by Frederick A. Matsen III, MD
Frederick A. Matsen III, MD, is professor and chairman, department of orthopaedics, University of Washington School of Medicine, Seattle, Wash.
Orthopaedic surgeons make a difference! It is virtually axiomatic that orthopaedic surgery improves the well-being of millions of individuals each year. Each of us can recount case after case in which our care restored someone's functional independence, ability to work or to resume their favorite recreational activities.
Wouldn't it be wonderful if each of us could measure the amount of good we do for the conditions we treat? This information would be of great value to share with our patients and their families: "85 percent of my patients who couldn't walk a block before hip arthroplasty can do so within three months of my surgery." How nice it would be to have our own data on our own efficacy, rather than having to quote the results presented by Someother Medical Center.
On the other hand, occasionally our best efforts produce no change in the patient's well-being and, rarely, we may make them worse. We're not talking about complications here, but rather those patients who just didn't get any improvement in function from our treatment. How often does this happen in my practice? If I could easily identify the patients who didn't improve, I could learn whether I have a problem in patient selection, surgical technique, implant selection, aftercare or patient compliance. I might find that my operation works less well for individuals hurt on the job, or those over a certain age or those who want to resume weight lifting.
By identifying these factors in my own practice, I could have an even more reasonable preoperative discussion with my patients. I could say, "While I know you've got a bad problem there, my success in getting folks injured longshoring back to work after disk surgery has been less than 10 percent."
While many other reasons can be advanced for measuring the efficacy of our treatment, one of the best reasons is that it provides the most personal continuing medical education. If the individual practitioner keeps track of the differences in patients' function and well-being resulting from his/her treatment, and if this information is used to optimize patient selection and treatment, everyone involved benefits.
In order to know if a specific treatment made a difference, it is essential that the status of the patient before treatment (the "ingo") and after treatment (the "outcome") are quantitated using the same tool. In this way the difference is obtained by simple subtraction. If only the outcome of treatment is known, the efficacy of the treatment cannot be known. Thus, the routine measurement of "ingo" becomes a matter of great importance: unless these data are collected before treatment, it is virtually impossible to collect them in a reliable way later.
Because we are all getting increasingly busy, "ingo" and outcome data are ideally collected in a way that is minimally intrusive to our practice. Since a major reason for measuring the difference we make is to communicate this information to our patients, the data need to be expressible in terms patients can readily understand, rather than in terms of medical metrics (such as range of motion, foot-pounds of torque or scores on a grading system). In this regard, patients are most likely to be interested in information regarding changes in function, comfort and well-being. Fortunately, the most direct way to obtain this information also is the most efficient in the context of a busy office practice: patient self-assessment. Because patient self-assessment questionnaires can be completed at home, they have the additional advantage of not requiring the patient to return to the office every time outcome data are needed.
Short, simple lists of "yes" or "no" questions regarding the patient's ability to perform different functions are often sufficient to measure the difference resulting from treatment. These simple tests can be designed to reflect deficits common to the problem being treated: "Does your knee allow you to get in and out of a car easily?" "Does your shoulder allow you to sleep comfortably on that side?" Such lists of questions, structured so that a positive response indicates the ability to perform the function, are easily answered and recorded. Ingos and outcomes are easily compared for individual patients and groups of patients (e.g., those men under age 50 having total knee arthroplasty). The data can be easily communicated to patients considering a procedure: "Only 20 percent of my patients answered 'yes' to this question before surgery whereas 85 percent answered 'yes' one year after the procedure." These data also identify the 15 percent who are still unable and motivate the question, "Why not?" Using this simple test paradigm, both our patients and we become more informed.
The right reason for measuring our individual efficacy as physicians and surgeons is because it shows us where we've made a difference to our patients and when we have not. It helps us inform them of reasonable expectations of treatment in our hands. It helps us inform ourselves on where we have room for improvement. In short, measuring the difference we make helps make good orthopaedics better.