Perioperative smoking has been linked to surgical complications including poor wound healing, infection, myocardial infarction, prolonged length of stay, need for mechanical ventilation, and death. This study evaluated the effectiveness of preoperative counseling on smoking cessation for patients undergoing elective total joint arthroplasty. Thirty smokers with hip or knee osteoarthritis seeking hip or knee replacement surgery were enrolled prospectively. Interventions included counseling, referrals to smoking cessation programs including the California Smokers' Helpline and the Fontana Tobacco Treatment Program, nicotine replacement therapy (NRT), or instructing patients quit through the "cold turkey" method of abstinence. Patients were scheduled for surgery if they demonstrated abstinence from smoking, confirmed via expired carbon monoxide (CO) breath testing. Short- and long-term smoking cessation rates were evaluated. Thirty patients were enrolled; 21 patients (70%) passed the CO test, whereas 9 patients (30%) failed or did not follow up with a CO test. Thirteen of 21 patients (62%) quit using the "cold turkey" method, 5 of 21 patients (24%) quit using NRT, and 3 of 21 patients (14%) quit using outpatient treatment programs. Eighteen of 21 patients (86%) who quit smoking underwent surgery, and 14 patients had surgery within 6 months of smoking abstinence. Nine of the 14 patients (64%) remained smoke-free 6 months postoperatively confirmed through telephone questionnaire. These results suggest that elective surgery offers a strong incentive for patients to quit smoking, and surgeons can play a role offering a teachable moment and motivating this potentially life-altering behavioral change. [Orthopedics. 2017; 40(2):e323-e328.].
Confronted with rising costs and patients who often have multiple comorbidities, the orthopaedic surgeon needs to face the challenge of providing high-quality health care. One solution is to increase and improve coordination, communication, and teamwork. The orthopaedic surgeon also needs to work effectively and efficiently to manage a fluid and shifting mix of health-care personnel partners from other disciplines and specialties to deliver high-quality patient care. The orthopaedic surgeon must collaborate in a new way with fellow health-care professionals, providing care by following teaming protocols.In the appropriate leadership role and employing the necessary motivational, communication, and conflict-management skills, the orthopaedic surgeon must build the proper foundations for teaming through the selection of compatible, effective team members and establish the necessary collaborative teaming environment. The orthopaedic surgeon needs to lead these teams and promote communication, listening, and collaboration. The emphasis on effective communication through a horizontal hierarchy rather than an autocratic management style by the orthopaedic surgeon allows the seamless incorporation of specialty physicians as needed and facilitates teaming among orthopaedic staff.With a facilitative environment and clear communications, teaming in patient care will occur as a learning cycle of diagnosis, design, action, and reflection. Each of these steps is critical for teaming to be successful. During diagnosis, the orthopaedic surgeon needs to effectively frame the situation. In design, the orthopaedic surgeon needs to encourage participation in the determination of the next appropriate steps for patient care. During the action step, teaming protocol emphasizes both the process of care through care-tracking and the result of that care, which is critical for reflection. Reflection is necessary for the team to improve its effectiveness and learn from its experience. However, for successful reflection and learning, the orthopaedic surgeon needs to be truly open to criticism.Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
EHRs have the potential to become a powerful tool that may improve many processes related to health care, including quality, safety, and economical aspects. The involvement of physicians in every step of the process, from electronic medical record selection to acquisition, implementation, and ongoing optimization, is crucial for enabling the achievement of the medical organization's mission.
Morrison argued that demography, economy, and technology drive the evolution of industries from a formative first-generation state ("First Curve") to a radically different way of doing things ("Second Curve") that is marked by new skills, strategies, and partners. The current health-reform movement in the United States reflects these three key evolutionary trends: surging medical needs of an aging population, dramatic expansion of Medicare spending, and care delivery systems optimized through powerful information technology. Successful transition from a formative first-generation state (First Curve) to a radically different way of doing things (Second Curve) will require new skills, strategies, and partners. In a new world that is value-driven, community-centric (versus hospital-centric), and prevention-focused, orthopaedic surgeons and health-care administrators must form new alliances to reduce the cost of care and improve durable outcomes for musculoskeletal problems. The greatest barrier to success in the Second Curve stems not from lack of empirical support for integrated models of care, but rather from resistance by those who would execute them. Porter's five forces of competitive strategy and the behavioral analysis of change provide insights into the predictable forms of resistance that undermine clinical and economic success in the new environment of care. This paper analyzes the components that will differentiate orthopaedic care provision for the Second Curve. It also provides recommendations for future-focused orthopaedic surgery and health-care administrative leaders to consider as they design newly adaptive, mutually reinforcing, and economically viable musculoskeletal care processes that drive the level of orthopaedic care that our nation deserves-at a cost that it can afford.
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