A game-changing approach to medical care

Dr. Lionel Ivashkiv, chief scientific officer at Hospital for Special Surgery (HSS) is first and foremost, a scientist. But for Dr. Ivashkiv, research is a means to his real passion: improving the lives of patients. "The greatest value that we could bring would be to make breakthrough discoveries that could be translated into improving care," he says.

This approach to scientific research, translating basic findings into new ways of treating and preventing musculoskeletal conditions, is at the core of HSS's research mission. It relies on an unusual collaboration between researchers, doctors and patients.

"In most institutions, the relationship between basic and clinical research hasn't been fully developed," says Ivashkiv. "Thus scientists are often unaware of important clinical questions, or work on diseases without the benefit of a clinician's insights about the disease or the healing process. A true partnership builds upon ideas and expertise from both sides."

Since he joined the rheumatology department of HSS in 1992, Ivashkiv has studied immune mechanisms pioneering research that may one day lead to a cure for autoimmune diseases such as rheumatoid arthritis. So far, the results of their research have been astonishing.

"In my lab, one of the discoveries we made in 1994 was actually linking something called the JAK-STAT pathway to rheumatoid arthritis," he says. The JAK-STAT pathway is a signaling mechanism in the body. An overactive JAK-STAT pathway can result in autoimmune and inflammatory diseases like rheumatoid arthritis.

"Because we linked it to a disease, and because we're in an environment like HSS, both my lab and many other labs started working on this as a potential therapeutic," Ivashkiv says. As a result of this research, new drugs were developed and approved by the FDA. "That is one of the greatest satisfactions I've experienced."

While HSS is perhaps best known for its top ranking in Orthopedics, the Hospital is rated #2 in the nation for Rheumatology according to US News & World Report Best Hospitals 2016-17 survey.

Success isn't created in a vacuum. At HSS, multidisciplinary teams must collaborate to solve the musculoskeletal problems presented by their patients.

Ivashkiv offers knee replacement surgery as one example. "About 15 percent of all people who have knee replacement surgery experience pain and dissatisfaction. It really limits their range of motion and their ability to function." To address this, Ivashkiv has gathered a team to study this complication and determine the best way to prevent it, and the best course of treatment when it strikes.

"One of the ideas is that it might be related to how the knee joint moves after surgery and impacts on joint tissues," Ivashkiv says. "So we're doing imaging on patients and at the same time we brought in a team of bioengineers, biologists and immunologists. I think we're really one of the few, if not the only, center that's bringing these kinds of scientists together."

Dr. Robert Hotchkiss, who serves as the medical director of innovation and the director of clinical research at HSS, concurs. He says that all the different medical departments at HSS work together closely – something he terms a "culture of innovation" that is unique to HSS.

"Our bioengineering department is literally two floors down from here," Hotchkiss says. "On a frequent basis, I will invite one of the engineers, if they're available, and say, 'You've got to come up and see this patient with me.'"

This collaboration results in better patient outcomes, says Hotchkiss. Engineers who can study the patient directly have a "completely different conception" of how to design a prosthetic or an implant. "If you tried to do that by a meeting or webinar or something, you wouldn't have that tangible sensibility," Hotchkiss says.

When research and innovation are aligned and prioritized, says Dr. Catherine MacLean, chief value medical officer at HSS, this drives significant value for the patient.

"We add value by facilitating the development of cutting edge therapies for our patients that are going to help them achieve better outcomes," MacLean says. As an example, she cites the design and development of arthroplasty devices, which are prostheses that go into a patient's joint in hip and knee replacements. "We are actually one of the original developers of these devices in the United States," she says.

"It's a really nice ecosystem we have," says MacLean. "[HSS] is set up in such a way that we can take that research that's done and then turn that into products that we can use in the delivery of our care."

Value can be measured in myriad ways, says MacLean, from patient satisfaction to time spent in recovery. For patients and their employers, an important assessment of value is presenteeism, or productivity loss in the workplace due to a health condition.

"For patients who have hip or knee arthritis, it can be really painful to sit for long periods of time," says MacLean. "People who have more physical jobs where they have to lift or move things or walk around a lot can experience both pain and functional limitation. In either case, they're not fully present at their job because they can't work at full capacity."

According to the Integrated Benefits Institute, musculoskeletal conditions like lower back pain are some of the most common reasons for presenteeism in the work force, affecting nearly a quarter of employees. And this has been proven to be costly: researchers have found that lower back pain -- to say nothing of other musculoskeletal problems -- cost employers approximately $51,000 per 100 workers in medical treatment costs, as well as sick days, short term disability, long term disability, worker's compensation and presenteeism. Costs incurred due to presenteeism alone are roughly $8,000.

"If you have employees that you depend on, you want them present and performing to their full potential – that is what employers are paying for," says Lou Shapiro, chief executive officer of HSS. "Focus on what you're paying and not on what you're getting exposes employers to making the wrong decision on behalf of their employees, and their companies."

"We have individuals who do research, who innovate, who leverage that deep knowledge they have to say, how can we do better in the future?" says Shapiro.

For the innovators, it all comes down to the patient – people like Nicole Gronbeck who in 2013, newly married at 29 years old, shattered her elbow in a snowboarding accident. "I knew I wanted to start a family, but I couldn't even brush my hair or feed myself with that arm. I asked Dr. Hotchkiss, 'how am I going to care for a baby?' It was a scary and emotional time." But after five hours of surgery, Hotchkiss and his team had rebuilt her elbow.

Recently, Gronbeck, now the mother of a two year-old, showed the doctor how she carries her child and can "throw him in the air" with her reconstructed arm.

"I thought, 'this is it'," Hotchkiss says. "That's value."

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