Benchmarks in Orthopaedic Care: Not without Pitfalls

Karl-André Lalonde, M.D., FRCSC
Ottawa, ON

Over the last few years, timely access to care has become a problematic issue for Canadian orthopaedic patients. In an effort to address this problem, payors and health care administrators have adopted "access to care" parameters so that waiting times do not exceed certain established benchmarks. In most cases these benchmarks are based on available evidence and have been established by surgeons themselves who have then lobbied health organizations to adopt them.

 

It is generally accepted that articulating benchmarks can help us in improving quality of care for our patients. The pitfalls arise when government payors dedicate so many resources to these targeted patients that they become detrimental to other orthopaedic patients.

Managed care risks removing some of the decision-making from clinicians and placing it in the hands of administrators. In Ontario for example, hip fracture patients are now prioritized based on benchmarks: all hip fracture patients are to undergo surgery within two days of presentation to the emergency department. Hospitals are assessed based on their ability to meet this benchmark. In response to imperatives imposed by the benchmarks, hospital administrators mobilize their finite resources so that the hip fracture patients can get their surgery within the prescribed timeframe.

The result of such a measure can be that hip fracture care is expedited, but often at the expense of other non-elective patients with tibial plateau fractures, femur fractures or upper extremity fractures for whom no benchmarks exist. The patients who are not prioritized are therefore pushed down the surgical wait list to allow the hip fracture patients to jump the queue.

Cannibalization of resources for a specific subgroup of patients may be good for this subgroup, but implementation has to be done with respect to the rest of our patients. On the elective orthopaedic side, the experience over the last few years has given us a first hand look on how devoting resources to hip and knee arthroplasty has led to relative neglect of the rest of the orthopaedic patients (spine, shoulder, foot and ankle...).When used indiscriminately, hip fracture benchmarks may lead to similar problems with the rest of our fracture patients.

Managing resources can also be a challenge for on-call surgeons. When administrators prioritize a hip fracture, they sometimes fail to appreciate the other imperatives the clinician is facing. They may be unaware of the necrotizing fasciitis case in the ICU, the young patient with displaced femoral neck being transferred or the subspecialty case that needs to be done by the specific surgeon on call. Achieving the benchmark becomes the only priority and while it may often be desirable, clinicians need to retain the ability to manage the resources available and set their own clinical priorities.

Prioritizing patients within the orthopaedic service should always be the surgeons' role; each patient is unique and hospital managers and nursing coordinators will never have the understanding of the clinical subtleties which influence our decisions on a daily basis.

In conclusion, the issue is not really with benchmarks themselves, but with the implementation of such goals. These types of goals have to be used with consideration to the resources available and the clinical imperatives facing the orthopaedic service. Some discretion needs to remain with the clinician and we cannot allow administrators to dictate our clinical priorities.

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