Update on diversity, equity, and inclusion (DEI) initiatives

By Kate Hutchison, M.D. and Bopha Chrea, M.D.

The last year has provided many opportunities for new and old initiatives alike in the orthopaedics and rehabilitation department. Orthopaedic surgery remains the least gender-diverse medical subspecialty with approximately 15% of residency positions filled by women. Additionally, the racial and ethnic diversity within orthopaedics has in fact decreased within the last 20 years. As medicine becomes more aware of issues of diversity and inclusion both within the ranks of physicians as well as within the interactions with patients, we will continue with efforts to bring a focus to these issues within our own community.

While COVID-19 precautions have limited the ability of visiting professors to present grand rounds in person, it has also allowed for multiple grand rounds speakers to virtually visit the program to speak on issues of structural inequalities. Dr. Jaysson Brooks of Texas Scottish Rite Hospital for Children joined us to speak on neuromuscular scoliosis and then met with the residents for a deeply engaging session on structural racism. Dr. Selina Poon of Shriner’s Hospital for Children in Southern California, a leading expert in research on diversity and inclusion within orthopaedic surgery, also joined us for Grand Rounds to highlight her research on trends in gender, racial, and ethnic diversity within orthopaedics as well as the impact on USMLE exam performance. Finally, Grand Rounds will also be given by Dr. Nancy Yen Shipley, one of the co-founders of Speak Up Ortho, an initiative to address bias, inequities, and harassment within orthopaedic surgery. She and fellow Speak Up Ortho panelists will discuss their work and research as part of this important initiative with the department.

Thanks to a grant obtained by Dr. Chrea, in April 2022 a resident journal club focused on DEI topics allowed for discussion of equity and inclusion within the program and within orthopaedics as a subspecialty. Articles discussed included several by Dr. Poon. This is a journal club focus we hope to continue moving forward into the future. An additional new program for 2022 is a DEI subinternship scholarship for visiting medical students rotating with OHSU orthopaedic surgery. Scholarship funds are available to students who are underrepresented in medicine (URM), with the hope that a lower financial burden for away rotations allows for more equity within the already complex and costly residency application process.

Finally, we are excited to have been able to resume community outreach partnerships outside of OHSU. Dr. Friess, Dr. Chrea, and Amy Sothern PAC spent a morning at the Jefferson High School career fair as part of the Ontrack OHSU partnership to highlight orthopaedics as a career choice with an interactive demonstration for 9th grader students. The Wy’east Partnership has also been active this year, with portions of musculoskeletal education taught by orthopaedic surgeons including clinical workshops with physical exam skills and casting and splinting workshops. We look forward to more opportunities to interact with the community outside of OHSU in the year to come.

Iron in the Fire

By Laura Sokil, M.D.

Inspired by an idea: Built on personal experience, Dr. Zachary Working, Director of Orthopaedic Trauma at OHSU, and Dr. Danielle Peterson, OHSU PGY-3, set out to develop an investigator initiated, randomized controlled drug trial investigating the use of intravenous iron therapy (IVIT) for anemia after orthopaedic fracture care. With this idea of developing a high-quality trial with level 1 evidence came the need for considerable funding. They were recently awarded three grants to fund various aspects of the study, including the Medical Research Foundation Early Clinical Investigator Grant (Peterson), Collins Medical Trust Grant (Working), and Orthopaedic Trauma Association Resident Research Grant (Peterson).

Premise for the trial: Acute blood loss in orthopaedic trauma and operative fracture care contributes substantially to perioperative anemia, which places patients at increased risk for complications including surgical site infection, cardiovascular complications, and even death. Anemia has further clinical implications in quality of life measures and is associated with fatigue, impaired physical performance, decreased exercise capacity, and mood disturbances. Thus, evaluation and treatment of perioperative anemia is critical in risk mitigation within orthopaedic surgery. The current standard of care for anemia is transfusion of packed red blood cells only in cases of severe anemia due to the substantial associated risks of transfusion. A safer alternative is desirable because a critical number of patients do not meet the restrictive transfusion threshold and may suffer negative effects from anemia during recovery from the acute insult. The focus of this project is to pilot investigation of the benefits of IVIT in traumatically injured patients. Working and Peterson aim to assess the effect of IVIT on resolution of anemia, patient-reported fatigue, physical function and depression, and immune cell function. Peterson states, “we expect this study to provide a better understanding of IVIT, which has the potential to alter our treatment approach of anemia in patients who sustain traumatic orthopaedic injury, thereby leading to decreased risks and improved recovery.”

Advancing the field: The study has expanded beyond the Orthopaedic Department, with critical partnerships in the Department of Hematology and Division of Trauma. Dr. Joseph Shatzel, Assistant Professor of Biomedical Engineering and fellowship trained in Hematology & Medical Oncology, has been a crucial clinical advisor in anemia and the use of IVIT in their patient population. Dr. Joseph Aslan, Assistant Professor of Biomedical Engineering, and his lab are contributing necessary basic laboratory resources to better understand the biologic consequences of anemia in the traumatic setting and the role iron repletion plays on platelet function. Dr. Nick Willett, Associate Professor in Bioengineering at the University of Oregon Knight Campus, will be collaborating with the team to further characterize immune cell response after trauma. Dr. Martin Schrieber, Professor of Surgery, has graciously offered to be an advisor to the project as he is extensively experienced in clinical research, funding acquisition, and large-scale trials.

Reflecting on her work over the past several months, Dr. Peterson states that, “Success so far has been marked by hard work and many failures - hundreds of hours of prep work, rejected grant applications, unanticipated road blocks. We have learned so much in getting this study off the ground and with each failure came the opportunity to grow. We knew we had a great idea, but without the bumps in the road, we would never have had such an incredible team or study plan. We are excited by the possibilities this study has to expand and positively impact the care of our trauma patients. I personally am truly thankful to have the unwavering support of Dr. Working and the Orthopaedic Department to go after my research dreams during residency!”

Gigli Saw Olecranon Osteotomy for Distal Humerus Fractures: A Cadaveric Study

Ryan W Hadden, M.D.; Austin R Thompson, B.S.; Omar F Nazir, M.D.; Zachary M Working, M.D.; Adam J Mirarchi, M.D.

PURPOSE

A novel plate-on Gigli saw osteotomy technique has been developed to simplify olecranon osteotomy management. The goal of this study was to evaluate the difference in procedural time, osteotomy surface area, and surgeon self-reported confidence in performing the standard chevron osteotomy and novel plate-on Gigli saw technique.

METHODS

Four board certified orthopaedic surgeons and ten residents each performed chevron and Gigli saw olecranon osteotomy techniques on cadaveric specimens. All osteotomies were stabilized with an olecranon plate and screws. Time to complete the procedure and time to complete each osteotomy were separately collected for each technique. Osteotomies were analyzed for quality of reduction using three separate reduction parameters. Digital images of the osteotomized surface areas were captured and analyzed via ImageJ Software. Pre and post simulation surveys were completed addressing participant experience. A Likert scale was used to discern self-reported confidence.

RESULTS

The chevron technique required more total time on average than the Gigli saw technique, however, the difference was deemed equivalent. Time to complete the olecranon osteotomy was greater on average with the chevron technique than Gigli saw technique, however, the difference was only trivial. The surface area resulting from the chevron technique was larger on average than the surface area from the Gigli saw technique; this was a trivial difference. While half of the reductions with the chevron technique were of poor reduction quality, only one reduction with the Gigli saw technique was of poor reduction quality. Nonetheless, the proportion of participants that achieved poor reduction quality with the chevron technique but not the Gigli saw was found to be equivalent to the proportion of participants that achieved poor reduction quality with the Gigli saw technique but not the chevron technique. Self-reported confidence was significantly greater with the Gigli saw technique than with the chevron technique.

CONCLUSIONS

The two techniques demonstrated equivalence in total time and reduction quality, and only a trivial difference in surface areas. However, the Gigli saw technique demonstrated a better pattern of reduction, and greater participant confidence than the chevron technique.

CLINICAL RELEVANCE

The plate-on Gigli saw osteotomy technique is a simple alternative to the standard chevron osteotomy that yields a more predictable reduction pattern and is easy to perform.

Oncology Patients Are High Cost Outliers in Total Joint Replacement Bundled Payment Systems.

Erik Woelber, M.D.; Kenneth R. Gundle, M.D.; Jonah Geddes, M.P.H.; Kathryn L. Schabel, M.D.; James B. Hayden, M.D., Ph.D.; Saifullah R. Hasan, B.S.; Lauren M. Raymond, B.S.; Yee-Cheen Doung, M.D.

BACKGROUND

In 2016, the Centers for Medicare and Medicaid Services began its first mandatory bundled payment program, the Comprehensive Care for Joint Replacement (CJR) model, which covers a 90-day episode of care. This study determined whether oncology patients enrolled in the CJR bundle incur higher hospital costs than patients with osteoarthritis (OA).

METHODS

A retrospective review of all patients enrolled in the CJR bundled payments system from April 1, 2016 to June 31, 2018 at a single academic medical center was conducted. To determine whether tumor patients had higher total episode costs, this group was compared to patients diagnosed with OA using a 2-tailed t-test. To adjust for moderators of total hospital costs, we used generalized linear regression with a log-link, including multiple variables abstracted from chart review.

RESULTS

Three hundred fourteen patients met inclusion criteria (12 primary or metastatic tumors, 302 OA). Fifty-eight percent of tumor patients were over the target price vs 16% of OA patients. The mean tumor patient had $40,862 for total internal hospital costs compared to $16,356 in the OA group (P < .001). Length of stay was greater in the tumor group (6.75 vs 2.0 days, P < .001). A greater percentage of tumor patients were discharged to a skilled nursing facility (67% vs 27%, P = .006) with significantly higher skilled nursing facility episode costs ($18,852 vs $7731, P = .04). With adjustment for fracture status, tumor patients were 5.36 times more likely to exceed the CJR target price than OA patients (risk ratio 5.36, confidence interval 3.44-8.35, P < .001) and 50 times more likely to be outliers over the regional threshold than OA patients (risk ratio 50.33, confidence interval 16.33-155.19, P < .001).

CONCLUSION

Oncology patients enrolled in the CJR bundled payment model incur significantly higher costs and have higher cost variability than patients with OA. We recommend that oncology patients be excluded from the CJR bundle.