily practice. Current CPGs also can be incorporated into EMR systems, therefore, actively guiding providers through the decisions needed to provide the best evidence-based care.
Challenges will remain with recommendations with limited evidence or low quality studies, such as platelet rich plasma, laser treatment and extended cryotherapy. However, the framework of a well-defined clinical care pathway creates a well-structured opportunity to study outcomes and improve the understanding of value of care.
CPGs can theoretically empower orthopedic surgeons to improve evidence-based care of common conditions. However, moving from theory to practice has met tremendous resistance due to the added burden on physician workflow and patient management.
Orthopedic surgeons should embrace CPGs and continue to develop more guidelines to help guide evidence-based care. With the increasing reliance and sophistication of EMR systems, CPGs can be incorporated into the daily practice of orthopedic surgeons. Physicians, administrators and payers will be increasingly dedicated to evidence-based CPGs built into the decision algorithms for disease conditions to prevent variation in care, support higher quality outcomes while reducing the overall cost of care.