July 1996 Bulletin

Across the President's Desk

We can make a difference in the future

As I sit here writing this column it's hard to believe that the first quarter of the Academy year has come and gone so quickly. There is so much going on in virtually every area of Academy activity that it is truly difficult to choose what to highlight. I have decided to summarize current initiatives which address the four areas that were singled out in my First Vice Presidential address where I believe we have an opportunity to make a difference - education, accountability, public education/advocacy, and influencing the future of musculoskeletal health care. While some of these initiatives are new and are still being developed, implementation should be underway by September.


In addition to continuing the many ongoing, outstanding educational offerings, several new initiatives include a commitment to proceed with limited expansion of the Orthopaedic Learning Center (OLC), the completion of the first interactive electronic orthopaedic CME program ("The Athlete's Knee"), and several new publications which are being developed.

Even though the OLC is a state-of-the-art surgical skills facility, and Academy surgical skills courses at the OLC have been well-received and educationally have been very successful, current OLC facilities outside of the laboratory itself are cramped, to say the least. To address these problems as soon as possible, the Board of Directors has approved an expansion of the OLC, which will add a multipurpose room suitable for didactic and interactive sessions and a separate lab for computer- assisted learning.

These changes will ease the acute problems being encountered in our current courses, but are perceived as short-term measures. To better develop and analyze our longer-term options for the OLC, a work group, chaired by Second Vice President Jim Heckman, MD, has been appointed and will be reporting to the Board in September. Throughout these deliberations we have been and will continue to be in close communication with our OLC partner, the Arthroscopy Association of North America, and with the OLC Board of Directors.

The next innovation of the Academy's electronic line is the soon-to-be-released interactive multimedia program, "The Athlete's Knee." This program was demonstrated at our recent Board of Directors meeting and is an exciting and powerful tool for individual education.

New Academy publications projects recently proposed by the Committee on Publications and approved by the Council on Education include Selected Scientific Exhibits to consist of abstracts accompanying radiographs and other illustrations from selected scientific exhibits displayed at the 1996 Academy's Annual Meeting; Osteonecrosis, to be based on an upcoming American Orthopaedic Association workshop chaired by James Urbaniak, MD, to be held in November; and Selected Bibliography of the Shoulder and Elbow, proposed by the American Shoulder and Elbow Surgeons.


The Academy is developing three major programs to assist its members in providing meaningful documentation of the quality and cost-effectiveness of services we provide - outcomes, guidelines, and cost-effectiveness studies.

The four generic outcomes instruments developed by the Academy and many of the COMSS specialty societies are in the final testing phase (sensitivity testing) and are available for use in draft form. The second phase of our outcomes data management development program is being overseen by a task force chaired by Joseph Buckwalter, MD. The number of participating practices is being increased from the 54 who participated in last year's pilot study to as many as 800. General and focused outcomes assessment will be conducted, and we will test our ability to also collect cost and utilization data on the same patients. There has been a tremendous response from practice groups all around the country who want to get involved in the program.

After reviewing the recommendations from the Oversight Committee on Guidelines and the Council on Research and Scientific Affairs, the Board of Directors has just approved the Phase I and Phase II Algorithms on Low Back Pain for limited-use testing and publication in Spine. These algorithms have undergone extensive peer review by the Board of Councilors, members of COMSS and a number of other medical specialty organizations. The revised Phase I ankle injury algorithm and the Phase II knee pain algorithm are ready to undergo peer review and are being forwarded to the Board of Councilors, COMSS, and other appropriate medical specialty organizations.

Our initial cost-effectiveness study, carried out by Loyola University, has been submitted for peer-reviewed publication. The primary conclusion from this study was that for specific diagnoses treated by both primary care physicians and orthopaedic surgeons, the earlier the patients were referred for orthopaedic care the lower the overall cost for that episode of care. Contracts recently have been signed for two additional cost-effectiveness studies to be performed at The Brigham and Women's Hospital in Boston and the Mayo Clinic. Once our Outcomes Data Management System has been shown to be capable of linking quality and costs in individual episodes of care, we will be able to initiate even better prospective cost-effectiveness studies.

Public education, advocacy

We believe our ongoing efforts to educate the public and health policy makers, and to influence legislation and regulatory agencies through the Patient Access to Specialty Care Coalition in Washington, D.C. have provided our views and issues wide exposure and credibility, and we are still vigorously pursuing these initiatives. At the same time we believe that we need to access the outcomes and value of our existing programs and determine whether we need to consider making any changes in our messages or the vehicles being employed to deliver them. A Task Force of the Council on Health Policy and Practice, chaired by Alan Morris, MD, has been appointed to carry out this assessment and will be reporting its findings and recommendations to the Board of Directors in September.

Since private sector forces have had increasing impact on health care delivery and our ability to provide quality care to our patients, it was clear that we needed to refocus and enhance our efforts in regard to managed care, the dominant player in the private sector health care marketplace. Last year's Work Group on the Role of Orthopaedic Surgeons in Future Delivery Systems for Musculoskeletal Care, chaired by First Vice President Doug Jackson, MD, recommended that the Council on Health Policy and Practice develop and implement a plan for private-sector tracking, analysis, education, and communication. A detailed plan has been developed by the Committee on Health Care Delivery of the Council on Health Policy and Practice, and reviewed by the Board of Directors. Now being implemented, the plan includes studying open panel managed care programs which addresses the Resolution passed by the fellowship in Atlanta.

Influence the future

Our internal and external bridge building efforts, initiated last year under the leadership of Jim Strickland, MD, are continuing to move forward with encouraging early progress. Our efforts to reach out to other organizations that represent physicians who provide musculoskeletal health care has progressed to the point where a steering committee has been formed with high-level representation from the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Academy of Physical Medicine and Rehabilitation, in addition to the Academy. The steering committee had its first meeting in early April and reached consensus on the initial areas of focus for joint effort. These include education of musculoskeletal caregivers, outcomes, guidelines, and education for the public and physicians. Specific action plans for joint activity are being developed for each of these initiatives.

Internal bridge-building to address educational issues within orthopaedics is also progressing well. Representatives of the American Board of Orthopaedic Surgery, the Residency Review Committee for Orthopaedics, the Academic Orthopaedic Society, the Ruth Jackson Orthopaedic Society and the Academy have met. This group agreed on the issues to be addressed and are developing specific action plans to work on modifications of orthopaedic resident education, orthopaedic fellowship education, and continuing medical education.

The third issue relating to the future that has raised widespread concern is the orthopaedic workforce. Our major effort to address these widespread concerns is the Rand Study on Workforce Issues. The contract has been signed and the study is underway. This important study will provide valid data on current workforce levels and will also serve as a workable model in the future since projections can be updated by inputting changing demographic and workforce data.

It is important to emphasize that this is not just an Academy effort, but is truly an orthopaedic initiative because the American Orthopaedic Association, the Academic Orthopaedic Society, and several of the COMSS specialty societies (to date, the American Orthopaedic Foot and Ankle Society, the American Orthopaedic Society for Sports Medicine, the American Society for Surgery of the Hand, and the American Association of Hip and Knee Surgeons) all have joined in to actively participate and to help fund the study, and other COMSS societies are considering participation.

There are many things we can do to make a difference, and this has been a summary of the major evolving and ongoing initiatives we are currently pursuing. I welcome your comments and suggestions for additional things we should consider. In addition, the draft version of our 1997-1998 Strategic Plan is included in this Bulletin. Formal review and comment is being solicited from the Board of Councilors, COMSS and Academy councils and committees prior to final revision and adoption by the Board of Directors in December. I also invite your individual comments and suggestions.

Kenneth E. DeHaven, MD

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