July 2019

Low Value Medical Practices

Marc Hochberg, MD, MPH, MACP, Immediate Past President, USBJI

I have come to the conclusion of my two-year term as President and wish to thank not only my colleagues and friends on the Executive Committee and Board of Directors of the U.S. Bone and Joint Initiative (USBJI) but also the staff of USBJI who work tirelessly in the home office in Rosemont, IL, especially Mr. Toby King and Ms. Shari Maier. I would like to use my last “President’s Message” to comment on a recent article by Herrera-Perez and colleagues in the journal “eLife” that was mentioned in an article in The New York Times on Tuesday, July 2, 2019 by Ms. Gina Kolata. I will mention here that one of my colleagues at the University of Maryland School of Medicine, Dr. Daniel Morgan, was a coauthor of the article in “eLife”.
 
Low value medical practices are those that either have been found to be ineffective by clinical studies, including randomized controlled trials, or for which there are similarly or more effective treatments that are less expensive or safer. “Choosing Wisely”, an initiative of the American Board of Internal Medicine, was begun in 2012 to have national professional organizations provide a list of five tests or procedures commonly used in their field that were considered to be either unnecessary or of low value. The complete list of recommendations can be found at “https://www.choosingwisely.org/clinician-lists//” and includes, for example, the recommendation not to prescribe opioid analgesics for acute or chronic low back pain before consideration of a trial of alternative medications and treatments (American Academy of Physical Medicine and Rehabilitation and North American Spine Society), not to use lateral wedge insoles, glucosamine and chondroitin and needle lavage to treatment patients with symptomatic osteoarthritis of the knee (American Academy of Orthopedic Surgeons) and not to perform magnetic resonance imaging of peripheral joints to routinely monitor patients with inflammatory arthritis (American College of Rheumatology).
 
Herrera-Perez and her colleagues added to the concept of low value medical practice and the Choosing Wisely initiative by describing “medical reversals”, a subset of low value medical practices that have been found through randomized controlled trials to be no better than a prior or lesser standard of care. Of almost 400 medical reversals identified through their review of RCTs published in three leading international medical journals, 23 (6%) and 3 (1%) were in orthopedics and rheumatology, respectively. Ten of these medical reversals included 1) acetaminophen is ineffective for treatment of acute low back pain, 2) a comprehensive exercise program was not better than a one-time consultation with a physiotherapist for relieving chronic neck pain due to whiplash, 3) neither diclofenac nor spinal manipulative therapy were effective for pain relief in patients with acute low back pain who had seen their primary care provider and been given acetaminophen (see #1 above), 4) radiofrequency denervation was no more effective than a standard exercise program in patients with chronic low back pain, 5) home-based rehabilitation was as effective as inpatient rehabilitation in improving mobility after total knee arthroplasty in patients with osteoarthritis, 6) surgical repair was not more effective than nonsurgical management of acute proximal humeral fractures in older adults, 7) neither cyclobenzaprine nor the combination of acetaminophen with oxycodone was more effective than placebo for treating acute low back pain when added to naproxen, 8) physical therapy did not improve pain or function more than sham therapy in patients with hip osteoarthritis, 9) hydroxychloroquine did not improve symptoms of eye dryness, fatigue or pain compared to placebo in patients with Sjogren syndrome, and 10) neither the addition of calcium nor vitamin D reduced the risk of new fractures in older adults who had sustained a low-trauma osteoporotic fracture. The authors suggest that de-adoption of these and other low-value practices would lead to improvements in medical care as well as cost savings.
 
Finally, I wish the incoming President, Dr. Matthew Dobbs, success in his tenure in guiding USBJI to fulfill its mission of raising the priority of musculoskeletal health through the collective action of all its stakeholders.

The American Medical Women’s Association has worked to improve the health of women for over a century.  We are currently focusing that effort on raising awareness among healthcare professionals of sex and gender differences, as women and men differ in the risk for, presentation of, and response to treatment for all health conditions.  One area that demonstrates sex- and gender-based differences is chronic pain and related opioid use and addiction.  Women are more likely than men to develop conditions that can lead to chronic pain, such as osteoarthritis, most inflammatory arthropathies, fibromyalgia, and low back pain.  While sex-based differences in perception of nociceptive stimuli have been identified, more research is needed in this area.  Other co-morbidities, such as depression or PTSD, can alter either the sex-based perception or gender-based expression of pain.  There are also sex-based differences in response to opioids, with women typically having a delayed onset of pain relief and being more likely to become addicted to opioids at lower doses and over shorter periods of time.  The chronic use of opioids is of concern for women of all ages, but especially impacts the independence of older women, as opioids can increase the risk of falls and related fractures, and the lives of women of childbearing age, due to the risk of a newborn developing neonatal withdrawal (abstinence) syndrome (NAS).  In addition, deaths from opioid overdoses, both prescribed and synthetic, increased 5-fold for women between 1999 and 2017, with the percentage increase in deaths higher for women than men during this period of time (MMWR January 11, 2019).

To address this complex issue, AMWA created the Opioid Addiction in Women Task Force in 2018 under the leadership of Connie Newman, MD, who was AMWA President at the time, and Kim Templeton, MD, AMWA Past-President.  The task force is collating a series of PowerPoint presentations, targeted at healthcare professionals, that discuss sex and gender differences in opioid use and addiction from a variety of perspectives.  Also under development are a video for the public that describes the role of Naloxone in countering opioid overdose and a shorter video that demonstrates how Naloxone is administered.  AMWA provided input to the HHS Pain Management Best Practices Interagency Task Force during their initial deliberations in September 2018, as well as in March 2019 in response to their draft report, “Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations”. The recommendations of AMWA testimony were to 1) eliminate “pain control” as a measure of quality care by third parties; 2) promote education of health care providers and the public about sex-based differences in pain frequency and intensity, the associated increased risk of addiction to prescription opioid analgesics in women, and the benefits of non-opioid alternatives; 3) encourage healthcare professionals to speak with their patients about all options for pain management, including non-opioid alternative therapies, in order to develop a treatment plan that will allow optimal function; 4) encourage healthcare professionals to assess women with chronic pain for the presence of comorbidities such as depression and PTSD; and 5) recommend discussion of family planning as part of medication assisted and other treatment for addiction.  The task force is also working with the Office of the US Surgeon General to raise awareness of the issue of women and opioids and will be collaborating with the Office on the distribution of information through social media and other outlets.    AMWA is a member of the National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic and will be participating in the upcoming HealthyWomen’s Science, Innovation and Technology Summit: Chronic Pain in Women: Focus on Treatment, Management & Barriers. 

What is defined as “women’s health” has expanded far beyond what is referred to as “bikini medicine”.   Chronic pain, opioid use, and addiction are critical women’s health issues, and the AMWA Opioid Addiction in Women Task Force will continue to address this through collaborative projects and programing to attempt to reverse the current trend. 

Position Statement on Opioid Epidemic
The National Association of Orthopaedic Nurses (NAON) has released a position statement regarding the opioid epidemic. Opioid use, misuse, and abuse have been on the rise over the past several decades, and increased scrutiny has been placed on the prescribing and use of opioids. Increased opioid usage has led to several unintended consequences for individual patients and society at large. Opioids use can lead to tolerance, addiction, and result in worse treatment outcomes (Morris & Mir, 2015). This phenomenon, now known as the opioid epidemic, has been wreaking havoc in the general healthcare population, specifically among orthopaedics patients with acute and chronic pain from genetic, acquired, or traumatic musculoskeletal conditions.

The rise in opioid prescriptions began in the 1990’s when pain was declared as the fifth patient vital sign. Today the U.S consumes an estimated 80% of the global opioid supply. Subsequently, the diversion of opioids for nontherapeutic use began to dramatically increase as well (Morris & Mir, 2015). Nearly thirty years later, opioid overdose is now the leading cause of accidental death in young adults. Opioids are associated with a higher risk of postoperative death, contribute to post-operative complications, and increase the risk of falls and fractures in the elderly (AAOS, 2015).
Nurses, especially those caring for patients who have either used, abused or are currently being prescribed opioids for chronic or acute musculoskeletal conditions from trauma or surgery, are in a unique position to directly impact the continued spread of the opioid epidemic. To view the full position statement, click here.

Jack Davis MSN, RN, ONC – Welcomed as NAON President 

NAON members welcomed Jack Davis, MSN, RN, ONC as its new president during its 39^th Annual Congress, held this year in Atlanta, GA. Attended by more than 900 delegates and 30 exhibitors, session topics included:

• Bringing It Home with Bone Health
• I Wish Someone Had Told Me: Proactive Wellness Care for the Patient with Osteoarthritis
• If Not You, Then Who? The Role of Orthopedic Nurses as Researcher or Scientist
• The Future of Outpatient Total Joint Surgery
• Easy Does It: Common Overuse Injuries
• Acute Sport Related Injuries in the Pediatric/Adolescent Athlete

NAON’s 40^th Annual Congress will take place May 30-June 2, 2020, in Pittsburg, PA.
 
For a full list of NAON’s new Board of Directors, click here. For more information on the association, visit www.orthonurse.org, or e-mail NAON Headquarters at naon@orthonurse.org.
 
NAON Honorary Membership Award
 
USBJI’s Executive Director, Toby King, has received the NAON Honorary Membership Award for exemplifying the mission and vision of NAON.

The Pediatric Society of North America (POSNA) takes the musculoskeletal health of our young patients very seriously, both in treating injuries and disorders, as well as preventing them whenever possible. To that latter end, POSNA created the extremely successful Act Your Age campaign within the last several years.

At Your Age focuses on high-risk activities that can result in significant harm or disability to children. We focus on educating families and providers regarding the dangers these activities pose. We specifically discuss how to minimize risk if participating in these activities and whether the risks are significant enough that we might recommend avoiding these activities all together. The advocacy committee of POSNA collaborates with our sister societies, including the American Academy of Pediatrics (AAP) and the American Pediatric Surgical Association (APSA), to promote these safety guidelines.

Our most recent campaigns have focused on utilization of social media as a tool for wide dispersion of information to the public. For the second year in a row, POSNA and the Section on Orthopaedics (SOOr) of the AAP worked closely together to encourage lawnmower safety. We created a lawnmower safety video along with infographics that can be distributed at physicians’ offices to families. This spring, these informational tools were dispersed over Facebook and reached over 5,000 people within the first two weeks.

We led a similar campaign for Gun Violence Awareness month in June. The Advocacy Committee of POSNA joined with APSA to disseminate daily facts regarding the dangers guns pose to our children. We also created infographics that were posted to Twitter, Facebook and Instagram for easy consumption and mass distribution. We focused on current trends in gun safety and how to stay safe if there are guns in the home. This campaign has resulted in the highest number of positive interactions with our social media accounts to date.

Our upcoming initiative on trampoline safety will be featured in the fall Focus column of AAP News. We specifically highlight the most common injuries with trampoline use both at home and in trampoline parks. We present the best ways to stay safe and still enjoy these toys. Moving into the fall, we will also be highlighting the risks of early youth sport specialization and lack of cross training. In the winter, we will be focusing on off-road vehicles including snowmobiles and ATVs.

The goal of the Act Your Age campaign is to highlight how to best enjoy high-risk activities and keep our children safe. We focus on what activities are appropriate for which age groups and try to provide the logic for modifying or avoiding these activities altogether for younger children. Our goal is to provide this information at a time that coincides with when families are engaging in these activities so that our information is front of mind and has the highest chance of modifying behaviors. In the coming year, we will be adding topics to our campaign and look forward to continuing to be a link between our families and our national societies.

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The United States Bone and Joint Initiative (USBJI) is delighted to announce the following elections at its meeting on Friday, June 7, held at the University of Maryland Medical Center.
 
New Board representatives, and the organizations which they represent, for the period 2019-2022: New Officers:
About New President Matthew B. Dobbs, MD, FAOA, FACS


Matthew Dobbs began his involvement with the USBJI as a participant of the Young Investigator Initiative (YII). He joined the Board of Directors in 2016 representing the Orthopaedic Research & Education Foundation. As President Elect and during development of the Strategic Plan approved in 2018, he advocated a back-to-basics approach, to refocus the USBJI on raising the priority of MSK health, and the importance of burden of disease data to achieve this. With the need for greater emphasis on Low Back Pain, the most prevalent MSK disorder, Dr. Dobbs convened the Low Back Pain Task Force which presented its recommendations during the June Board meeting. Dr. Dobbs is a faculty member of the Early-Funded Investigator Program’s pilot workshop, to take place August 2019, for investigators who have secured funding and seek mentoring to develop their research careers, a possible expansion of the YII program. 
 
Professionally, Dr. Dobbs is the Dr. Asa C. and Dorothy W. Jones Professor of Orthopedic Surgery at Washington University School of Medicine. Dr. Dobbs specializes in pediatric orthopaedic surgery and is the founder and director of the Ponseti Clubfoot Treatment Clinic.  He is nationally and internationally recognized for his clinical work, research, and innovation and is consistently listed in Best Doctors in America.  Clinically his focus on minimally invasive surgery led to the development of a novel treatment for congenital vertical talus which like the Ponseti method for clubfoot treatment avoids extensive surgery.
 
Dr. Dobbs currently serves on the Board of Directors for the Orthopaedic Research and Education Foundation, the Association of Bone and Joint Surgeons, Miraclefeet, the Missouri State Orthopaedic Association, and has served on the Board of Directors for the American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America. He is currently Secretary for the Association of Bone and Joint Surgeons, Chair of Grants for the Orthopaedic Research and Education Foundation, Treasurer for the Missouri State Orthopaedic Association, Treasurer for the World Orthopaedic Concern, Chair of the Research Academy for the International Society of Orthopaedic Surgery and Traumatology and serves on the board of the International Society of Orthopaedic Surgery and Traumatology, and President for the International Federation of Pediatric Orthopaedic Societies.
 
In his research, he and his team are actively searching for the genetic factors responsible for clubfoot, scoliosis, and other musculoskeletal anomalies. Along with Dr. Christina Gurnett, Dr. Dobbs is co-director of the Washington University Musculoskeletal Genetics Laboratory which is NIH RO1 funded.
 
Dr. Dobbs earned his medical degree from the University of Iowa in Iowa City in 1995. Following a residency in orthopedic surgery at the University of Iowa Hospital and Clinics, he completed a fellowship in pediatric orthopedic surgery at Shriners Hospital for Children in St. Louis.
 
The following recently joined the Board representing USBJI Founding Members: