For our November discussion, we took a look at the both “Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis” (https://www.jhandsurg.org/article/S0363-5023(22)00385-9/fulltext) and “Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System” (https://www.jhandsurg.org/article/S0363-5023(22)00466-X/fulltext), both of which can be found in Volume 47, Issue 11 of The Journal of Hand Surgery. We thank everyone who participated, especially those who joined us for their first time!
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Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
J Hand Surg Am- ASSH @JHandSurg:
November’s #JHSJC is happening NOW! Let’s get the discussion going.
David Kalainov MD MBA @dkalainov:
I’m new to Twitter. Can you see this message. Dave K #jhsjc
RyanC @RPCalfeeSTL to @dkalainov:
We can see message David K! Welcome #jhsjc
David Kalainov MD MBA @dkalainov:
Great. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
you’re in! #jhsjc
Brent Graham @BgTalkinman:
Welcome to the November discussion! #jhsjc
If you are not using the TwChat chatroom please remember to add the JHSJC hashtag #jhsjc
Since we have @dkalainov with us, let’s start with his article, https://www.jhandsurg.org/article/S0363-5023(22)00466-X/fulltext #jhsjc
David Kalainov MD MBA @dkalainov:
Ok, ready. #jhsjc
Brent Graham @BgTalkinman:
The authors report the results of an attempt to help guide post-op opioid prescriptions in hand surgery, general plastic surgery, general orthopaedic surgery and spine surgery across a 10-institution health system using a prescribing tool embedded in their EMR. #jhsjc
The prescribing recommendations were based on a stakeholder team who reviewed the literature and created a 4-tiered system of expected opioid requirements in each of the four clinical areas and then compliance was measured from a dashboard. #jhsjc
RyanC @RPCalfeeSTL:
I really like the effort to improve care with trying to standardize this #jhsjc
Brent Graham @BgTalkinman:
Over 1-yr, the mean system-wide compliance with the recommendations improved by less than 5%. #jhsjc
Just for context here, does anyone else have experience with a similar system in their institution? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
We have worked to decrease opioid use but individualized without a system #jhsjc
Warren @whammert to @RPCalfeeSTL and @BgTalkinman:
same for me at two institutions. #jhsjc
Brent Graham @BgTalkinman:
What I am asking is whether others have similar guidelines for opioid prescribing or, for that matter, any other form of decision support embedded in the EMR? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
We have no such system. #jhsjc
David Kalainov MD MBA @dkalainov:
Multi factorial problem in gaining traction with an electronic order set in a multi hospital healthcare system. Disparate prescribers, different workflows in EHR, ability to personalize EHR, inconsistent messaging and leadership support, no incentivization, no feedback… #jhsjc
Warren @whammert to @BgTalkinman:
We have had a relative consensus within the division- xx for soft tissue cases,yy for bone procedures, but nothing in the EMR to guide this #jhsjc
RyanC @RPCalfeeSTL to @dkalainov:
I am very interested then in what your next steps are to get more traction. Are you trying anything new with it already? #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
Is this something to blame the doctors for or is it an issue with the EMR/implementation? #jhsjc
“blame” is probably too strong a word – what I am getting at is whether this is some kind of intransigence related to custom, unwillingness to change etc? #jhsjc
David Kalainov MD MBA to @dkalainov:
Consensus on prescribing and use of specific order sets is easiest in single group and single institution settings for multiple reasons. With ever enlarging healthcare systems, there is loss of consensus, peer support, collegial feedback, single leadership support. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
so what is the answer there? Does every place have to have its own approach to implementing programs like this? #jhsjc
David Kalainov MD MBA @dkalainov:
We are all doing better as opioid prescribers, for the most part. I think the most important finding in our paper is the difficulties encountered in changing prescriber behavior in a large healthcare system. ERASs and other EHR efforts are tough to push out for adoption. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
Does this speak to a bigger question of the role of decision support programs? Do they have a future? #jhsj
Aaron Kearney @aaronkearney:
My own opinion, I do think decision support has a future, it is just a question of how much focus a hospital wants to put on it. #jhsjc
David Kalainov MD MBA to @dkalainov:
If more than 1 Hospital, the approach to change requires a lot of messaging, leadership support, an understanding of work flows, and likely incentivization of sorts. Gov laws can push, but ? I believe our PCPs are incentivized to complete Medicare Annual Wellness visits. #jhsjc
Aaron Kearney @aaronkearney:
I see a giant pop-up in Epic every time a patient has an incidental CXR finding and it recommends ordering a follow-up CT. The prompts with opioid prescribing have not reached that level of “alerting” the surgeon #jhsjc
David Kalainov MD MBA @dkalainov:
Clinical decision support tools have a future, but likely with “invisibility” and easy/friendly prompting. Example, AI to assess patient variables and procedure to provide a precision medicine rec for pain. #jhsjc
Dafang Zhang @DafangZhang:
We have a post-op opioid protocol for the hand/upper extremity division that has really helped standardize prescribing, but not institution-wide #jhsjc
Brent Graham @BgTalkinman to @DafangZhang:
I think that that is like what @whammert and @RPCalfee both describe. I get that this piecemeal approach works bc there has been steadily increasing awareness but the findings in this paper raise questions for me about decision support programs in general. #jhsjc
Jack Michaud @JackMichaud to @dkalainov and @aaronkearney:
Really enjoyed the paper. Were you able to see how individual uptake went? (e.g., once a physician started to use it, they continued…?). #jhsjc
David Kalainov MD MBA @dkalainov:
Current clinical decision support tools can be a burden in one’s workflow, although with good intentions. Our healthcare system is now very careful about implementing new BPAs in Epic. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
I hope you are correct but seemingly this was a small undertaking (for the users, not the developers) that didn’t really succeed as might have been expected. It is disappointing if the only thing that works are incentives. #jhsjc
Brent Graham @BgTalkinman to @JackMichaud:
this is a good question. I think the paper showed that those who were invested in it showed continued improvement during the observation period. #jhsjc
David Kalainov MD MBA @dkalainov:
We excluded cancer, peds, and hip/knee arthroplasty in the clinical decision support tool for specific reasons. Of note, our joint docs created an ERAS for the entire healthcare system. A lot of pushback from other arthroplasty docs on the pain med part. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
Why did they push back? #jhsjc
David Kalainov MD MBA @dkalainov:
I heard that not everyone in joints was at the “table”. Difficulty is that even when we are invited to the table, we don’t always take up the offer. Very hard to get people to help design/contribute outside if one’s own sphere of influence. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
Agreed! #jhsjc
Aaron Kearney @aaronkearney to @jackmichaud:
That is one analysis I wish we could’ve done. We were able to see what % prescribed in line with the suggested amounts, but no way for us to see what % of users opened the order set and unchecked the suggested pill amt., etc. #jhsjc
Brent Graham @BgTalkinman to @aaronkearney:
That would be very interesting to know. #jhsjc
Jack Michaud @JackMichaud to @aaronkearney:
Thanks for the reply. It seems like the order set would be more efficient. Just a matter of having it be the cognitive default for ordering physicians in their workflow. #jhsjc
Brent Graham @BgTalkinman to @JackMichaud:
Maybe when the luddites are gone that is what it will look like. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
even if a small undertaking, it’s effort. CDS tools need to provide benefit to user. Most surgeons may feel they prescribe well without it. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I agree that is what they may think but it doesn’t seem to be very well-supported by these findings since the protocols were based on a consensus of stakeholders. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
Even if protocol designed by stakeholders, in the moment of prescribing (amongst all other distractions/ongoing issues) a lot of surgeons are likely confident in their behavior and “dont need the help” especially if it takes time #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Presumably the blame may then be best placed on the EMR itself. Surely that could be streamlined so that it wouldn’t take more time and could leverage the advantages of decision support more effectively! #jhsjc
Dafang Zhang @DafangZhang to @BgTalkinman, @whammert, and @rpcalfee:
Really interesting question about “bottom up” versus “top down” incentive programs. Perhaps one of the reasons these piecemeal programs are effective is because the end-users designed and have buy in? #jhsjc
Brent Graham @BgTalkinman to @DafangZhang:
That is clear from the findings of this study and as @dlalainov indicated, awareness probably played a large role in that #jhsjc
Aaron Kearney @aaronkearney:
Re @dkalainov’s point, may be more effective to have prompting that appears when a surgeon tries to write an rx for discharge — my suspicion is that some surgeons bypass the order set where the suggested pill quantities appear & never see suggested amounts #jhsjc
David Kalainov MD MBA @dkalainov:
Hopefully, the mistakes we made in thinking that a tool like this would be an automatic “accept” by surgeon stakeholders won’t be made by others. Expensive and time consuming. #jhsjc
The EHR does provide too much latitude for an initiative like a universal order set. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
Even if it wasn’t as successful as hoped for, it’s an excellent starting point and people will learn from those experiences. #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other study: out-of-pocket expenses for pts undergoing common hand procedures. #jhsjc
The authors examined out-of-pocket and total costs associated with five common hand surgery procedures in the outpatient setting between 2008 and 2016. #jhsjc
The paper makes the interesting observation that the elective nature of much of hand surgery means that OOP costs might allow patients to essentially shop for the best deal as it were. #jhsjc
What might the impact of that kind of “shopping” be for the average practitioner? Will there – can there — be discounting of prices to compete for patients concerned about OOP? #jhsjc
David Kalainov MD MBA @dkalainov:
Hospitals are perversely incentivized to creat contiguous outpatient surgery centers rather than ASCs, driving up the costs of healthcare in the US. More and more docs in the US are becoming employed by Hospital groups. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
What is the impact of that for patients in terms of OOP? #jhsjc
David Kalainov MD MBA @dkalainov:
Consumers don’t shop for best surgical prices in Chicago. They are directed to surgeons by friends, PCPs, insurance network stipulations. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
So is the idea that there is “greater patient choice and price sensitivity, where patients may be able to choose lower-cost centers to minimize OOP costs.” – a direct quote from the paper – not a reality? #jhsjc
Jack Michaud @JackMichaud to @BgTalkinman:
Patient “shopping” is dependent on availability of price transparency tool. Currently, these are cumbersome, inaccurate, and not easy to access. But they are definitely becoming more available. Stanford has one, but only for select services. #jhsjc
RyanC @RPCalfeeSTL to @JackMichaud:
I wish we had more price/cost transparency. I know OR is never inexpensive but very hard to know both true bills generated and even harder to know out of pocket for patients #jhsjc
Brent Graham @BgTalkinman to @JackMichaud:
Agreed that transparency is an important concern but a person will know how much they are going to have to pay for a service OOP. Will that not just bypass the issue of price transparency? #jhsjc
Jack Michaud @JackMichaud to @dkalainov:
Re: contiguous outpatient hospital vs. ASC, In our study – outpatient hospital was ~$70 more in OOP costs for the patient compared to ASC. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Does that mean when a patient plans an elective procedure with you, they don’t know what their OOP costs will be until a later time?
RyanC @RPCalfeeSTL to @BgTalkinman:
Mostly yes. They have to call their insurance and inquire about out of pocket costs as every plan is different and OOP costs vary with deductibles and how much they have spent year to date. Very hard. #jhsjc
BUT – they know exactly if have no deductible left and have no more OOP cost for year – then want everything done #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Chaos!! #jhsjc
David Kalainov MD MBA @dkalainov:
Price transparency I’d now required by US law. But, not adhered to by all insurance carriers and hospitals. The final bill is tough to calculate accurately in advance (facility, surgeon, anesthesia). #jhsjc
Brent Graham @BgTalkinman:
Office-based procedures were associated with lower OOP. But, a study just published in JHS in the last few days (https://jhandsurg.org/article/S0363-5023(22)00509-3/fulltext) shows that there hasn’t been much movement towards office-based procedures. #jhsjc
Brent Graham @BgTalkinman:
Before we finish, I want to get to this… #jhsjc
As the paper indicates, the increasing costs in hand surgery are being disproportionately borne by patients in the form of OOP. That seems likely to have inevitable effects on access and worsen already substantial disparity. What can hand surgeons do to lessen that effect? #jhsjc
Dafang Zhang @DafangZhang to @BgTalkinman:
As much of hand surgery is elective, oop can deepen disparities.. all the more reason to practice cost effective care #jhsjc
David Kalainov MD MBA @dkalainov:
Office based procedures make sense, but the infrastructure costs may outweigh the financial returns for providers. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
There will be a timely article about that in The Hand Surgery Landscape next month! #jhsjc
Brent Graham @BgTalkinman:
Are those increasing OOP going to further limit access to care? #jhsjc
Jack Michaud @JackMichaud to @dkalainov:
Yes interesting new CMS guidelines re: price transparency (https://cms.gov/hospital-price-transparency) Unsure the downstream impact of this specifically. But long term, I think price will becoming importance to patients in choosing where they get care #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
Yes, as OOP costs rise (and if more surgeons move to ASC rather than HOPD), access will likely get worse. #jhsjc
David Kalainov MD MBA @dkalainov:
I don’t think access to care will be the issue. I think a patient’s willingness/ability to pay is more of the issue. People can default on there medical bills without a lot of repercussions in the US. #jhsjc
Brent Graham @BgTalkinman @dkalainov:
ability to pay and limited access seem like the same thing to me! #jhsjc
I’m sure defaulting on medical costs isn’t easy! #jhsjc
David Kalainov MD MBA to @dkalainov:
Kind of related…Anyone can seek care in an ER regardless of ability to pay. There are also safety net hospitals. Timely elective care is an issue in safety net hospitals. #jhsjc
Brent Graham @BgTalkinman to @dkalainov:
Needless to say, these are not issues in a single payer system. Thanks for participating! It was great to have you.
David Kalainov MD MBA @dkalainov:
Thanks! Fun chatting. Dave #jhsjc
Jack Michaud @JackMichaud to @BgTalkinman:
I do think access will suffer as OOP costs increase. Would be interesting to see if patients delay treatment (such as for CTS) if they have higher OOP vs those with low OOP. Challenging study to design though! #jhsjc
Brent Graham @BgTalkinman to @JackMichaud:
I agree that would be very interesting and I hope someone looks at that. #jhsjc
Brent Graham @BgTalkinman:
Terrific discussion! Thanks to everyone for their ideas and input on these two interesting papers. We return Dec 13 @ 9 pm EST #jhsjc
Jack Michaud @JackMichaud:
Thanks all for the discussion and the interest in these paper! #jhsjc
