Doctors

Data On Doctors To Be Available

RICARDO ALONSO-ZALDIVAR

Los Angeles Times August 30, 2007 WASHINGTON

Whether it's a hernia repair or heart bypass, doctors who perform a given operation more frequently get better results. The problem for patients has been finding out who those physicians are before picking one.

Now a court ruling appears to open the way for consumer access to such information for the first time, possibly transforming the relationship between doctors and their patients, as well as the business of health care.

In a little-noticed decision last week, a federal judge in Washington ruled in favor of a consumer group that sued the Health and Human Services Department to allow disclosure of doctor-level detail from the vast Medicare claims database. U.S. District Judge Emmet G. Sullivan concluded "a significant public benefit" could be served by releasing the data, and ordered the department to turn it over by Sept. 21.

With information on more than 40 million patients and 700,000 doctors, the Medicare database is far richer than any private insurer's. Although it would not have information on some doctors, such as pediatricians, who don't treat Medicare patients, it is considered the mother lode for data on those who treat adults, because Medicare recipients are a mainstay of most practices.

The database's usefulness has been limited by a decades-old government policy that protects the privacy of doctors, who fear the information could be used to micromanage the practice of medicine. But as the cost of medical care has skyrocketed, employers, insurers and consumer groups have pressured the government to open up Medicare's files on individual doctors.

Those files could reveal far more than how many times a year a surgeon performs a hip replacement operation. The data could also be analyzed to determine how individual doctors make critical decisions on tests and procedures that determine both quality and costs. They would show which doctors fail to order prudent preventive tests that could catch disease early. And they could indicate which ones order duplicative tests or unnecessary hospitalizations...

...Those files could reveal far more than how many times a year a surgeon performs a hip replacement operation. The data could also be analyzed to determine how individual doctors make critical decisions on tests and procedures that determine both quality and costs. They would show which doctors fail to order prudent preventive tests that could catch disease early. And they could indicate which ones order duplicative tests or unnecessary hospitalizations.

"These data will make it possible to develop measures that will be very helpful to consumers," said Robert Krughoff, president of Consumers' Checkbook, the nonprofit group that sued for the information.

"Someone who is thinking they need a knee replacement--or a prostatectomy--will be able to go on our website and see how many of these procedures their physician has done for Medicare patients," added Krughoff.

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All About Hip Resurfacing

Hip resurfacing is all the rage in the orthopedic community these days. In fact, I had four different hospitals pitch me stories on it in the last year, independent of one another.

But is it right for everyone with chronic, debilitating hip problems? NYMD News panelist Dr. William Macaulay, attending orthopedic surgeon at New York Presbyterian Hospital/Columbia and director of Columbia's Center for Hip and Knee Replacement, has the answers below and after the break.

By William Macaulay, M.D.

You just turned 40 or 50. Your mind tells you you’re younger, but you feel older because you have real hip pain that won’t quit. You limp everyday. You do a little research and come across a new procedure called total hip resurfacing. Then you wonder: Is this the right procedure for me?

I hear the same story over and over from my patients. Looking for a solution to their hip pain, they have stumbled upon total hip resurfacing, which was approved for use in the U.S. in May of 2006. While many patients are ideal candidates for resurfacing, often I must inform them that hip resurfacing is not for everyone.

Hip Surgery With a Future

By Barnaby J. Feder

Correction Appended

Hip replacement, an operation that about 300,000 Americans undergo each year, is one of the great success stories of modern medicine.

But woe to those who outlive their artificial hips, which typically cannot be counted on to last more than 20 years or so.

Because it is difficult to extract and replace a worn-out or defective artificial hip, doctors routinely advise patients to put off hip replacement as long as possible. For middle-aged or younger people whose hips have been damaged by disease or injury, that typically means a punishing waiting game.

Now, though, an alternative to total hip replacement can offer an interim solution to many younger patients.

The alternative, called hip resurfacing, usually yields at least as many short-term benefits as a total replacement. It costs about the same and is typically covered by insurance.

And though many patients can expect to outlive the treatment’s effectiveness, hip resurfacing has the advantage of preserving enough healthy bone to allow for a future total hip implant.

“It’s nice to know that down the road, if necessary, it will be an original total hip — not a revision,” said Keith McDonald, a 54-year-old air traffic controller from Melville, N.Y., whose right hip was resurfaced late last month. This past Tuesday, just 15 days after the operation — and at least a week earlier than doctors would recommend — Mr. McDonald drove his car. “Every day I do more,” he said.

Tens of thousands of patients around the world have had hips resurfaced in the past decade. That includes some Americans who went overseas before the Food and Drug Administration started allowing it to be done in this country last May.

“The demand from patients and surgeons is tremendous,” said Brian Austin, of Smith & Nephew, the British maker of the F.D.A.-approved resurfacing system.

More than 400 surgeons in the United States have now been trained to use Smith & Nephew’s product, which is known as the Birmingham Hip System. Competing devices already sold overseas are expected to begin arriving in this country later this year...

...

“You should have pain every day before you even think about it,” said Dr. William B. Macaulay Jr., a Manhattan surgeon who performs hip resurfacing surgeries. “If you are doing it in people with moderate pain who just want to improve their tennis game, that’s crazy.”

Experts say that 10 percent to 15 percent of hip-replacement candidates may find hip resurfacing a viable alternative. But unless they are Web-savvy like Mr. McDonald, who learned about it only through his own Internet research, they may not have heard about the procedure...

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Learning curve may be longer than thought for placing hip resurfacing components

 

It took surgeons 55 to 60 cases to get femoral components within ?5? of planned placement.

 

By Susan M. Rapp ORTHOPEDICS TODAY 2007; 27:12 May 2007

 

British and Australian researchers collaborating on a prospective study identified a longer-than-expected learning curve to accurately perform hip resurfacing arthroplasties.

 

Hip surgeons taking part in the study, all of whom had performed more than 1,000 hip surgeries, found they had to complete three-times more resurfacing surgeries than they expected in order to place the femoral hip resurfacing components within ?5? of the desired neck/head angle, said Diane L. Back, FRCS.

 

The surgeons had initially estimated their learning curve at 10 to 20 cases, Back told Orthopedics Today.

 

"The results actually showed that it took 55 to 60 cases for most of our surgeons to get the femoral component where they actually planned it," she said.

 

...Four surgeons participated Back and colleagues prospectively analyzed the first 100 hip resurfacing procedures of four consultant orthopedic surgeons, three from Australia and one from the United Kingdom.

 

They performed all procedures with the recently reintroduced Birmingham Hip Resurfacing System [Smith & Nephew]. The FDA approved the implant for sale in the United States last year.

 

All surgeons used standard instrumentation and a posterior approach. Investigators focused on femoral component position, but also analyzed notching and other complications.

 

To determine how accurately they placed the femoral components, surgeons first marked the ideal implantation site on preoperative radiographs. Investigators then calculated the corresponding neck/head angle.

 

...The longer-than-expected learning curve has huge implications for surgeons' success with this type of hip replacement, Back told Orthopedics Today.

 

"Hip resurfacing is good. I think that is well proven. You have to choose your right cases, but it does take you longer than you expect to learn. I think medico-legally it does have some implications."

 

For example, surgeons just learning the procedure should tell patients they are at the beginning of their learning curve and have not done many of the procedures, she said.

 

In the United States where orthopedists begin practicing after completing fewer hip replacements than surgeons in the United Kingdom or Australia, "It actually means their learning curve may take them 10 years to get out of," Back said.

 

Back said she wonders how, with the worldwide trend toward reduced orthopedic training hours, many new surgeons would be able to accrue enough cases to become proficient with the technique.

 

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Health Alert: New hip surgery available in Toledo

 

WTVG--August 17, 2007 - In today's health alert a cutting edge surgery is now available in Toledo. It's for younger patients in need of hip replacement surgery. Doctors say Birmingham hip resurfacing has a lot of advantages for patients, including quicker recovery, the preservation of more of the leg bone, and the ability to continue to live an active life.

 

It looks seem enough, but a stroll down the hall at the University of Toledo Medical Center is somewhat of a miracle for 50-year-old Rick Janicki. About three months ago, he says he couldn't walk or do just about anything without crippling hip pain shooting down his right leg and up his back. Normally a very active man, he says he felt useless.

 

In late May, Rick had surgery, not to replace his hip, but to resurface it. Doctor Haleem Chaudhary is one of the first surgeons in the entire country trained in the new Birmingham hip resurfacing technique. He capped the head of Rick's femur, like a dentist would cap a tooth.

 

More of the leg bone is preserved with resurfacing, as opposed to the traditional hip replacement, which requires sawing off the top of the femur.

 

Dr. Chaudhary says, "Additionally, it has a much larger head than a typical hip replacement and that gives the advantage of a higher range of motion."

 

And less of a chance of dislocation.

 

"After Birmingham's hip replacement and after the healing process is done, I don't really put any restrictions on patients, in terms of their activity or their range of motion."

 

The procedure lasts one to two hours and patients can return to normal activity by six weeks. Dr. Chaudhary spares the major muscles around the hip during surgery, which also helps patients recover faster. Rick goes to physical therapy. He says he feels good. In fact, at times, he says he forgets which hip was resurfaced. Dr. Chaudary says this surgery isn't for everyone. He says good candidates are under sixty-years-old, with a diagnosis of osteoarthritis, and good bone stock.

 

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Hi Pat,

 

Thanks for the mail.

 

Of course I remember you very well. I direct patients frequently to your remarkable website when they are seeking specific information.

 

It is a commonly used statement that a BHR is as 'stable' as a normal hip. However this is a highly qualified statement.

 

This statement is true only if the following criteria are met.

 

1. Native angles, inclination , offsets and all anatomical parameters have to be replicated.. If this is not done fully and only accuracy of say 80% is obtained - then the stability is likely to be approx in the region of 80% only. Having said this ,even in this situation, the stability is likely to be many times that of a conventional THR. Therfore i would not call it a surgical error.As surgeons, we get better and better at this replication as we gain experience.

 

2. The capsule should be repaired to capsule preferably as it restores the joint 'proprioception'( or position sense). This would kick in the event of a potential dislocation as it would in a normal hip. If the capsule is repaired to bone , it is many times better than doing nothing but does not achieve the proximity to the stability of a normal hip. Again it is not a surgical error if capsule to capsule repair is not done but one cannot expect natural stability.

 

3. Other factors that can potentially cause dislocation like impingement must be carefully addressed . The most common offender is the non -restoration of the head neck offset

 

One must keep in mind that the BHR is the Ferrari of hips and the conventional THR is an old fiat.

 

Even if the Gear knob of a ferrari is not the right size for the driver it shows up because it is pushed to the limit and built for performance. However even if the chassis is broken in an old fiat , it would probably go unnoticed by the owner as it is never 'pushed' for performance. There are many patients after THR s with trochanteric non-unions going on for many years without even being aware of it!

 

Coming to the specifics of this patient.- The Relocated BHR is likely to be stable with time and is unlikely to affect longevity. THe only issue is that this patient must avoid extremes of movement to prevent another episode.

 

I hope this helps

 

with best regards vijay bose chennai Hip Resurfacing India Dr. Bose Website

Hip Resurfacing: A New Tool For Orthopaedic Surgeons

 

By Nancy K. Crevier

 

Don Sweeney of South Salem, N.Y., and Albert Viscio of Redding are both men in their mid-fifties. Running, tennis, basketball, and even mountain climbing are activities they enjoy.

 

But about ten years ago, both men began to experience the discomfort that comes with osteoarthritis of the hip.

 

"The arthritis progressively became worse," said Mr Viscio, "and I found I had to reduce some of my activities."

 

Mr Sweeney developed increased mobility issues along with significant pain in his hips, until it became apparent a little over a year ago that he would have to take action, or face a debilitated future. Hip replacement surgery was performed on his left hip in 2005, and he then was told that his right hip would be a candidate for surgery in the near future.

 

When Mr Viscio had to cut short a climb to the summit of Mount Kilimanjaro in Tanzania in December of 2006 due to intense hip discomfort, he realized he had pushed his limits. "I knew it was time to address the problem," he said. Both men were candidates for hip surgery, joining the ranks of nearly 500,000 people in the United States who undergo the knife for reconstruction of hips damaged by arthritis. And both men were ideal candidates - relatively young, in good physical condition, and active - for a newly FDA approved hip resurfacing technique.

 

...For younger hip surgery patients, hip replacement is an operation that will probably be repeated in their lifetimes.

 

That is why Drs Sanjay Gupta and Robert Deveney, both affiliated with Danbury Hospital, are pleased to provide the hip resurfacing procedure, approved by the FDA just six months ago. Rather than completely removing the head of the femur as in hip replacement surgery, hip resurfacing preserves the femur head, reshaping it to save more bone. During surgery, a chromium cobalt metal cap is fit over the patient's hip ball and a metal cup, also made of chromium cobalt metal, is set into the pelvic socket.

 

Why It Works

 

The metal-on-metal construction of the replacement parts means less friction and longer life to the prosethic parts. Hip resurfacing preserves more bone than when traditional hip surgery is performed, an important factor if hip replacement surgery is required in the future.

 

Dr Gupta has been certified to perform this surgery in the United States since the FDA approved the procedure, but having practiced as a medical resident in the United Kingdom where hip resurfacing has been embraced for the past ten years, he was very familiar with the procedure. He participated in more than 25 surgeries while a fellow at The Hospital for Special Surgeries in Manhattan after coming to the United States, and has already performed two hip resurfacing surgeries since joining Orthopaedic Specialists of Connecticut in Brookfield in September 2006.

 

Beyond bone preservation, there are other advantages to hip resurfacing, said Dr Gupta. By preserving more of the femoral head, hip dislocation is less likely.

 

"Hip resurfacing gives patients a better quality of life," said Dr Gupta, "especially if they have a more active lifestyle."

 

With hip resurfacing, patients spend approximately three to six weeks on crutches to allow the bone to bond to the metal cap on the femur head, said Dr Gupta.

 

"Then they can do whatever they want, except contact sports, running, and jumping for one year. After that, I tell them they are free to do everything," he said. That is a far cry from the restrictions that come with hip replacement, when activities like jogging, gymnastics, and dancing are severely curtailed.

 

"This is a good choice for a very active person, someone under the age of 65 usually, who has good bone quality," Dr Gupta said...

 

Dr Devany's R&D The procedure was modified over the years in the United Kingdom, though, until the present metal-on-metal design became a positive option highly regarded there for the past ten years.

 

In 2006, Dr Deveney traveled to Canada to study the newest hip resurfacing techniques with Ronan Treacy, a colleague of Derek McMinn, the developer of the Birmingham Resurfacing technique that is most widely used. The changes he observed since his initial experiences with hip resurfacing were primarily in the design of the prosthetic, rather than the surgical technique itself.

 

"What is so exciting is that hip resurfacing is preserving the femoral head, allowing patients to function at a high level. Their range of motion is greater, and there is a lower risk of hip dislocation than with traditional hip replacement," Dr Deveney said. "What is really appealing to patients is the activity level and recovery level that is faster due to improved surgical techniques, rehabilitation, and the improved designs. We have people up and walking the same day as surgery. They are often in outpatient therapy by the fourth day, and I tell them that they can drive whenever they feel comfortable."

 

Previous to newer developments, initial recovery often meant a time period of three to five months before patients were comfortable returning to daily routines.

 

"Now, I would say that many patients are back to their normal routines, back to work, three to four weeks after surgery," Dr Deveney said.

 

There is an extremely low wear rate with the new metal-on-metal ball and joint construction used in hip resurfacing, and that means that the surgery has the potential of lasting much longer than the ten- to 15- year life expectancy of the plastic and ceramic metal combination used in conventional hip replacement surgery. The longevity of the metal replacement parts means that many hip resurfacing patients may never face hip surgery again.

 

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This is a list of questions compiled by Pat Dukes, Vicky Marlow and members of the Yahoo Surface Hippy Discussion Group.  Print it out and take it to the doctor with you.

 

 

You should ask your doctor as many of the questions that seem appropriate for your situation.  Your doctor should be patient, willing to talk about what to expect and answer your questions.  If he or she isn't, I would try to find a doctor that is open and helpful. There are many wonderful hip resurfacing surgeons that will answer any question you have. Having all your questions answered will give you peace of mind and will make your surgery much less stressful.

 

How many resurfacings have YOU done? (not observed or assisted with)
Where did you train?
How many complications have you had?
How many resurfacing failures with revision to THR have you had?
How many times during surgery have you had to change to a THR instead
of a resurfacing and why was the change made?
What device (prosthesis) do you use, how long have you been using it
and why do you prefer it?
Do you use cemented or uncemented? Why?
Do you cement the stem?

What anesthetic do you use?
How long does the surgery take?
What surgical approach do you use? Anterior or Posterior?
What is the incision length?
What is your post-op pain control plan?
What hospital do you use?
What is their infection rate?
Have any of your patients had infections that required IV antibiotics
following resurfacing?
What drugs/methods do you use for anti-coagulation after surgery?
How long will I be in hospital?
How successful have you been obtaining insurance approvals for
resurfacing?

What is the rehab protocol?
When will I be 100% weight bearing?
What assistive devices will I use for walking after surgery?
How long on 2 crutches, 1 crutch, cane?
What if any restrictions do you place on your patients after surgery
and how long do they last?
Will I be given any at home nurse or PT care?

How does my other hip look at this time?
If both hips are bad, how do you handle bilateral resurfacing?
Is there anything unusual about my hip that might present problems?
Do you have a resurfacing patient who you've done surgery on that I
could talk to about their experience?

What is your opinion of my returning to (whatever work or activities
you do)
Have you done resurfacing for anyone who has returned to these
activities?"