Outcomes of a joint replacement surgical home model clinical pathway

General vs Neuraxial Anesthesia in Direct Anterior Approach Total Hip Arthroplasty: Effect on Length of Stay and Early Pain Control

BACKGROUND

Recent literature has suggested some benefits for neuraxial anesthesia (NA) as an alternative for general anesthesia (GA) for primary total hip arthroplasty patients. We examined the impact of NA vs GA on outcomes for patients undergoing direct anterior (DA) approach total hip arthroplasty (THA) in an institution with established rapid recovery protocols.

METHODS

A retrospective review was conducted for 500 consecutive THA patients from a single institution. Univariate analysis and multivariate linear regression were used to compare outcomes for THA patients receiving NA and GA.

RESULTS

There was a significant difference in length of stay with NA patients having a shorter length of stay (NA 32.7 hours vs GA 38.1 hours, P = .003). Patients receiving NA had significantly lower PACU morphine milligram equivalents (MME) (NA 10.2 MME vs GA 15.6 MME, P < .001) and reported a lower score on the PACU pain numeric rating scale (NA 2.1 vs GA 3.7, P < .001).

CONCLUSION

Neuraxial anesthesia is associated with decreased LOS, decreased PACU MME, and a lower PACU pain score for patients undergoing primary DA THA. These trends remained consistent when controlling for age, gender, BMI, and ASA.

Who Did the Arthroplasty? Hip Fracture Surgery Reoperation Rates are Not Affected by Type of Training-An Analysis of the HEALTH Database

OBJECTIVES

This study compares outcomes for patients with displaced femoral neck fractures undergoing hemiarthroplasty (HA) or total hip arthroplasty (THA) by surgeons of different fellowship training.

DESIGN

Retrospective review of HEALTH trial data.

SETTING

Eighty clinical sites across 10 countries.

PATIENTS/PARTICIPANTS

One thousand four hundred forty-one patients ≥50 years with low-energy hip fractures requiring surgical intervention.

INTERVENTION

Patients were randomized to either HA or THA groups in the initial data set. Surgeons' fellowship training was ascertained retrospectively, and outcomes were compared.

MAIN OUTCOME MEASUREMENTS

The main outcome was an unplanned secondary procedure at 24 months. Secondary outcomes included death, serious adverse events, prosthetic joint infection (PJI), dislocation, discharge disposition, and use of ambulatory devices postoperatively.

RESULTS

There was a significantly higher risk of PJI in patients treated by surgeons without fellowship training in arthroplasty (P = 0.01), surgeons with unknown fellowship training (P = 0.03), and surgeons with no fellowship training (P = 0.02) than those treated by an arthroplasty-trained surgeon. There were significantly higher odds of being discharged to a facility rather than home in patients who underwent surgery by a surgeon with no fellowship training compared with arthroplasty-fellowship-trained surgeons (P = 0.03).

CONCLUSIONS

Arthroplasty for hip fracture can be performed by all orthopaedic surgeons with equivalent reoperation rates. Infection prevention strategies and use of "care pathways" by arthroplasty-fellowship-trained surgeons may account for the lower risk of PJI and higher rate of discharge to home. The authors advocate for the use of evidence-based infection prevention initiatives and standardized care pathways in this patient population.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effects of a Total Knee Arthroplasty Care Pathway on Cost, Quality, and Patient Experience: Toward Measuring the Triple Aim

BACKGROUND

Care pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience.

METHODS

A historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

RESULTS

In total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (-8.501%, 95% confidence interval [CI] -9.639 to -7.350), a decrease in LOS (-26.966%, 95% CI -28.516 to -25.382), and an increase in discharges to home (odds ratio [OR] 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient.

CONCLUSION

TKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually.

Perioperative Surgical Home Models

The rising prominence of value-based health care and population health management supports evolving perioperative surgical home (PSH) models that rely on continuously evolving evidence-based best practice and telemedicine and telehealth, including mobile technologies and connectivity. To successfully deliver greater perioperative valued-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing perioperative management and its associated services and care provider skills must be expanded. This article focuses on the PSH model as continued opportunity and mechanism for delivering greater value-based, comprehensive perioperative assessment and global optimization of surgical patients.

Implementation of a Total Hip Arthroplasty Care Pathway at a High-Volume Health System: Effect on Length of Stay, Discharge Disposition, and 90-Day Complications

BACKGROUND

Standardized care pathways are evidence-based algorithms for optimizing an episode of care. Despite the theoretical promise of care pathways, there is an inconsistent literature demonstrating improvements in patient care. The authors hypothesized that implementing a care pathway, across 11 hospitals, would decrease hospital length of stay (LOS), decrease postoperative complications at 90 days, and increase discharges to home.

METHODS

A multidisciplinary team developed an evidence-based care pathway for total hip arthroplasty (THA) perioperative care. All patients receiving THA in 2013 (pre-protocol, historical control), 2014 (transition), and 2015 (full protocol implementation) were included in the analysis. Multivariable regression assessed the relationship of the care pathway to 90-day postoperative complications, LOS, and discharge disposition. Cost savings were estimated using previously published postarthroplasty episode and per diem hospital costs.

RESULTS

A total of 6090 primary THAs were conducted during the study period. After adjusting for the covariates, the full protocol implementation was associated with a decrease in LOS (mean ratio, 0.747; 95% confidence interval [CI; 0.727, 0.767]) and an increase in discharges to home (odds ratio, 2.079; 95% CI [1.762, 2.456]). The full protocol implementation was not associated with a change in 90-day complications (odds ratio, 1.023; 95% CI [0.841, 1.245]). Payer-perspective-calculated theoretical cost savings, including both index admission and postdischarge costs, were $2533 per patient.

CONCLUSION

The THA care pathway implementation was successful in reducing LOS and increasing discharges to home. The care pathway was not associated with a change in 90-day complications; further targeted interventions in this area are needed. Despite care standardization efforts, high-volume hospitals and surgeons had higher performance. Extrapolation of theoretical cost savings indicates that widespread THA care pathway adoption could lead to national healthcare savings of $1.2 billion annually.

Perioperative surgical home: a new scope for future anesthesiology

The health care system is changing from ‘pay for volume’ to ‘pay for value.’ These changes are turning health care delivery into a more cost-effective and coordinated care setup that drives hospitals to lower costs and greater quality gains. The present perioperative care service in Korea has proven to be costly, fragmented, and neither evidence-based nor patient-centered. Recently, a new concept of a perioperative care model termed perioperative surgical home (PSH) has been proposed. The PSH is a patient-centered, team-based, and coordinated perioperative care setup, composed of the head anesthesiologist-perioperativist in tandem with dedicated nurse practitioners and other PSH team doctors. All pre-, intra-, and postoperative patient care functions are performed by a single PSH team, not several different departments. The PSH care extends from the decision to operate till 30 days post-discharge. Several evidence-driven perioperative strategies for reducing postoperative complications and shortening hospital stay can be adapted to each specific hospital situation, rather than strictly applying any given strategies. With the PSH, patients are more satisfied and experience better outcomes. It is also a good hospital business model. The expanded role of anesthesiologists in the PSH has the potential to invigorate the specialty.

Total knee arthroplasty: improving outcomes with a multidisciplinary approach

Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a multidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice.

The Perioperative Surgical Home: Improving the Value and Quality of Care in Total Joint Replacement

PURPOSE OF REVIEW

The perioperative surgical home (PSH) is a patient-centered, physician-led, multidisciplinary care pathway developed to deliver value-based care based on shared decision-making. Physician and hospital reimbursement will be tied to providing quality care at lower cost, and the PSH model has been used in providing care to patients undergoing lower extremity arthroplasty. The purpose of this review is to discuss the rationale, definition, development, current state, and future direction of the PSH.

RECENT FINDINGS

The PSH model guides the patient throughout the pre and perioperative process and into the postoperative phase. It has been shown in multiple studies to decrease length of stay, improve functional outcomes, allow more home discharges, and lower costs. There is no increase in complications or readmission rates. The PSH pathway is a safe and effective method of providing value-based care to patients undergoing hip and knee arthroplasty.

Creation of an Online Wiki Improves Post-Operative Surgical Protocol Adherence in Arthroplasty Patients

BACKGROUND

Perioperative care pathways are tools used in high-volume clinical settings to standardize care, reduce variability, and improve outcomes. However, the mechanism by which the information is transmitted to other caregivers is often inconsistent and error-prone. At our institution, we developed an online, user-editable ("wiki") database to communicate post-operative protocols. The purpose of this study is to evaluate the hypothesis that implementation of the wiki would improve protocol adherence and reduce unintentional deviations inpatient care.

METHODS

We conducted a retrospective review of patients who underwent primary lower extremity arthroplasty at our institution during three 6-month time periods including immediately before, 6 months after, and 2 years following introduction of the wiki. Adherence to defined perioperative care pathways (laboratory studies, post-operative imaging, perioperative antibiotics, and inpatient pain medications) was compared between the groups.

RESULTS

After wiki implementation, adherence to protocols improved significantly for laboratory orders (P < .0001), imaging (P < .001), pain control regimen (P = .03), and overall protocol adherence (P < .001). Improvements were seen in some areas almost immediately, while others did not show improvements until 2 years after implementation. Costs associated with unnecessary testing were reduced by 82%.

CONCLUSION

Development of an online wiki for tracking post-operative protocols improves care pathway adherence and reduces variability in care while lowering costs associated with unnecessary testing, although some benefits may not be immediately realized. Several practical barriers to implementing the wiki are also discussed, along with proposed solutions.

Early commencement of physical therapy in the acute phase following elective lower limb arthroplasty produces favorable outcomes: a systematic review and meta-analysis examining allied health service models

BACKGROUND

Temporal and dose-response relationships between allied health (AH) and recovery in the acute phase following lower limb (LL) arthroplasty are unclear. This systematic review investigates whether early commencement, additional therapy and/or weekend AH affects length of stay (LOS) and patient outcomes in the acute phase following LL arthroplasty.

METHODS

Electronic databases were searched in February 2015. Studies were included if they evaluated any of the following aspects of AH for adults following LL arthroplasty in the acute phase: Early compared to later therapy commencement; Additional therapy; or a 6- or 7-day service compared to a lesser service.

RESULTS

Twenty-four studies met the inclusion criteria, of which 19 investigated effects of physical therapy (PT) alone. Earlier PT reduced LOS (WMD = -1.23 days; 95% CI, -2.16 to -0.30) and resulted in higher probability of discharge directly home (relative risk = 1.45; 95% CI, 1.26-1.67). Addition of weekend PT reduced LOS (WMD = -1.04 days; 95% CI, -1.66 to -0.41) and improved function (SMD = 0.37; 95% CI, 0.02-0.73). Increasing PT from once to twice daily did not affect LOS (WMD = -0.35 days; 95% CI, -0.96-0.26) or function (SMD = 0.31; 95% CI, -0.06-0.71).

DISCUSSION

Early PT commencement and a weekend service may produce favorable outcomes following LL arthroplasty when baseline LOS is 4 days or more. Redistributing PT resources to commence as early as day of surgery regardless of weekday may accelerate postoperative recovery. Current, high quality research is needed to confirm these findings.

Geriatrics and the Perioperative Surgical Home

An ever-changing health care system with a constantly increasing aging surgical population creates both opportunities for providing improved health care as well as significant challenges. Coordinated health care initiatives are needed if one is to adequately balance the need for evidence-based improved patient outcomes and the often-associated increased costs. In this article the authors postulate that a protocol-driven, multidisciplinary approach may be a pathway for implementing an effective triple aim to health care, especially in a frail geriatric population.