June_19_TM_Commentary

Former Texas Medical Association President Josie Williams, MD, was tenacious in advocating that organized medicine pay zealous attention to two topics: data and guidelines. In this, she was both sage and prescient.

We have done well in following her recommendations on data, but we continue to fall far short of where we need to be on guidelines.

Dr. Williams, whom I treasure as a mentor, told us that we needed to be intrinsically involved in collecting data on our practices and tracking results, that we needed to develop the metrics used, and we needed to own the results – the owner of the data in large part would own health care. Physician involvement in accountable care organizations, bundled payment projects, and large practice analysis have helped safeguard practice viability as well as increase value in patient care. We are not where we need to be yet, but we are improving.

Dr. Williams also held the seemingly anodyne position that we practice better when we follow guidelines. In a best-case scenario, this is apodictic, but it depends on the quality of the guidelines.

A trio of recent articles in the Journal of the American Medical Association (JAMA), supplemented by some additional literature, point to this problem.

Guidelines promulgated by the American Academy of Orthopaedic Surgeons (AAOS) suggest both cortisone injection and tramadol as early, pre-operative agents for osteoarthritis of the knee. The fact that cortisone is a potent catabolic agent and that osteoarthritis of the knee is a primarily mechanical, not inflammatory, process gave some surgeons pause, especially when multiple bench studies have shown that cortisone causes apoptosis of chondrocytes. Tramadol is an opioid agonist, and the most common dose of tramadol is equal to the most common dose of hydrocodone in morphine milligram equivalents. Numerous studies have already shown that patients on opioids prior to knee or hip replacement have longer stays, poorer pain control, higher complications, and (for knees) higher revision rates, both early and late.

In May 2017, a randomized controlled trial published in JAMA showed statistically significant cartilage volume loss in knees subjected to cortisone injections, with no mid-term nor long-term pain benefit.1 In March of this year, a JAMA-published study with about 89,000 patients showed a statistically significant increase in all-cause mortality in patients on tramadol compared with three different nonsteroidal anti-inflammatory agents.2 This second study also pointedly noted that tramadol is a first-line treatment for osteoarthritis in guidelines by both the AAOS and its comparable organ for rheumatology.

Now, in March of this year, comes another article in JAMA pointing out that the American College of Cardiology/American Heart Association guidelines derive from very few randomized controlled trials, and there has been very little improvement in the 10 years between 2008 and 2018.3 What are we to do?

TMA members tend to be members of their specialty societies, and TMA has always counted amongst its members leaders in all walks of organized medicine. We can no longer allow treatment guidelines to be promulgated by a consensus of elder statesmen, or a vote on a report by a special committee. The first is prone to evidence-based medicine of the level 5 variety – expert opinion – and is no better than a parliamentary body guided by the technique of “Loudest Voice in the Room.” The second is tailor-made to suppress meaningful debate – surely our expert committee would not give us a report that needs modification. Let’s vote and move on.

Dr. Williams was and is right: We are far better if we follow guidelines, but only if they are properly derived. They must come from peer-reviewed studies in refereed journals, which are at least large cohort studies, and preferably randomized controlled trials.

Since all commentary apparently now requires at least one sports metaphor, let me close with this: Dr. Williams has gotten us into the red zone – we need to push this across the goal line.

Dr. Brotherton is an orthopedic surgeon in Fort Worth. He was TMA president in 2013-14.

References

1. McAlindon T, LaValley M, Harvey W, Price L, Driban J, Zhang M, Ward R. Effects of Intra-Articular Triamcinolone v Saline on Knee Cartilage Volume and Pain with Knee Osteoarthritis. JAMA. 2017 May 16;317(19):1967-1975. doi: 10.1001/jama.2017.5283.

2. Zeng C, Dabreuil M, La Rochelle MR, Lu N, Wei J, Choi HK, Lei G, Zhang Y. Association of Tramadol with All-Cause Mortality Among Patients with Osteoarthritis. JAMA. 2019 Mar 12;321(10):969-982. doi: 10.1001/jama.2019.1347. (See also Schwenk in NEJM Journal Watch March 14, 2019).

3. Fanaroff A, Califf R, Windecker S, Smith S, Lopes R. Levels of Evidence Supporting ACC/AHA and European Society of Cardiology Guidelines, 2008-2018.  JAMA. 2019 Mar 19; 321(11):1069-1080. doi:10.1001/jama.2019.1122.

Tex Med. 2019;115(6):4
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June 03, 2019