Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Kevin J. Bozic, MD, MBA*,
Department of Orthopaedic Surgery and the Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California
Posted February 2007
The article, "Antibiotic Dosing
Before Primary Hip and Knee Replacement as a Pay-for-Performance Measure," by
Bhattacharyya and Hooper, addresses a timely and important issue in orthopaedic
health care delivery. Health care costs in the United States continue to rise
at an unsustainable rate. Yet despite per capita health care expenditures that
are 30% to 70% higher than in any other industrialized nation, there is
surprisingly little evidence that the additional money spent on health care in
the United States has resulted in corresponding improvements in the health or
quality of life of Americans. The number of uninsured and underinsured Americans
continues to grow at an alarming rate; according to a report from the Institute
of Medicine, only 55% of Americans receive accepted standards of care as
dictated by evidenced-based practice guidelines1. These trends have led to
growing demand among health care purchasers (both large and small employers,
the government, and taxpayers) for increased accountability in health care.
One of the fundamental criticisms
of the United States health care system is the fact that provider-reimbursement systems
are "quality blind," in that payment is based on the volume and intensity of
services provided, with no consideration for the quality, efficiency, or
cost-effectiveness of those services. Value-based purchasing describes a series
of health policy reforms initiated by health care purchasers to use their
purchasing clout to require more transparency and better value, based on some
measures of quality and efficiency, for the money they spend on health care.
Pay-for-performance (P4P) is one such health care policy reform that seeks to
link provider payment to measures of performance, with the overall goal of
improving quality and efficiency in the health care system.
Although the benefits of
restructuring provider reimbursement systems to incentivize and reward quality
and efficiency rather than volume are intuitive and obvious, the implementation
of such a dramatic paradigm shift in health care payment policy is fraught with
challenges. Those challenges include the difficulty in defining and measuring
quality and efficiency, the cost of collecting and analyzing performance data, the
need to develop and implement appropriate risk-adjustment models, the lack of
additional funding to reward quality, and the unintended consequences of
provider "gaming" and patient deselection (e.g., "cherry-picking") and the subsequent
impact on low-tier, low-quality providers. Although P4P systems have rapidly
gained widespread acceptance and use in primary care and preventative medicine
disciplines, acute care specialties such as orthopaedics face additional
challenges in measuring and rewarding quality and implementing P4P programs.
The study by Bhattacharyya and
Hooper addresses one of the commonly used process measures used in P4P
programs, that of administration of intravenous antibiotics within one hour before
a surgical incision. As noted by the authors, there is ample level-I evidence
supporting the use of prophylactic antibiotics in patients who undergo total
joint arthroplasty. Despite this evidence, the authors found that 13% of
patients at their institution did not receive antibiotic prophylaxis during the
recommended window of time.
A strength of this study is that
the authors attempted to identify process of care factors, including patient
factors (age, gender, and medical comorbidities), provider factors (surgeon,
surgeon volume, anesthesiologist, and anesthesiologist volume), and procedure
factors (procedure type, time of day, anesthesia induction time, surgical time,
operating-room personnel, and type of antibiotic delivered), that were
associated with lack of compliance with accepted guidelines for antibiotic prophylaxis.
One of the benefits of analyzing and reporting process measures is that they
provide feedback regarding processes of care that can theoretically be modified
in order to enhance compliance with evidenced-based treatment guidelines.
Unfortunately, due to the relatively small number of cases reviewed at a single
institution, only three of the processes factors (procedure type, anesthesia
induction time, and surgeon volume) were found to be correlated with suboptimal
antibiotic dosing. This may represent a type-2 error, which is a limitation of
the study. Another limitation related to the small number of cases studied is
the inability to correlate the process measure—appropriate administration of
antibiotic prophylaxis—with the outcome measure of interest, which is
infection. Outcome measures, such as infection, are considered by many health-policy
experts to be more clinically relevant as performance measures than as process
measures. However, outcome measures are more difficult to employ in P4P programs
due to inherent difficulties in measuring outcomes, problems with risk
adjustment, and the long lag time that often exists between the intervention
and the outcome of interest.
Another important finding of this
study is that institutions and surgeons who treat less medically complex
patients, which was the case with the higher-volume surgeons in this study, are
often more likely to be rewarded by P4P programs. This is a common concern
regarding P4P programs, given the impact that these programs might have on
patient deselection (e.g., "cherry-picking"), which could have implications for
access to care for patients with more complex medical disorders. It should be
noted that the authors did not address the issue of surgical complexity, since
revision total joint replacement procedures were excluded from the study. Also,
the finding that higher-volume surgeons who treat less medically complex
patients have better compliance with recommended treatment guidelines might be
confounded by other factors, such as more well-developed treatment protocols,
since the mean Charlson comorbidity index was not significantly different
between patients who did or did not receive optimal prophylactic antibiotic
dosing.
One final point brought up by the
authors is that poor documentation may have contributed to the high rate of noncompliance
with recommended treatment guidelines. As the authors point out, proper
documentation has become increasingly important in the P4P era, and there are
no concessions made by payers for inadequate documentation.
Overall, this study provides
important information for providers and payers on a commonly used performance
measure for a common surgical procedure. Further study is needed to assess (1) the
generalizability of these findings to the larger population of patients who
undergo total joint replacement at both high-volume and low-volume institutions
by both high-volume and low-volume surgeons, and (2) the association (if any) between
adherence to recommended antibiotic prophylactic treatment guidelines and the
rate of infection following total joint replacement procedures.
*The author did not receive any
outside funding or grants in support of his research for or preparation of this
work. Neither he nor a member of his immediate family received payments or
other benefits or a commitment or agreement to provide such benefits from a
commercial entity. No commercial entity paid or directed, or agreed to pay or
direct, any benefits to any research fund, foundation, division, center,
clinical practice, or other charitable or nonprofit organization with which the
author, or a member of his immediate family, is affiliated or associated.
References
1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.
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