Rousmaniere: Reducing Surgery Risks: Are You Doing Enough?

For one-out-of-eight work injuries, doctors consider surgery as an option. One-third of lost time compensable claims involve one. I suggest we try to understand surgeries by looking at risks in perhaps a new way.

The major surgeries that eventually happen usually are for a knee, a shoulder, or the lumbar region of the back.  We don’t have very good data on the volume of surgeries in workers’ compensation over time. We do know that surgery rates have changed, throughout American society, sometimes dramatically. The first total knee replacements took place in the 1970s. Today over 4 million Americans are walking around with an artificial one. On the other hand, in Texas the frequency of spinal surgery for lost time claims has declined by two-thirds since the early 2000s.

What about costs?  This area of medicine suffers from huge price volatility, which can be controlled only in part by fee schedules. Even among fee schedule states prices can vary by double. Moreover, any surgical procedure can have multiple discreet components related to complexity which can easily drive the full cost up or down by $10,000 or more. 

But these variances can be relatively unimportant in the big picture. NCCI and WCRI reports suggest that the costs of surgeries are a minor share of the total medical costs of these claims. The biggest questions are: is surgery appropriate and will the result achieve both the clinical and vocational goal?

To address these questions, consider first the risk of potential medical errors. This risk, it turns out, is not just about what happens in the operating room, it’s also about deciding if the patient should enter the room. Take MRIs, a standard diagnostic tool used to rule in or out surgery. In one study, 10 diagnostic interpretations on one patient were so varied one could not find a consensus for either conservative care or surgery. The Occupational Health Institute at Best Doctors reports that orthopedic surgeons change their diagnoses a-third of the time. Its finding reflects the wide variations in individual physician practice patterns and the pressing need for user friendly tools to measure physician quality.

And we should be concerned about the performance of doctors who initially see the patient and, upon their evaluation, recommend that the patient be referred to a surgeon. To understand the role of the initial treating doctor, I spoke with Michael Shor, managing director of Best Doctors Occupational Health Institute, and John Burress, an occupational medicine specialist at OccMed Consulting & Injury Care. The both work in the Boston area.

How knee problems are evaluated captures the essence of what the initial doctor is supposed to do. The worker presents, maybe, with a possible meniscus or anterior cruciate ligament tear. The doctor’s first task is to create an atmosphere of trust. Then, taking a history, the doctor needs to determine how the problem arose out of work, if her patient had knee problems earlier, how they relate to other health issues.

She needs to define the condition precisely, such as what kind of tear if there is one at all. A well interpreted MRI exam may produce a highly reliable finding for or against surgery. But Burress told me that MRIs can produce false positives and false negatives. Her job is not yet done. She needs to assess whether surgery is a consideration and which (not any) surgeon is the best to treat this particular patient and clinical problem.   

And the doctor needs to help her patient set realistic expectations for treatment, time off work, and recovery.

Dr. Burress says that both a prompt MRI exam and a recommendation that surgery be done expeditiously may conflict with the utilization review guidelines of the claims payer. In that case, the doctor may need to get on the phone with the payer, without additional compensation. 

This same process the doctor follows for shoulder and low back conditions, for which the care pathways are more challenging, since the body mechanics are that much more complex.

Stepping back, we can see that if the initial treating doctor does not perform these tasks, which must be dealt with in one or two time-limited office encounters, then the case is compromised. The surgery outcomes will be compromised.  

Add, now, an even bigger problem: many surgeons have mediocre skills in what is called patient selection. Some surgical candidates, for reason of pre-injury risk factors such as obesity, smoking, histories of depression, etc., have poor prospects for recovery after surgery. These major risks for recovery failure fly under the radar of utilization review and treatment guidelines.

Summing up, we see that one way to improve surgical outcomes for injured workers is to improve the triaging of patients into surgery, by well-trained initial treating doctors. There are not many of them: only about 1,500 occupational medical clinics exist, plus a relative handful of occ med doctors like Burress who work out of a small practice yet cover many aspects of occupational medicine.

Are you investing enough in this aspect of reducing surgery risks? Have you invested enough in making sure the medical care is optimal before surgeon sees the patient?

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