Does Transparency of Ankle Implant Costs Influence Surgeon Behavior?

Background: Ankle fractures are a common injury treated by orthopaedic surgeons. Unstable, displaced ankle fractures are often fixed with open reduction internal fixation (ORIF) using different implant constructs at various cost. No study to date has looked at transparency in ankle implant costs to surgeon behavior. Our surgeons self-identified that the biggest barrier for lowering implant cost was the lack of cost transparency. This was a surgeon-led-study to evaluate whether increased transparency in implant costs affected surgeon behavior. Methods: Monthly operative logs from December 2021 to September 2022 were reviewed at our level 1 trauma center for operative fixation of ankle fractures. The cost data of each fixation construct was reported to trauma-trained surgeons at the end of each month from March 2022 to June 2022. Average costs of implants were compared before and after education. A linear mixed model was used to explore what factors were associated with changes in costs. Surgeons also participated in a poststudy survey. Results: The implant costs of 110 ankle fracture fixations were reviewed over the period before education (n = 60), during education (n = 30), and after education (n = 20). The mean implant cost difference for unimalleolar fractures was -$204.80 (P = .68), whereas the mean cost difference for bimalleolar fractures was -$9.82 (P = .98). Trimalleolar fractures had a mean cost difference of +$94.47 (P = .84). Linear mixed model demonstrated fracture pattern as the only factor significantly associated with implant costs (P < .01). Post-education surgeon survey revealed that 6 of 7 surgeons felt that monthly updates affected their implant selection. However, only 2 surgeons demonstrated a change in practice with decreased implant costs during the study. Conclusion: The majority of surgeons self-reported being influenced by the implant cost education, but the detected change in implant cost was only observed in less than one-third of surgeons. Our results suggest implant selection and related costs are not influenced by increased cost transparency education alone. Level of Evidence: Level III, case control study.

Redesigning continuing professional development: Harnessing design thinking to go from needs assessment to mandate.

BACKGROUND: The world of medicine is constantly changing, and with it the continuing professional development (CPD) needs of physicians. As the CPD landscape is shifting away from unidirectional delivery of knowledge through live large group learning (conferences) and is placing increased emphasis on new approaches for skills training not taught a decade ago, a new approach is needed. APPROACH: Using design thinking techniques, we hosted a full-day retreat for emergency medicine stakeholders in Hamilton and the surrounding region. Prior to the retreat we collected medico-legal data on emergency physicians in our region and performed a needs assessment survey. At the retreat, we had participants brainstorm ideas for CPD, generate archetypes for end-users, then generate solutions to the problems they had identified. These proposals were presented to the larger group for feedback and refinement. EVALUATION: The Design Thinking Retreat generated five main pillars for action by our CPD team. 1) Simulation/procedural learning (staff simulation, procedural skills day, in situ simulation); 2) Asynchronous learning (website and podcast); 3) Synchronous learning (small group sessions for staff); 4) Community connectivity (online platform for collaboration and communication); and 5) Coaching & mentorship (focused coaching for specific practice improvement, improved onboarding for new staff). REFLECTION: These ideas have vastly increased engagement in CPD. Stakeholder consultation via design thinking may be a key approach for educators to use.

Linagliptin-Associated Alopecia and Bullous Pemphigoid.

Bullous pemphigoid is a chronic autoimmune blistering disease. Recently, several reports suggested dipeptidyl peptidase 4 (DPP-4) inhibitors, also known as gliptins, were a potential cause of drug-induced bullous pemphigoid but not of both bullous pemphigoid and alopecia areata together. Here we describe the case of a 68-year-old man with type 2 diabetes mellitus who developed new onset diffuse alopecia on the scalp with diffuse tense bullae over his body a few months after linagliptin was introduced for better control of his diabetes. DPP-4 inhibitors are not known to increase the risk of alopecia. To the best of our knowledge, this is the first report of linagliptin-associated alopecia areata and bullous pemphigoid, which may help demonstrate if there are any links between DPP-4 inhibitors and alopecia. LEARNING POINTS: This is the first report of linagliptin-associated alopecia areata and bullous pemphigoid (BP), which may help demonstrate a link between DPP-4 inhibitors and alopecia.Since the time of onset of BP after initiation of a DPP-4 inhibitor varies, a high index of suspicion is needed for diagnosis.Early diagnosis is essential as DPP-4 inhibitor withdrawal has a significant effect on disease remission.

Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate.

BACKGROUND: Total joint arthroplasty (TJA) episodic payment models shift risk and cost of periprosthetic joint infection (PJI) to surgeons and hospitals, causing some to avoid treating high-risk patients. Furthermore, there are little data to support optimization of host factors preoperatively to decrease PJI, and recent literature supports using extended antibiotic prophylaxis following reimplantation TJA. The purpose of this study was to evaluate whether extended oral antibiotic prophylaxis minimized PJI after primary TJA in high-risk patients. METHODS: A retrospective cohort study was performed of 2,181 primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs) carried out from 2011 through 2016 at a suburban academic hospital with modern perioperative and infection-prevention protocols. Beginning in January 2015, extended oral antibiotic prophylaxis for 7 days after discharge was implemented for patients at high risk for PJI. The percentages of patients diagnosed with PJI within 90 days were identified and compared between groups that did and did not receive extended oral antibiotic prophylaxis, with p ≤ 0.05 indicating significance. RESULTS: The 90-day infection rates were 1.0% and 2.2% after the TKAs and THAs, respectively. High-risk patients without extended antibiotic prophylaxis were 4.9 (p = 0.009) and 4.0 (p = 0.037) times more likely to develop PJI after TKA and THA, respectively, than high-risk patients with extended antibiotic prophylaxis. CONCLUSIONS: Extended postoperative antibiotic prophylaxis led to a statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection. We encourage further study and deliberation prior to adoption of a protocol involving extended oral antibiotic prophylaxis after high-risk TJA, with the benefits weighed appropriately against potential adverse consequences such as increasing the development of antimicrobial resistance. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does testing enhance learning in continuing medical education?

BACKGROUND: There has been growing interest in using theory-driven research to develop and evaluate continuing medical education (CME) activities. Within health professions education, testing has been shown to promote learning in a variety of different contexts, an effect referred to as test-enhanced learning (TEL). However, the extent to which TEL generalizes to CME remains unclear. The purpose of this study was to investigate whether physicians who received two intervening tests following a CME event would experience a TEL effect relative to physicians who received additional study material to review without testing. METHODS: Forty-nine physicians were recruited during a local CME activity. Physicians were randomized to either a) the test group (n=26), where participants completed two 20 multiple-choice question (MCQ) quizzes related to the lecture content or b) the study group (n=23), where participants studied the same information without testing. Testing and studying occurred independently during the CME activity, and then four weeks later online. At eight weeks, participants completed a final 20-item MCQ online test. A between-subjects t-test was used to compare performance on the final test as a function of the initial educational activity (test group vs. study group). RESULTS: Performance on the final MCQ test was equivalent for both test (Mean (SD): 75% (9.9)) and study-only (77% (7.3)) conditions (t(47) = 0.94, p=0.35). CONCLUSION: The null findings in the present study are contrary to previous findings demonstrating TEL among novice learner populations. The lack of TEL highlights several programmatic considerations that should be factored in before implementing TEL as a part of CME.

An innovative approach to identifying learning needs for intrinsic CanMEDS roles in continuing professional development.

CONTEXT: The CanMEDS framework promotes the development of competencies required to be an effective physician. However, it is still not well understood how to apply such frameworks to CPD contexts, particularly with respect to intrinsic competencies. OBJECTIVE: This study explores whether physician narratives around challenging cases would provide information regarding learning needs that could help guide the development of CPD activities for intrinsic CanMEDS competencies. METHODS: We surveyed medical and surgical specialists from Southern Ontario using an online survey. To assess perceived needs, participants were asked, 'Describe three CPD topic you would like to learn about in the next 12 months'. To identify learning needs that may have arisen from problems encountered in practice, participants were asked, 'Describe three challenging situations encountered in the past 12 months.' Responses to the two open-ended questions were analyzed using thematic content analysis. RESULTS: Responses were received from 411 physicians, resulting in 226 intrinsic CanMEDS codes for perceived learning needs and 210 intrinsic codes for challenges encountered in practices. Discrepancies in the frequency of intrinsic roles were observed between the two questions. Specifically, Leader (28%), Scholar (43%), and Professional (16%) roles were frequently described perceived learning needs, as opposed to challenges in practice (Leader: 3%; Scholar: 2%; and Professional: 8%. Conversely, Communicator 39%, Health Advocate 39%, and to a lesser extent Collaborator 11%) roles were frequently described in narratives surrounding challenges in practice, but appeared in <10% of descriptions of perceived learning needs (Communicator: 4%; Health Advocate 6%; Collaborator: 3%). CONCLUSION: The present study provides insight into potential learning needs associated with intrinsic CanMEDS competencies. Discrepancies in the frequency of intrinsic CanMEDS roles coded for perceived learning needs and challenges encountered in practice may provide insight into the selection and design of CPD activities.

Contemporary Dual Mobility Head Penetration at Five Years: Concern for the Additional Convex Bearing Surface?

BACKGROUND: Dual mobility (DM) bearings are increasingly popular and second-generation designs contain highly cross-linked polyethylene. The purpose of this study is to report head penetration rates in modern DM bearings. METHODS: A review of 63 consecutive DM bearings was performed. Radiographs were analyzed for head penetration using Martell methodology at regular postoperative intervals. RESULTS: Thirty-four DM bearings were analyzed. Mean linear head penetration was 1.59 mm/y at 1 year, 1.07 mm/y at 2 years, and 0.27 mm/y at 5 years following an exponential regression model (R2 = 0.999). Mean volumetric wear was 783 mm3/y at 1 year, 555 mm3/y at 2 years, and 104 mm3/y at 5 years following an exponential regression model (R2 = 0.986). CONCLUSION: Initial head penetration of DM bearings is larger than contemporary cross-linked polyethylene bearings; however, rates approach steady state after 2 years, analogous to traditional bearings. The larger "bedding-in" head penetration may be due to the additional convex bearing surface, creating 2 surfaces for deformation/wear.

Mid-term Results of Femoral and Tibial Osteotomies and Fassier-Duval Nailing in Children With Osteogenesis Imperfecta.

BACKGROUND: Patients with osteogenesis imperfecta (OI) have significant burden of both fractures and bony deformities. The present approach to care in this disorder is a combination of surgical care with intramedullary rod fixation, cyclic bisphosphonate therapy, and rehabilitation with goal of maximizing patient function and quality of life. METHODS: Retrospective chart review identified 58 children with OI who had realignment osteotomies with Fassier-Duval (FD) intramedullary nailing of the lower extremity by a single surgeon. This is a consecutive series treated between 2003 and 2010. Postoperatively, patients were followed up clinically and radiologically. Motor function was assessed using the Brief Assessment of Motor Function score and the walking scale subset of the Gillette Functional Assessment Questionnaire. RESULTS: Fifty-eight patients had 179 lower extremity FD intramedullary rods placed. This technique allowed for intervention on multiple long bones, with 29% having bilateral femur and tibial rodding in the same procedure. Revisions were required in 53% of patients, which occurred at a mean time of 52 months after initial rodding surgery. In most cases, revision surgery was related to patient growth and subsequent fracture, although rod migration did occur in a minority of patients. Nonunion or incomplete union was 14.5% in this series. Bisphosphonate infusion was not postponed after surgical procedures. Patients had improvement in mobility status at the latest follow-up. CONCLUSIONS: This series lends evidence to the medium-term utility of FD intramedullary rods as an effective and less invasive platform for stabilization and correction of deformity in long bones of patients with OI. Relatively low blood loss and relatively short hospitalizations were noted. Nonunion rate was comparable with existing literature noting that our patients did not have postsurgical postponement of bisphosphonate therapy. LEVEL OF EVIDENCE: Therapeutic study to investigate the results of treatment with FD rods. Retrospective case series model of Level IV evidence quality.

Effectiveness of test-enhanced learning in continuing health sciences education: a randomized controlled trial.

BACKGROUND: Increasing concerns over the effectiveness and quality of continuing medical education (CME) programs has encouraged educators to use theoretically driven empirical research to improve the educational value of these activities. Within cognitive psychology, theories of learning and knowledge acquisition, such as test-enhanced learning (TEL), may be used to enhance the effectiveness of CME protocols and delivery. The present study examined whether the pedagogical benefits of testing can be observed in practicing physicians. METHODS: A total of 83 physicians were recruited following an education session on constipation management and were randomized to either (a) the test condition (n = 43), where learners wrote a short test consisting of 10 short-answer questions (SAQs), or (b) the study condition (n = 40), where learners studied the same information. Four weeks later, 56 (68%) physicians completed a final test with 10 new SAQs, with 27 being from the initial test condition and 29 belonging to the initial study condition. RESULTS: Performance on the final SAQ test was equivalent for both test (42.5%) and study-only (41.2%) conditions (p = .71). DISCUSSION: The null findings in the present study are inconsistent with previous research showing the pedagogical benefits of testing relative to studying. Given that most TEL research focuses on novice learners, who lack strong associative memory networks, it is possible that TEL is specific to novices and not generalizable to experts. Alternative explanations focus on the importance of repeated, distributed testing with feedback.