The Asymptote to Utopia

Transcription

1 The Asymptote to Utopia Michael J Dunbar MD, FRCSC, PhD Professor of Surgery, Biomedical Engineering, and Community Health and Epidemiology Dalhousie University QE II Foundation Endowed Chair in Arthroplasty Outcomes

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3 Arthro plasty Arthron Joint Plastos Formed/Molded

4 Types of Arthroplasty Hip Knee Shoulder Elbow Wrist Fingers/toes Ankle Spine

5 Ratio of Cost to Quality of Life Improvement by Procedure Laupacis et al Cost/QALY $ (Thousands) THA HTN CABG Hemo Liver HIV

6 The 5 National Priorities for Wait Times Reduction Hip and Knee Arthroplasty Cancer Cardiac Cataracts Diagnostic Imaging

7 Asymptote to Utopia Phase&I& Phase&II&

8 The Paradox of Arthroplasty Outcomes Standard Effect Size (Post-op score - Pre-op score) SD Post-op score

9 Standard Effect Size Medical Management of Arthritis 2.8& 0.4& 0.6& 0.8& Small Medium Large TJA

10 Health Outcome Questionnaires Bad Pre-op Post-op A1& B1$ Noise Good A2$ B2$

11 Risk-Benefit Ratio for Innovation Past Present Benefit Risk Benefit Risk

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13 Percentage of Hip Replacements in Patients <55 that were Resurfacings by Country in % % % 0.6% UK Australia Norway Sweden

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15 Resurfacing Has Significantly Worse Outcomes

16 New Technology New Problems

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18 Jan 2003 Dec new hip and knee implants introduced Only ¼ used in more than 100 cases

19 Outcome of New Components Compared to 3 Best Performing Prostheses with > 5 Year data (Australia) Resurfacing acetabular Resurfacing femoral Cemented femoral Cementless acetabular Cementless femoral Better Same Worse 0% 20% 40% 60% 80% 100%

20 Asymptote to Utopia Phase&I& Phase&II&

21 Phased Innovation Registries$ *High$ Precision$ Metrics$ )$RSA$ RCT s$ Pre)clinical$

22 Atlan2c&Innova2on&Fund&Award& $5&Million&

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26 Dynamics of Human Motion Lab

27 Knee Adduction Moment (Nm/kg) Higher$$ knee$adduc?on$ moment$ MOMENT$ MTPM$ Medial$?lt$ Percent Gait Cycle

28 EMG&and&Migra2on& Lateral Gastrocnemius Neutral Migration Vastus Medialis Posterior Migration

29 Orthopaedic Research Surgical&Naviga2on

30 Principal Component Analysis (PCA) of Surgical Navigation Data on 600 cases 30 First 3 PC Loading Vectors 25 PCA& Flexion/Extension PC1 PC2 PC Varus/Valgus Direction Patient i = a 1 x + a 2 x + a 3 x PC1$ PC2$ PC3$ 96%

31 An Objective Framework TKA Prescription & Assessment Pre-operative Joint Function (Dynamic during gait and Passive) Post-operative Joint Function (Dynamic during gait and Passive) Patient-Specific Surgical Prescription Post-Operative Outcome Intraoperative Patient Functional & Morphological Characteristics

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35 10 Year % Change in Knee Cases in Canada >300% < Total 87% Males Females

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37 Implant survival based on revision as endpoint for six different age groups (Sweden -THA)

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39 Nova Scotia Compared to Canada Oldest Heaviest Most Arthritis

40 First one on when the music stops gets todays hip operation

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48 Arthroplasty Patients Waiting for Surgery (QEII) 2003/ Hips Knees Scopes Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March

49 Number THR Performed Number Primaries Revisions Year

50 Real Life vs. the Simulation System Attributes Patient Arrival Rates Operation Type Surgery Time Recovery Time Doctors Schedules Recovery Beds System Process Wait List Patient Flow Resources Needed

51 Model Development Verification and Validation Determine Patient Through Put Determine Patient Discharge Rate Determine Patient Time in System Determine Patient Time in a Queue Determine Bed Utilization Determine OR Utilization Determine Waitlist Growth Rate Compare and Contrast to Actual System

52 Actual Arena Model Create Patients and Doctors Schedule Reduces Doctor s Schedule after Surgery Acts as Hospital. Patients Flow Through Creates Emergency Patients and Sends them to Hospital

53 Ortho Wait Times as a Function of Beds and OR Time Wait Time (Years) Beds % 10% 20% Increase in OR Time

54 Wait Time (Months) Wait Time Growth as a Function of Time Time (Months) Current Resources 25 Additional Beds 25 Additional Beds, 30% Extra OR Time 50 Additional Beds

55 Nova Scotia Department of Health Announcement 25 new Orthopaedic beds 1 new OR 33 long term care beds opening

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57 Average Days Waited by Preoperative Procedure Days MRI CT Scan Clinic Follow-up Cardiology X-Ray Other Pulm Func Test Respirology Radiology Anesthesiology PAS Phys & Testing

58 URGEN CY Count 0 Ge n Surg Ne uro Ortho Pla stics Thoraci c Vascul ar 2 1 DIVISION

59 Operating Room Efficiency Problems With patient hours/day out of 10 hour day Used 40% Used 17% Idle 60% Idle 83% 10 Hour Day 24 Hour Day

60 Turn Around Time OR Time (mins) 95% Confidence Intervals of OR Time per Case Setup Time (mins) % Confidence Intervals of Setup/Clean up Time per Case HI VG HI VG Site OR Time Turn Around Time (Minutes) (Minutes) HI VG

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65 Recipe for Failure Set rules Enforce the rules Set the prices Eliminate competition

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67 Number of Primary Arthroplasties Performed Over Same 2 Weeks Blitz

68 Cancellations No cancellations for run-over No increase in OR overtime Some rooms completed lists early 4 cases/room/day was realized

69 Silo Mentality OR budget in silos, no overall coordination for a program, such as hip and knee replacement e.g., cases can be cancelled early, for fear of paying overtime Easy to measure some costs Hard to measure cost of not doing case Costs about to go up! Build programs around procedures

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74 The best way to predict the future is to invent it Alan Kay

75 Roentgen D Modern X-rays?

76 Surgery T2& Family& Doctor& T1& Surgeon&

77 Alternate Care Models Change from vertical to horizontal management structure Team building with allied health care Under capacity Medi/surgi centres Improve outcomes and reduce wait times

78 Validation

79 NORMAL HIP ARTHRITIC HIP

80 4.5 Effect Of TKA on Asymmetrical Gait (Lurch) Better Worse Improved (p < 0.01) Gait WOMAC Pain Stiffness Phys Function SF-36 PF BP VT SF PCS Worsened (p < 0.01) Gait Improved (p < 0.01) WOMAC Pain Preoperative Postoperative

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83 Family& Doctor/ Allied& Health& T1& Surgeon&

84 By Hamed Mirzaei 5 th Year Industrial Engineering Dalhousie Co-op Placement

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87 AIF - Accelerometers as Surrogates

88 Metrics of Knee OA Progression Knee OA Translational Research: We use cross-sectional and longitudinal progression models to understand how biomechanics change (during gait) with severity and progression of knee OA. We also study specific risk factors such as obesity, female sex, and in vivo measurements of physical activity to see how biomechanics change with these factors. We develop and use sophisticated mathematical tools Asymptomatic Moderate OA Severe OA Our goal is to design and validate metrics that can be captured easily either clinically or remotely based on the extensive scientific foundation we have developed. Kinematics The pattern of how individuals move their joints during gait changes with OA severity. We see lower peak angles and less range of motion throughout gait. Kinetics A key OA variable is the dynamic knee adduction moment during gait. This is the net resultant torque acting on the joint in the frontal plane attempting to push the joint into more varus ( bowlegged ) and subsequently loading the medial compartment of the joint. This loading tends to be higher and more sustained during gait in those with knee OA. Musculature Those with knee OA have altered neuromuscular control during gait, often characterized by higher and more sustained muscle activations, and often coactivation between muscles. Astephen et al. 2008; Astephen et al. 2011; Hubley-Kozey et al. 2006; Hubley-Kozey et al., 2009

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92 Canadian Joint Replacement Registry (CJRR) Information Package on Implementing Mandatory Reporting 93

93 CJRR Data Can Link To Many Other Data Sources DAD In-patient hospitalization care data NACRS Emergency department data CJRR Clinical and Surgical (implant) data CMDB Costing data CCRS Continuing care (long-term care) data HCRS Home care data NPDUIS Drug data NPDB Physician billing data (select provinces) NRS Rehabilitation data 94

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96 An Objective Framework TKA Prescription & Assessment Pre-operative Joint Function (Dynamic during gait and Passive) Post-operative Joint Function (Dynamic during gait and Passive) Patient-Specific Surgical Prescription Post-Operative Outcome Intraoperative Patient Functional & Morphological Characteristics

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103 Contemplation Before Surgery Joseph R. Wilder, MD