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Five Hospitals Share Three Secrets to Improve Knee Surgery Outcomes

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   May 25, 2012

When surgeons at five healthcare systems shared their individual processes for 11,000 knee replacement operations, three best practices emerged that reduced lengths of stay, lowered readmission rates, and improved other outcomes for hospitals that embraced them.

That's the finding from the High Value Healthcare Collaborative, composed of orthopedic surgical teams from Cleveland Clinic, Dartmouth-Hitchcock Medical Center, Denver Health, Intermountain Healthcare, and the Mayo Clinic.

"These are five very different organizations—all of whom by any gold standard have good results for complications, readmissions and other outcomes,"explains Ivan Tomek, MD, orthopedic surgeon at Dartmouth-Hitchcock. "But the fact is there was still significant variation, even though we're all doing the same knee operation."

Tomek and colleagues published their findings in a paper published in this month's Health Affairs journal.

Managing patient expectations
The first best orthopedic practice was discovered in one of the five hospital systems, which informed patients how long they would be in the hospital, what to expect the day of surgery, and what to expect thereafter until a relative would pick them up to take them home, Tomek says.

"We all think we do this, but as it turned out, one organization spends more time with a multidisciplinary team of nursing staff, physical therapists, and physicians letting these patients know exactly what to expect, and that when they go home, things aren't going to be perfect. They're still going to have pain, and have limits on how they move around,"he says.

This practice limits the typical length of stay, he says, "because patients aren't surprised on day two, for example, that it still hurts them to get out of bed and go to the bathroom." The practice reduces patients' anxiety, which does much to improve outcomes.

He adds that although Dartmouth-Hitchcock offers pre-surgery classes for its knee replacement patients, a visit to them revealed that "they don't stress a timeline as much as they should. ...You need to set clear expectations—for example, these are the points you have to hit before you can go home, and 70% of people hit those by day two."

Multidisciplinary teams for complex patients.
Tomek says that a look at the data revealed 85%-90% of the knee replacement candidates were obese or morbidly obese, and many of them had been diagnosed with associated co-morbidities like diabetes, precarious kidney function, or peripheral vascular disease.

"What we discovered was that one healthcare system that did well had a multidisciplinary team—not just orthopedists, but anesthesiologists and internists that triaged patients preoperatively to identify the ones they think would run into trouble," he says. These patients were then singled out for special scrutiny.

"It may turn out that someone would really be better off having surgery three months from now, once they get their blood sugars under control. And if so, you would cancel the surgery until that time,"Tomek says. "It was a valuable lesson that if you take the time at the front end, involving internists and affiliated medical staff to enter the discussion about whether the surgery is safe to do, it pays dividends."

Dedicated nurses in the OR
It's important for surgeons to be efficient with their time in the operating room, and the study found that experienced surgeons did so. But the organization with the shortest operative times was the only one with a dedicated team of knee replacement surgery nurses. "At most other hospitals, the nurse is in orthopedics one day, in urology the next, and the next day somewhere else. We have to remember that the Honda mechanic fixes it faster than a mechanic who sees a Honda one a year,"Tomek says.

Other procedures are on tap for similar multi-health system analysis, including diabetes, congestive heart failure, depression, spine surgery, labor and delivery, asthma, hip surgery, and bariatric surgery.

The collaborative selected knee replacement surgery to evaluate first because the lifetime risk of knee osteoarthritis is 50%, and because in 2008, total knee replacement inpatient costs exceeded $9 billion, "the highest aggregate cost among the 10 procedures for which demand is growing the fastest," according to the paper.

Each procedure costs somewhere between $20,000 to $25,000 in technical and professional fees, adjusted for geographic variables.

"Between 2005 and 2030, the demand for primary knee arthroplasty in the United States is projected to grow by 673% or 3.48 million procedures annually,” according to the paper.

Tomek says that when word about certain system processes that improved care was passed around to other participating hospitals, "there was a lot of pushback from surgeons."

"I'll be honest with you,"he adds. "We're trying to leverage these results to influence change. ... It's an uphill push because in some cases, having a dedicated team is not aligned with what nursing or anesthesiology might want to do. We're hoping this paper will be a catalyst to say, Look, this does make a difference.”

Since the results on knee procedures were circulated, 11 other health systems have agreed to adopt the approach. They are Baylor Health Care System, Beaumont Health System, Beth Israel Deaconess Medical Center, North Shore-LIJ Health System, MaineHealth, Providence Health & Services, Scott & White Healthcare, Sutter Health, UCLA Health System, University of Iowa Health Care, and Virginia Mason Medical Center.


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