- Presidentâ€™s Message
- Blood Borne Pathogens
- Tips & Tricks
- PA Update
- Staff Profile
A New Decade, the old problems. It is not long since the General Meeting, we have all been busy with the year end and beginning the New Year and decade. A product of the â€œbig brother watchingâ€ style of our Provincial College, the Blood Borne Pathogens issue continues to be at the forefront. Dr. Wilson has been working hard with COA and CMPA taskforces, so
read her article and see where we are.
We all are working harder to meet the wait time prerogatives set out by our politicians. Have you considered hiring a Physicianâ€™s Assistant to help? There will be graduates from various programs, McMaster, NOSM, and University of Toronto.
If they can increase your output by fifty percent then you will make a profit with less work. Are you up to date on the Schedule of Benefits? We have certainly not received all we want or deserve from the updates to the Schedule of Benefits but take advantage of everything you can. We have increased your consult fees and have requested further increases to come.
We are currently assembling another specialty specific committee to review the Schedule of Benefits â€œtemplateâ€ in which we hope to modernize the descriptors and fees.
The OMA and MOH will consult with this committee and we hope will produce some improvements in the schedule.
The new Special Visit fees are complex but could significantly increase your on-call income. Some examples will be shown in the â€œbillingâ€ column of this newsletter.
Finally, as you heard at the AGM there will be no dues increase this year due to efficiencies in the administration of the OOA.
This has included this Newsletter and the advertising that is included.
We are also updating the website and are currently looking at methods to keep it concurrent. This may include linking the Newsletter to the website similar to many of the electronic journals. There will be interactive sections of both the newsletter and the website so become active in your association.
|Dana Fleming MD, President OOA
We are going to present some cases and give some billing options. Feedback is appreciated as billing is usually an individual interpretation.
Case: Called to the emergency room for an open fracture, you leave your office to review the patient and initiate treatment and admission. The operating room is not available for a few hours. You return from your home to perform the procedure.
Open Fracture of the tibia is treated. To this point you could bill A065, K961(SV travel fee), K992(SV fee), E082(Admission fee (30%add to consult), F079, E555, E556, E409.
To discharge you could charge further visit fee (C062) times 2 and discharge fee C124 plus E083 (+30%) if you are MRP.
If this were another case and the patient arrived in an emergency clinic you might be able to charge a travel fee to go to the clinic U963 (letâ€™s say it was a weekend) and for each patient seen you could charge U998 or U999 for each patient up to 20 patients for the period from 0700 to 2400.
For 20 patients plus a travel fee the total pay for a Saturday day period might be (20 x 56.25+36.40) $1061.40 for special visit fees alone for the 0700 to 2400 time period. After 2400 hours until 0700 there is no limit to travel or visit fees.
The E082 fee is an interesting fee as it appears to apply to every MRP who admits his own patient and adds a 30% add-on to the admission fees (C122) Similarly the E083 adds to the subsequent visit fee but for a MRP surgeon it is suggested that you add it to the C124 discharge fee (an applicable fee).
If you do not treat a patient surgically but you are the MRP you can add the E082 or E083 to any of the C122/123/124/142/143 codes adding 30% to each. Since writing this article I have discovered that Special visit fees do not apparently apply to a surgical visit that is going to the OR.
When they first were published I asked the OMA if you could charge Special Visit Premium for Surgical call, going to the OR and I was told yes.
Unfortunately we have tried to bill that fee and have been rejected; in fact our program will not even accept it.
I will attempt to clarify this in our favour this year.
|Dana Fleming President OOA
|Blood Borne Pathogens (BBP) Update
The past year has been quite worrisome for many
of our members as they contemplate their insurance coverage and practice patterns, in the face of changing legislation around the issue of BBP. The OMA President, Dr Strasberg, assured us in
her last letter (December 06, 2009) that the OMA, CPSO and MOHLTC are all committed to develop a decision-making process for infected physicians that is rapid, impartial and provides fair, evidenced based outcomes that will not be unnecessarily restrictive. Unfortunately, they are still in the planning stages for the impartial, arms length Expert Panel and it is not yet clear who will appoint the â€˜expertsâ€™ to this important panel.
In the meantime, the CMPA continues to offer advice and support to our seroconverted members. They have assembled their own information gathering BBP expert panel, who will hopefully educate all stakeholders, including the CPSO.
The COA National Standards Committee has hired a research assistant, who is presently reviewing all pertinent literature, and will report back to the committee in one month. It is hoped that we will be able to create a policy paper for orthopedic surgeons across Canada with recommendations for MD testing (or not), patient testing, and equipment provisions. I will continue to fight for our rights!
|Tracy Wilson, OOA Past President
Arthroscopic Bankart Repair: Tips & Tricks
1 .Open vs Arthroscopic:
||â€¢ Considered â€œgoldâ€ standard results
â€œEasyâ€ to learn / Regular instruments
Large destructive approaches, Difficult visualization
|â€¢ Results Improving
â€¢ Difficult to learn / Many specialized instruments
â€¢ Minimally invasive, Easy visualization
â€¢ LESS Painful / Easier Recovery
||â€¢ Bankart 4% - Rowe 1978
Capsular Shift 6-12% - various studies
In general <10%
|â€¢ Early results 1990â€™s : 10-30%
â€¢ 21st Century results:
Romeo et al: 0%
Kim et al: 4%
Sugaya et al: 4.8%
||â€¢ Bony Bankart or glenoid loss > 25%
Engaging Hill Sacks
Capsular shift in chronic dislocator
Revision Bankart +/- augmentation with Latarjet
|â€¢ New GOLD Standard
Easier Bankart preparation
Posterior capsular tensioning
- Ball-and-socket joint with poor bony stability
- Glenoid labrum, surrounding capsular ligaments important for static stability
- Rotator cuff muscles important for dynamic stability
- Inferior Glenohumeral capsulolabral complex is the major ligamentous restraint for both anterior and posterior stability:
â€œTâ€ â€“ Traumatic
â€œUâ€ â€“ Unidirectional
â€œBâ€ â€“ Bankart lesion
â€œSâ€ â€“ responds to Surgery
â€œAâ€ â€“ Atraumatic
â€œMâ€ â€“ Multidirectional
â€œBâ€ â€“ Bilateral
â€œRâ€ â€“ responds to Rehabilitation
â€œIâ€ â€“ rotator Interval lesion
Multidirectional Instability (MDI)
4. Techniques (Tips & Tricks)
1. Patient positioning
- Beach Chair
- After trying both, I prefer lateral for labral repairs
- Both require tractioning/positioning device
- STAR Sleeve
Use 1 viewing and at least 2 working portals:
I use 7 mm cannulas for working portals
3. Diagnostic Arthroscopy
- Look for additional pathology: HAGL, SLAP, GARD, etc
- Measure glenoid bone loss
- ? Engaging Hill-Sacks by AB/ER of shoulder (out of traction)
4. Prepare Glenoid
- Release adhesions:
- Free labrum and capsule totally
- â€œfloatâ€ labrum to glenoid
- Debride glenoid (rim and medial neck): â€œif it doesnâ€™t bleedâ€¦ it wonâ€™t healâ€
5. Pass Shuttle Suture
- I pass a suture shuttle 1st as this is the most technically difficult part of the procedure: Spectrum with #1 Prolene
- Start @ 6 oâ€™clock position inferiorly
- Grasp more capsule/labrum if significant capsular redundancy
- Can use single pass instruments if suture anchor placed 1st
6. Drill and Place anchor
- Use MRI lucent anchor (PEEK or Bio) with #2 High strength suture material
- Place on glenoid rim (in area decorticated) for anatomic repair and maximal biologic healing
- Try to get 1st anchor as low as possible (consider percutaneous 5 oâ€™clock portal)
- Affect a distal-to-proximal capsular shift by placing anchor superior to shuttle suture
7. Recreate the Labral Bumper
- Consider a mattress suture configuration for deficient labrum in chronic repairs
- For simple suture configuration: the â€œpostâ€ suture is the limb passing through the tissue
- Use sliding locking knot: Weston, SMC, Duncan, etc
- Back-up knot with 3 x Â½ hitches on alternating posts
- If suture not slidingâ€¦ construct Revo non-sliding knot
8. Center Humeral Head on Glenoid
- The essential end-point is to see the humeral head centered on the glenoid bare spot (from anterosuperior portal)
- Consider capsular plication sutures (anterior or posterior) to correct for humeral head shift
9. Understand Limitations
- Acute bony Bankart > 25% = ARIF/ORIF
- Chronic Glenoid bone loss >25% = open Latarjet
- Engaging large Hill Sacks Lesion = Remplissage vs. Bone Grafting vs Latarjet
- Combined moderate Glenoid bone loss + Hill Sacks Lesion = Remplissage vs Latarjet
- HAGL Lesion = open humeral capsular shift
|Davide Bardana, MD, FRCS(C),
In this article I will attempt to give a brief history of our problems with WSIB, how we got here and where we would like to go. Ontario Orthopaedic Surgeonsâ€™ dissatisfaction in treating and dealing with WSIB patients began in the mid 1980â€™s when the â€œWorkerâ€™s Compensation Boardâ€ unilaterally decided to only pay us OHIP rates. Prior to this, WSIB was billed OMA rates. This cause significant upset to the Orthopaedic Surgeons in Ontario and some types of job action were undertaken. Many surgeons refused to see or treat elective WSIB patients. However, as usual, we continued to work as these patients needed our help as well and the job action fell by the wayside. Currently, most of us see and treat WSIB patients but we know these patients take longer to see, have multiple problems (most of which are social-economic dealing with WSIB), take longer to get better, and generally do poorer than non-WSIB patients. The fees we receive for filling out forms and sending copies of our notes do not compensate for the additional time and problems with these patients.
This year the WSIB agreement is being renegotiated by the OMA. However the OOA is not at the table for negotiation, nor are plastics and anesthesia. To quote our current OMA president, â€œIf you are not at the table, then you are part of the menu.â€
Realizing this, the OOA has contacted Mr. Steven Mahoney, chair of the WSIB board. We have pointed out to him the current problems with our system and the subsequent problems with their patients. The vast majority of these problems are related to delays in being seen in consultation and delays in treatment. We have proposed a system similar to Alberta and B.C. where patients are given â€œexpedited careâ€ and the Orthopaedic surgeons are rewarded financially to provide this care. We have received a positive response from Mr. Mahoney, referring us to Donna Bain, Vice President, Health Services, in early December. We have not receive any response from her as yet. This letter was forwarded to her December 9, 2009
We, your board at the OOA, see this as a win-win situation at this time. The WSIB patients will receive faster care with better outcomes, the WSIB will save a significant amount of money and the Orthopaedic surgeons of Ontario will be compensated appropriately for the care they provide.
At the AGM a vote was taken regarding this situation. It was overwhelmingly passed to pursue this agenda and if WSIB is not responsive to consider some type of job action. Hopefully they will see the benefits in this agreement and proceed with an agreement with us. We will keep the members updated about this situation.
|Duncan MacKinlay, President Elect, OOA
It has been a very exciting year for the Physician Assistants (PAs) in Ontario and those of us hoping to work with them. The Northern Ontario School of Medicine and the Continuing Health Professional Unit offered a new degree program, a Bachelor of Science Physician Assistant, with applications last fall and a start date January 2010!
This is the second Ontario-grown PA program. The first was created at McMaster University in Hamilton; it will graduate its first class in the spring of 2010 and hopefully we can be some of the first to employ these grads! We have had some contact with their class and will be meeting with them in the New Year to discuss our MD-employed payment model.
At present, Ontario PAs are not regulated, but there is hope that our college will consider making PAs associate members of the CPSO. Similar legislation was passed August 13, 2009, in Manitoba.
Information regarding the PA Consortium and Ontario programs can be found at www.paconsortium.ca
|Tracy Wilson, OOA Past President
|An Academic Orthopaedic Staff Profile
Allied health professionals and staff combine to work with orthopaedic surgeons in the Ottawa academic environment. This allows better focus
on the part of the orthopaedic surgeon in managing his or her clinical practice.
Historically, the foundation of human resources in Ottawa has always been in the form of medical housestaff be they students, postgraduate residents and sub-specialty clinical and research fellows. Most medical students have a mandatory two week rotation in their third year. As they are adjusting to the clinical, ward, and patient issues they require additional energy and time from the orthopaedic surgeon. They are a part of the house staff. Their assistance is during the first pass at a patient, be it on the ward or in emergency department or clinic.
Residents are funded by the province to provide clinical service as they gain an orthopaedic education. Thus they can become certified and practice in the Canadian system and elsewhere. They learn with hands-on training and patient management. There is a recent increase in resident numbers but the Royal College requirement avoids an inappropriate â€œservice to education ratioâ€, forcing us to find additional help, particularly with the increase in hip and knee arthroplastic procedures. Clinical fellows are available sporadically, frequently with subspecialty
services. Fellows provide a significant role, but often without any ward duties. They assist the orthopaedic surgeon in the training and mentoring of residents and medical students and further the academic research mission, vital and valuable to an academic orthopaedic division such as ours.
Several of the local Family Physicians assist in the O.R. Some of these Physicians have a Sport Medicine sub-specialty and interest. A small core of these physicians assesses patients in an Intake Clinic for hip and knee arthritis. This model is beyond some of the more commonly used models using Advanced Practice Physiotherapists and Nurses in this role. Sport Medicine Physicians with extensive training and experience are able to review the gamut of conservative treatment options prior to surgical intervention.
A program has begun for the training and collegial work with Advanced Practice Physiotherapists in assessing Intake Clinic patients and managing post operative patients. Recent initiatives for APPâ€™s are Same Day Discharge for unicompartment knee replacement and accelerated discharge for anterior approach hip arthroplasty and subvastus total knee replacement. This model we hope will expand.
The Physician Assistant Pilot was made available to us last year. Unfortunately our hospital elected to accept the requests only for Internal Medicine. PAâ€™s may be able to provide a very significant role by filling the â€œserviceâ€ gaps that can not be met by resident/ fellow housestaff. We await a chance to assess this alternative.
|Geoffrey F Dervin, MD, MSc, FRCSC
Chairman, Division of Orthopaedic Surgery,
University of Ottawa