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Scientific Articles   |    
Provider Factors Associated with Intramedullary Nail Use for Intertrochanteric Hip Fractures
Mary L. Forte, PhD, DC1; Beth A. Virnig, PhD, MPH2; Lynn E. Eberly, PhD3; Marc F. Swiontkowski, MD4; Roger Feldman, PhD2; Mohit Bhandari, MD, MSc, FRCSC5; Robert L. Kane, MD2
1 Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Suite S11B, Baltimore, MD 21201. E-mail address: mforte@umoa.umm.edu
2 Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware Street S.E., Minneapolis, MN 55455
3 Division of Biostatistics, School of Public Health, University of Minnesota, MMC 303, 420 Delaware Street S.E., Minneapolis, MN 55455
4 Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Minneapolis, MN 55454
5 Division of Orthopedic Surgery, Department of Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 2X2, Canada
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Centers for Medicare and Medicaid Services to the Research Data Assistance Center (contract 500-01-0043). In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (United Health Group, Medtronic, and Lewin and Associates) and payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (SCAN Health Plan).

A commentary by Saam Morshed, MD, MPH, and Kevin J. Bozic, MD, MBA, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at the University of Minnesota, Minneapolis, Minnesota

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 May 01;92(5):1105-1114. doi: 10.2106/JBJS.I.00295
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Abstract

Background: 

Intramedullary nails provide no clear outcomes benefit in the majority of patients with intertrochanteric hip fracture, yet their use in the United States continues to increase. Non-patient factors that are associated with intramedullary nail use among Medicare patients have not been examined. The goal of this study was to identify the surgeon and hospital characteristics that were associated with the use of intramedullary nails compared with plate-and-screw devices among elderly Medicare patients with intertrochanteric hip fractures.

Methods: 

Medicare beneficiaries who were sixty-five years of age or older and underwent inpatient surgery to treat an intertrochanteric femoral fracture with use of an intramedullary nail or a plate-and-screw device were identified from the United States Medicare files for 2000 to 2002. Surgeon and hospital characteristics from the Medicare provider enrollment files were merged with the claims. Generalized linear mixed models with fixed and random effects modeled the association between surgeon and hospital factors and intramedullary nail use (compared with plate and screws), controlling for patient age, sex, and race; subtrochanteric fracture; Charlson comorbidity score; nursing home residence; and Medicaid-administered assistance. The adjusted odds ratios of receiving an intramedullary nail by year, surgeon, and hospital factors are reported.

Results: 

There were 192,365 claims for surgery to treat an intertrochanteric hip fracture that met the inclusion criteria and matched with surgeon and hospital information. There were 15,091 surgeons who performed intertrochanteric hip fracture surgeries in Medicare patients in 3480 hospitals between March 1, 2000, and December 31, 2002. The surgeon factors associated with intramedullary nail use include younger surgeon age (less than forty-five years old), an osteopathy degree, and operating at more than one hospital. The hospital factors associated with intramedullary nail use include a higher volume of intertrochanteric hip fracture surgeries, teaching hospital status, and having resident assistance during surgery. Surgeon factors improved the model fit more than hospital factors.

Conclusions: 

The use of intramedullary nails was strongly associated with early-career surgeons and surgeon training programs. Our findings suggest that orthopaedic faculty at teaching hospitals and younger surgeons may be selecting orthopaedic implants on the basis of factors other than clinical outcomes evidence. We expect that intramedullary nail use will continue to increase as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospital's burden of their choices for higher cost devices under the Medicare payment system.

Level of Evidence: 

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Mary L. Forte, PhD, DC
    Posted on June 08, 2010
    Dr. Forte and colleagues respond to Drs. Bernstein and Ahn
    Epidemiology and Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland

    We thank Drs. Bernstein and Ahn for their positive comments regarding our study of provider factors in intramedullary nail use based on 2000-02 Medicare claims (1).

    With regard to the size of the incentive for using an intramedullary nail, we acknowledge that after a 17-year duration of higher Relative Value Units (RVU) for intramedullary nail (CPT 27245) compared with plate/screw procedures (CPT 27244), the Centers for Medicare and Medicaid Services (CMS) dramatically cut the RVUs for intramedullary nail procedures in 2009. During the 2000-02 period of our study, however, there was a sizable payment difference between the procedures, which amounted to approximately $272-330 (2,3). While we agree that readers should not focus exclusively on what was a 2000-02 RVU difference, our comprehensive Discussion of RVUs, teaching surgeons and the effects of surgeon training programs in technology adoption did not center exclusively around reimbursement. The surgeon practice patterns that set in during the period of our study could have been shaped, at least in part, by the payment difference.

    Consulting arrangements may be one component of technology promotion and certainly one that has received a great deal of press recently. Yet, we do not believe that all surgeons, Department Chairs or other teaching surgeons who adopted intramedullary nails had large consulting contracts with industry. Nor were all of the adoptee surgeons young and in academics. A host of factors may motivate technology adoption in orthopaedics (2,4,5) and economic incentives from any source can provide a strong stimulus for behavior change among surgeons and non-surgeons alike.

    We disagree with Drs. Bernstein and Ahn about what constitutes a societal cost. In economic terms, if it costs $500 to make a plate/screws device and $1500 to make an intramedullary nail, the difference in social costs is $1000. The device manufacturer will earn some monopoly profit on both devices but suppose that it is a constant $1000. So, assume that the hospital buys each plate/screws for $1500 and each intramedullary nail for $2500. The cost difference remains $1000. If the surgeon orders an intramedullary nail instead of a plate/screws device, the hospital is out $1000, which it has to make up somewhere else or see its profits go down (you could say the hospital gets “nailed” for the extra costs). However, it doesn't matter whether the hospital shifts the costs or takes a loss on the device, the difference in social costs remains $1000.

    The actual cost of producing an intramedullary nail is elusive and may never determine its sales price. Determining the real cost of a device is very difficult given all the price adjustments that are routinely used. Anecdotally, we have heard that intramedullary nail manufacturing costs are, in fact, higher, and that these costs may not change over time. However, we have no means of obtaining accurate information from manufacturers in this area.

    In conclusion, we used multiple analytic models to examine and report orthopaedic provider patterns that could not be examined in smaller randomized clinical trials. Our study was not designed to examine marketing influences specifically. Regardless of which combination of forces initiate new technology adoption in surgeon training centers, surgeon practice patterns appear to be strongly developed in teaching hospitals, and device manufacturers, like the tobacco industry with young smokers, undoubtedly know it.

    References

    1. Forte ML, Virnig BA, Eberly LE, Swiontkowski MF, Feldman R, Bhandari M, Kane RL. Provider factors associated with intramedullary nail use for intertrochanteric hip fractures. J Bone Joint Surg Am. 2010;92:1105-14.

    2. Forte ML, Virnig BA, Kane RL, Durham S, Bhandari M, Feldman R, Swiontkowski MF. Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg Am. 2008;90:691-9.

    3. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; revisions to payment policies and five-year review of and adjustments to the relative value units under the physician fee schedule for calendar year 2002. Final rule with comment period. Fed Regist. 2001;66:55245-503.

    4. Bozic KJ, Jacobs JJ. Technology assessment and adoption in orthopaedics: lessons learned. J Bone Joint Surg Am. 2008;90:689-90.

    5. Lieberman I, Herndon J, Hahn J, Fins JJ, Rezai A. Surgical innovation and ethical dilemmas: a panel discussion. Cleve Clin J Med. 2008;75 Suppl 6:S13-21.

    Joseph Bernstein, MD, MS
    Posted on May 14, 2010
    Comments on "Provider Factors Associated with Intramedullary Nail Use for Introchanteric Hip..."
    University of Pennsylvania, Philadelphia, Pennsylvania

    To the Editor:

    Kudos to Forte and colleagues for their excellent study, “Provider Factors Associated with Intramedullary Nail Use for Intertrochanteric Hip Fractures” (1).

    We’d like to share these observations and request the authors’ comments.

    1. It would be wrong for readers to emphasize the higher Medicare payment for inserting a nail. The national payment by Medicare for CPT Code 27244 differs from that of CPT Code 27245 by only $17.68. For the average surgeon in this study, the difference in payment, about $60 per year, is trivial. (By contrast, the difference between accepting $5 million from an implant manufacture and accepting $10,001 is not trivial, though both trigger the same “conflict of interest” disclosure.) Quantitative differences impose qualitative ones.

    2. The added cost to the hospital for the nail is not a true social cost, but rather, a transfer payment from the hospital to the surgeon (who passes it on, for whatever reason, to the vendor): the third party payer doesn’t pay a penny more when the nail is used. The loss to the hospital is no more a cost to society than it is a benefit to society when the hospital saves money by hiring only one operating room team on nights and weekends. In that case, there is a transfer payment from the surgeon to the hospital, who pays with time and hassle, waiting for an open room to do his cases.

    3. There is no particular reason why the various nails (which seem pretty fungible to us) should cost more than plates. Indeed we predict that as this device becomes more prevalent, the differences in cost will disappear.

    In short, this was an enlightening study, one that should lay to rest the fiction that orthopedic surgeons are somehow exempt from the influences of marketing: clearly, the growing popularity of nails is not due to a perfusion of studies demonstrating their superiority. Hopefully, this study is one of many to come which examine the extra-medical forces influencing medical decision making.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    Reference

    1. Forte ML, Virnig BA, Eberly LE, Swiontkowski MF, Feldman R, Bhandari M, Kane RL. Provider factors associated with intramedullary nail use for intertrochanteric hip fractures. J Bone Joint Surg Am. 2010;92:1105-14.

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