Are You Ready for the Game?

Transcription

1 Are You Ready for the Game? The Role of Preoperative Patient Optimization in Elective Orthopaedic Surgery Daniel Adair, MD and Jennifer Perkins, RN, BSHA, ONC The planners and presenters of this CNE activity have disclosed no relevant financial relationship with any companies pertaining to this activity OBJECTIVES List two modifiable patient risk factors that may impact surgical outcomes Describe the interventions that lower risk in orthopaedic surgical procedures 1

2 WHY OPTIMIZE? THIS ISN T THE PROBLEM! 2

3 CULTURAL SHIFT Vigilant surveillance by government and industry Minimal antibiotic use on animal and fish farms (vaccines instead) Minimal use by physicians Pharmaceutical Consumption per Capita (1997) U.S. Norway Bergen, T. International Journal of Antimicrobial Agents, CUMULATIVE CHANGES IN HEALTH INSURANCE PREMIUMS AND WORKERS EARNINGS ( ) AUDIENCE POLL What percentage of United States gross domestic product does health care dollars consume? A. 5% B. 10% C. 18% D. 23% 3

4 AUDIENCE POLL - ANSWER What percentage of United States gross domestic product does health care dollars consume? C. 18% CENTERS FOR MEDICARE & MEDICAID SERVICES Control costs Zero sum Reward over-achievers Penalize underachievers Pay for performance VALUE BASED PURCHASING 4

5 13 Year Number of Procedures (Kurtz) CHALLENGES FACING ORTHOPAEDICS We are seen as low-hanging fruit Average Cost (10% annual incr.) Total Cost (All procedures) CMS Cost (100% Medicare, 50% Medicaid) ,007 $54,642 $36,228,275,402 $ 22,461,530, ,005,964 $88,002 $88,526,931,633 $ 54,886,697, ,481,977 $367,607 $1,279,997,578,608 $793,598,498,737 HEALTHCARE COST COMPARISON FOR ORTHOPAEDIC PROCEDURES International Federation of Health Plans 2012 Comparative Price Report First Curve Orthopedics Adapted and reprinted with permission from The Five Strategic Forces that Shape Strategy by Michael E. Porter, Harvard Business Review, January,

6 First Curve Orthopedics Second Curve CMS Adapted and reprinted with permission from The Five Strategic Forces that Shape Strategy by Michael E. Porter, Harvard Business Review, January, 2008 BUYERS OF HEALTH CARE Co-payments and deductibles % increasing Higher deductibles and co-payments Difficult to collect Activating consumers no longer passive Transparent pricing demand price transparency Cash 17 ALTERNATIVE TO AAOS QUALITY INITIATIVES? Payors/policymakers will define guidelines, appropriateness for musculoskeletal interventions 6

7 First Curve Orthopedics Second Curve CMS Second Curve Integrated Care Adapted and reprinted with permission from The Five Strategic Forces that Shape Strategy by Michael E. Porter, Harvard Business Review, January, 2008 SECOND CURVE HEALTHCARE Fee for Service to Fee for Health Serve more patients At higher levels of quality, safety, service At lower cost In systems of care less hospital-centric With value being defined by the customer Not if but when, and already well underway Evidence of Impact of Standardization in Orthopaedics 7

8 STANDARDIZED CLINICAL CARE PATHWAYS/INTEGRATED CARE PATHWAYS Protocols that standardize care across an episode Often used to translate guidelines into clinical practice Require multi-disciplinary teams, coordination of care across providers and delivery sites Provide a means to improve collection and abstraction of data for audit and promotion of change in practice AUDIENCE POLL Does your organization use integrated care pathways or electronic order sets? A. Integrated care pathways B. Electronic order sets NAKAR MULTI-CENTER STUDY North American Knee Arthroplasty Revision (NAKAR) Total of 308 patients enrolled Overall complication rate of 17% Patient baseline co-morbidities were the best predictors of future functional outcomes 8

9 RESULTS ARE GOOD TO EXCELLENT NOW WITH % have adverse outcomes.1 -.8% result in death. It may get harder to achieve the same results. AUDIENCE POLL Which of the following is considered an unavoidable risk factor for adverse complications following a major orthopaedic surgery? A. Unmarried marital status B. Race C. Male gender D. All of the above 9

10 AUDIENCE POLL - ANSWER Which of the following is considered an unavoidable risk factor for adverse complications following a major orthopaedic surgery? A. Unmarried marital status B. Race C. Male gender D. All of the above UNAVOIDABLE RISK FACTORS Age Race Marital status Gender MODIFIABLE RISK FACTORS Malnutrition Anemia Poorly controlled diabetes Functional status Obesity Metabolic Syndrome 10

11 MODIFIABLE RISK FACTORS Malnutrition Clinical signs apparent only in extreme cases Serum Albumin level less than 3.5 g/dl Classically identified by low body mass index but obese patients may also be malnourished Anemia Hemoglobin less than 10 g/dl Increases risk of postoperative blood transfusion Increases risk of postoperative morbidity MODIFIABLE RISK FACTORS Poorly controlled diabetes Hemoglobin A1C greater than 7 Increased risk of stroke Increased risk of wound infection Severely limited functional status Get up and Go Walking speed MODIFIABLE RISK FACTORS Obesity BMI greater than 30 1/3 of U.S. adults are obese Review of literature Proportion of obese TKA patients jumped from 11% in 2002 to 20% in 2009 Greater risk of postoperative complications Greater risk of technical error 11

12 METABOLIC SYNDROME Multifactorial disease Hypertension Elevated lipids Central obesity Abnormal glucose metabolism Associated with stroke, MI, and DVT/PE AUDIENCE POLL What is the number one cause of readmission within 30 days at your organization? A. DVT B. Cardiac complications C. Surgical Site Infections D. Other medical complication E. Other POTENTIAL CAUSES OF 30-DAY READMISSIONS Surgical site infection Joint stiffness Wound problems Cardiovascular issues Venous thromboembolism Medical complications 12

13 Reduced postoperative complications Reduced readmission rates OPTIMIZATION Will decrease adverse events Encompasses all medical specialties Neglected in the past Patient acceptance may be difficult PREOPERATIVE OPTIMIZATION PROGRAM Multidisciplinary: Orthopaedic surgeons and Primary Care Physicians/Specialty Physicians must communicate May encounter some resistance Engage entire health care team PAs, NPs, and nurses are great allies! 13

14 PREOPERATIVE OPTIMIZATION PROGRAM Designated program tailored to individual needs of the patient Global Health Assessment Medical assessment Diagnostic testing Physical assessment Lifestyle assessment PREOPERATIVE OPTIMIZATION PROGRAM Medical therapies Assessment and treatment of medical conditions such as diabetes, sleep apnea, high blood pressure, high cholesterol, depression Medications for weight loss, if indicated Lifestyle therapies Education classes: Group and individualized counseling Smoking cessation PATIENT EDUCATION - SMOKING Shared with permission from the American College of Surgeons 14

15 PREOPERATIVE OPTIMIZATION PROGRAM Nutritional counseling Diabetes education Education classes: Group and individual counseling Fitness assessment Skilled physical therapy Monitored group exercises with exercise physiologist PATIENT EDUCATION MEDICATIONS Shared with permission from the American College of Surgeons PATIENT A 67 year old male Required to sit after walking for one block Knee would buckle Orthopaedic surgeon told him he needed a knee replacement but he was at higher risk for postoperative complications Referral sent to optimization program 15

16 PATIENT A Obese Poor physical function Fitness goals established Worked with exercise physiologist 2 3 times per week Lost 60 pounds in 3 months PATIENT A Successful knee replacement surgery Continues to lose weight I m able to enjoy life again. I can ride the bicycle with my grandkids now. I haven t done that for 10 years. Characteristics of Study Participants by Physical Activity Status Study sample (N = 17,871) Characteristic Sample Size Physically Active Physically Inactive Physical Activity Chronic Health Conditions Arthritis Back Pain Cancer Diabetes Heart Disease Hypertension Lung Disease Psychiatric Problems Stroke Any questions on why you want to stay active? 16

17 CYCLE DIAGNOSIS Sizing up the situation and challenges Framing up the situation for the team Framing: One s perspective on the task at hand, which typically occurs passively and is shaped by past experiences Establishing expected performance standards and direction Uniting the team around shared purpose of comprehensive and effective patient care DESIGN Shifting from evaluating the situation to considering and selecting possibilities for action Determining the general plan of care of the patient Establishing individual and mutual accountability All members of the healthcare team will be contributing Crux of challenge lies with the deep rooted status hierarchy Patient outcomes significantly correlate with the degree of hierarchy in health care team interactions 17

18 ACTION Shifting from talking to doing Tracking what actually happens and the results Teaming emphasizes outcome data, which captures results, as much as process data, which describes how the work unfolds Gaining experience in how to optimally address a similar issue in the future REFLECTION Crucial for understanding what worked and what didn t, and to prevent any identified failures from reoccurring What did we set out to do? What actually happened? Why did it happen? What do we do next time? Also need to consider what went right Need to be open to: criticism from fellow team members, gathering data, and feedback PATIENT ACTIVATION Definition: Active engagement of the patient in the management of his/her own health Crucial for optimal management of chronic conditions By 2020, 50% of Americans will have at least 1 chronic condition Orthopaedic surgeons can work together with patient to personalize health care delivery Improvement in surgical outcomes: reported reduction in pain and disability following lumbar spine surgery Critical impact on cost, health status, decision making, care experience, and outcomes 18

19 EFFECTS OF PATIENT ACTIVATION Characteristics of more activated patients Alter behaviors to better manage their health Collaborate more with health providers More likely to receive preventative care Decreased likelihood of smoking, alcoholism, and obesity Experience greater positive changes in physical and mental health BARRIERS TO ACTIVATION Misconceptions and perceptions of poor selfefficacy Linked to poor clinical and behavior change outcomes Pain Chronic Condition Medication side effects Stress NOT lack of information! EXAMPLE OF A NON-FUNCTIONAL TEAM 19

20 AUDIENCE POLL What are the reasons that patients may resist optimization efforts? A. Too busy B. I can do it myself C. My doctor hasn t mentioned it before D. Information deficit E. All of the above AUDIENCE POLL - ANSWER What are the reasons that patients may resist optimization efforts? A. Too busy B. I can do it myself C. My doctor hasn t mentioned it before D. Information deficit E. All of the above PATIENT ACCOUNTABILITY Lack of willingness to participate Annual cost in U.S. (2012) 100 billion 290 billion from non-adherence to medication Patients with chronic diseases from developed countries worldwide Average of 50% noncompliance with long-term therapies May be higher in developing countries (2003) Effective patient care = Physicians + Patients Rosenbaum L, Shrank W. Taking Our Medicine Improving Adherence in the Accountability Era. NEJM Sciberras N, Gregori A, Holt G. The Ethical and Practical Challenges of Patient Noncompliance in Orthopaedic Surgery. JBJS Adherence to Long-Term Therapies: Evidence for Actions. WHO Kaye et al. Patient noncompliance before surgery. BJUI

21 ACA AND NONCOMPLIANCE = CATCH22? Possible results: Doctors penalized for either: High re-admission/poor outcomes from high risk patients Denying surgery to patient Public reporting of cardiac surgery outcomes in NY in 1980s led to: Turning away of high risk patients Disproportionate number of black and Hispanic patients denied surgery Werner RM, Asch DA, Polsky D. Racial profiling: the unintended consequences of coronary artery bypass graft Circulation Rosenbaum L, Shrank W. Taking Our Medicine Improving Adherence in the Accountability Era. NEJM ROLE OF THE CLINICIAN Focus more on patient engagement in health care Form more productive patient & family-centered care teams Provide individualized support to patients Provide access to self-empowerment tools like HER and patient portals Build trusting relationships Encourage patients to ask questions Listen actively Be compassionate Communicate more effectively with other physicians and minimize inter-professional criticism APPROACHES (HELPFUL TOOLS) ASA Anesthetic classification Strong for Surgery Charlson index 21

22 SPRING TRAINING GO! GO! GO! LESSONS LEARNED Recognition of the problem It s hard work! Accept small victories Expect resistance Big idea better patient care! 22

23 REFERENCES Della Valle, A.G., et al. The Metabolic Syndrome in Patients Undergoing Knee and Hip Arthroplasy. The Journal of Arthroplasty. 2012; 00:0 Radcliff, K.E. et al. Preoperative Risk Stratification Reduces the Incidence of Perioperative Complications After Total Knee Arthroplasy. The Journal of Arthroplasty. 2012; 27:8. Ottenbacker, K.J, et al. Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service medicare patients. The Journal of American Medical Association. 2014; 311:6. Johnson, J.P. Preoperative Assessment of High-Risk Orthopedic Surgery Patients. The Nurse Practitioner. 2011; 36:7. Dy, C.J, et al. Influence of Preoperative Cardiovascular Risk Factor Clusters on Complications of Total Joint Arthroplasty. The American Journal of Orthopedics. 2011; 40:11. Jafari, S.M., et al. Renal Impairment Following Total Joint Arthroplasty. The Journal of Arthroplasty. 2010; 25:6. REFERENCES Urquhart, D.M. et al. Incidence and Risk Factors for Deep Surgical Site Infection After Primary Total Hip Arthroplasty: A Systematic Review. The Journal of Arthroplasty. 2010; 25:8. Matar, W.Y., et al. Preventing Infection in Total Joint Arthroplasty. The Journal of Bone and Joint Surgery. 2010; 92 Lindstrom, D. et al. Effects of a Perioperative Smoking Cessation Intervention on Postoperative Complications. Annals of Surgery. 2008; 248:5. Harrris, A.H., et al. Preoperative Alcohol Screening Scores: Association with Complications in Men Undergoing Total Joint Arthroplasty. The Journal of Bone and Joint Surgery. 2011; 93: Fotland, S.S., et al. Does the Preoperative Iron Status Predict Transfusion Requirement of Orthopedic Patients? Transfusion and Apheresis Science. 2009; 40: Petersen, M.K., Madsen, N.T., Soballe, K. Efficacy of Multimodal Optimization of Mobilization and Nutrition in Patients Undergoing Hip Replacement: A Randomized Clinical Trial. ACTA Anesthesiology Scandinavia. 2006; 50: REFERENCES Grant-Casey, J., Madgwick, K. Assessment of Anaemia in Elective Preoperative Orthopaedic Patients. Nursing Standard. 2010; 24:50. Goodnough, L.T., et al. Detection, Evaluation, and Management of Preoperative Anaemia in the Elective Orthopaedic Surgical Patient: NATA Guidelines. British Journal of Anaesthesia. 2011; 106:1. Beattie, W.S., et al. Risk Associated with Preoperative Anemia in Noncardiac Surgery. Anesthesiology. 2009; 110:574 Saleh, E. et al. Prevalence of Anaemia Before Major Joint Arthroplasty and the Potential Impact of Preoperative Investigation and Correction on Perioperative Blood Transfusions. British Journal of Anaesthesia. 2007; 99:6. Weber, W.P., et al. The Association of Preoperative Anemia and Perioperative Allogenic Blood Transfusion with Risk of Surgical Site Infection. Transfusion. 2009; 49:

24 REFERENCES Dailey, E.A., et al. Risk Factors for Readmission of Orthopaedic Surgical Patients. The Journal of Bone and Joint Surgery. Voskuijl, T., Hageman, M., & Ring, D. Higher Charlson Comorbidity Index Scores are Associated with Readmission After Orthopaedic Surgery. Clinical Research Huang, R., et al. The Effect of Malnutrition on Patients Undergoing Elective Joint Arthroplasty. The Journal of Arthroplasty : Harris, A.H, et al. Hemoglobin A1C as a Marker for Surgical Risk in Diabetic Patients Undergoing Total Joint Arthroplasty. The Journal of Arthroplasty ; Odum, S.M, Springer, B.D., Dennos, A.C., & Fehring, T.K. National Obesity Trends in Total Knee Arthroplasty. The Journal of Arthroplasty ; QUESTIONS? 24