Letter to Editor: Editorial: Appropriate Use? Guidelines on Arthroscopic Surgery for Degenerative Meniscus Tears Need Updating

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To the Editor,
We at the Society for Patient Centered Orthopedics appreciate Dr. Leopold's call for the American Academy of Orthopaedic Surgeons (AAOS) to update their appropriate-use criteria regarding partial meniscectomy in patients with osteoarthritis of the knee [4]. The clinical evidence he documents makes a highly compelling case. We also agree with Dr. Zywiel and his colleagues [7] that physicians are best suited to lead efforts to improve medical effectiveness by developing and implementing evidence-based guidelines. Absent such physician leadership, insurers and other payers will inevitably follow a blunt instrument approach that includes both effective and ineffective surgical procedures. This will lead to increased frustration for both patients and their surgeons.
As a small orthopaedic society, we have been engaged with insurers, such as Blue Shield of California, in developing patient-centered, evidence-based preauthorization and evaluation programs to help maximize the effectiveness of orthopaedic care. This includes a focus on shared decision making and the development of evidence-based decision aids to help patients better understand the risks and benefits of proposed procedures. We hope the AAOS will become an even bigger player in this space and make such efforts a core component of our quality programming.
We believe that the list of low-value interventions is long and includes such procedures as open reduction and internal fixation of adolescent clavicle fractures, vertebroplasty, and repair of degenerative rotator cuff tears in elderly individuals. For these interventions, there is either scant evidence of their need and effectiveness or good evidence for low-value [1-3, 5, 6]. We urge the AAOS to call attention to these low-value orthopedic procedures through public forums such as the Choosing Wisely campaign
A sharp focus on higher-value care will undeniably lead to changes in current practice patterns and will not be universally accepted; however, it will undoubtedly lead to both higher-quality care delivered to our patients and higher levels of physician satisfaction over time. These efforts deserve no less attention and resources than does our work developing new, effective treatment options. Both lead to better value for our patients.
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