Fall 2006

Outcomes: The Tough Job of Finding What Works

In the practice of orthopaedic surgery, the simplest questions are often the hardest to answer. When two seemingly similar patients get the same hip replacement, why does one seem to recover so much better than the other? How does one evaluate the improvement in quality of life provided by a knee replacement, and how does one decide when the benefits of the operation outweigh the costs and risks?

UCSF researchers are committed to conducting a number of long-running studies to assess clinical outcomes of operative and nonoperative management of orthopaedic disorders. For orthopaedic surgeon Sigurd Berven, M.D., careful studies of therapies and their outcomes are essential to improving orthopaedic care.

"In order to practice evidence-based medicine, we have to regularly and systematically gather that evidence," Berven says. "Outcomes studies are essential not only in choosing the most medically appropriate treatments, but also — in a health care system in which there are limited dollars — in making choices about cost-effectiveness."

UCSF is now seen as one of the top centers for orthopaedic outcomes studies, Berven says. But making a commitment to obtaining accurate data comes at a price. "Gathering good data is incredibly expensive and time-intensive," he says.

In 2000, Berven and Kevin J. Bozic, M.D., M.B.A., formed the Clinical Outcomes Research Group. Berven oversees the spinal disorders portion of the study, while Bozic supervises outcomes studies for other orthopaedic disorders.

Berven works in collaboration with the UCSF departments of neurological surgery and neurology to design and perform prospective studies that evaluate efficacy of care. Prospective studies that are ongoing or currently in development include: evaluation of operative and nonoperative management of intervertebral disc herniation; evaluation and management of cervical spondylosis, a multidisciplinary approach; MR venography for the evaluation of DVT after anterior spine surgery; circumferential fusion vs. posterior fusion for isthmic spondylolisthesis; parenteral vs. enteral nutrition during staged spine surgery; filtered vs. unfiltered allogeneic blood transfusions; and prospective evaluation of every surgical procedure done by members of the spinal disorders service, including major deformity operations and outcomes of new technologies, including intervertebral disc replacement.

Improving Care

Outcomes in orthopaedic surgery can vary greatly, the researchers observe. There is tremendous variability in the management of patients with common orthopaedic problems, including non-operative care and a broad spectrum of operative options.

"Determining which option leads to the greatest and most reliable improvement of quality of life is an important goal of the outcomes effort," Berven says. "With accurate information on outcomes of different approaches to caring for a patient, we can empower the patient to make informed choices on what is best for them individually."

One important goal in these outcomes studies is to define a clinically important difference. Patients may self-report an improvement in health status after a surgical procedure. However, the threshold of change that is valuable to the patient needs to be defined in order to measure the utility of different interventions.

Finding such differences means sorting through a multitude of data points over years. "We have to gather data over two to five years after treatment," says Amanda Graves, a research associate with the Spine Center. "It doesn't prove anything if the data don't hold up in the long term."

The group also looks at psychosocial variables, which can have a large effect on how well patients do after surgery. The role of patient expectations and optimism about the care plan is important in predicting outcomes. Often, treating depression or anxiety may be more important than treating hip or spine pathology.

UCSF is recognized as a national leader in performing outcomes studies not only of use of new orthopaedic technology, but also of treatment of long-term deformities. Because each study is resource-intensive, the group is very selective about which studies to pursue. "We sometimes turn away industry-sponsored research that might bring in funding if we don't think that the questions that would be answered are scientifically important," says researcher Danielle Geula.

Sigurd Berven can be contacted at (415) 353-2218.

Related Information

News Releases

Orthopaedic Surgery Chair Named
Thomas Parker Vail, M.D., has been named the chair of Orthopaedic Surgery in the UCSF School of Medicine. Vail, director of adult reconstructive surgery at Duke University Medical Center, will assume his new post in January 2007.

UCSF Cited for Hospital Quality
UCSF Medical Center was one of eight California acute care hospitals among the top 50 U.S. hospitals named by the Washington, D.C.-based Leapfrog Group.