Value In Shoulder Care. VuMedi Webinar July 30, /29/2013. Mark Frankle, M.D.- Tampa Bernard Morrey, M.D.- Rochester J.P. Warner, M.D.

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1 Value In Shoulder Care VuMedi Webinar July 30, 2013 Hospital for Joint Diseases Department of Orthopaedic Surgery Mark Frankle, M.D.- Tampa Bernard Morrey, M.D.- Rochester J.P. Warner, M.D.- Boston Hospital for Joint Diseases Department of Orthopaedic Surgery Health care delivery is being redefined with a new vocabulary for us to Value understand and integrate Value-based purchasing Quality Clinical practice guidelines Appropriate use criteria ACOs Bundled payment systems Episodes of care Hospital for Joint Diseases Department of Orthopaedic Surgery 1

2 Value = patient health outcomes per dollar expended Value = health outcomes cost of delivering the outcome Requires us to measure outcomes and understand costs Hospital for Joint Diseases Department of Orthopaedic Surgery Value-based purchasing: CMS program to reward high performing institutions for process of care and patient satisfaction measurements Quality: being defined in many ways by many organizations Hospital for Joint Diseases Department of Orthopaedic Surgery CPGs: a transparent, reproducible, systematic evaluation of clinical evidence to assist the practitioner and patient in making decisions about appropriate health care for specific clinical circumstances AUC: specifies when it is appropriate to use a procedure by combining the best available scientific evidence with the collective judgment of physicians; derived from CPGs Hospital for Joint Diseases Department of Orthopaedic Surgery 2

3 ACOs: Responsible for quality, cost, and overall care of a defined population of patients Bundled payment system/episodes of care: CMS demonstration project that provides payment for defined period of care regardless of care provided Hospital for Joint Diseases Department of Orthopaedic Surgery 67 year-old male with significant shoulder pain and disability Hospital for Joint Diseases Department of Orthopaedic Surgery Evaluated by five orthopaedic surgeons #1: Viscosupplementation injections #2: Steroid injection #3: arthrosopic debridement #4: TSA #5: Reverse TSA Is this value-driven shoulder care? Hospital for Joint Diseases Department of Orthopaedic Surgery 3

4 Best Practice and Value VuMedi Webinar Logistics: Value in Shoulder Care Bernard F Morrey, M.D. Mayo Clinic, Rochester, MN U of Texas, San Antonio Best Practice and Value Disclosure none Value committee ASES Voting member of AAOS AUC: rotator cuff Why Important Best Practice and Value Health cost = 13% GDP: do the math

5 Best Practice and Value Goal Assess as to whether: There is evidence that Evidence based practice Improves care and Is not more expensive than poorer care Best Practice and Value Terms, definitions, and concepts Value Evidence - Practice guidelines - Appropriate use criteria Best Practice and Value What are we talking about? Best practice The use of current best evidence in making decisions about the care of patients i.e. Evidence based clinical practice

6 Evidence Based Cost Effective Medicine Levels of Evidence (1979) I. Random controlled II. Cohort, case controlled III. Case series 0 control IV. Expert opinion Best Practice and Value Value: what are we talking about? Value = quality/cost Where Quality = optimization of risk/benefit Cost = total cost of encounter includes managing complications So value = cost effectiveness Best Practice and Value So best practice and value is evidence based - cost effective

7 Best Practice and Value Evidence is used to define guidelines Guidelines (CPG) are used to define optimum (best) practice Appropriate use criteria (AUC) used to define appropriate indications Considers patient input Allows for expert experience Hypothesis: Variation Arbitrary choice Excessive costs Solution Decreased quality Standardize Practice - Evidence Based Guideline BFM to Mayo Brd of Gov, 2003 CP Best Practice and Value So, to simplify our question Have orthopedic clinical practice guidelines (N = 14) improved the quality of care? If so, have they affected cost of care?

8 Best Practice and Value So to simplify the question Have orthopedic guidelines (N=14) improved orthopedic practice? guidelines improve any practice? If so, have they decreased cost of care? Best Practice and Value Guidelines proven to improve process Little evidence they improve practice Coronary artery disease: Improved process and structure. No evidence of improved care Lugtenbery, et al. Effects of Evidence Based Clinical Practice Guidelines on Quality of Care Quality Studies of Health Care: 18, 385, 2009 Best Practice and Value Guidelines proven to improve process Little evidence they improve practice Coronary artery disease: Improved process and structure. No evidence of improved care Lugtenbery, et al. Effects of Evidence Based Clinical Practice Guidelines on Quality of Care Quality Studies of Health Care: 18, 385, 2009

9 Best Practice and Value Guidelines shown to improve process Little evidence they improve practice No evidence of successful transfer of evidence guidelines to improved practice NEJM, 2000, Lancet, 2003 Guideline based performance should be carefully evaluated before implementation to avoid incorrect assessment of quality of care. Lin, et al Impact of Changes in Clinical Practice Guidelines on Assessment of Quality Of Care Med Care: 48, 733, 2010 Best Practice and Value Guidelines proven to improve process Little evidence they improve practice Evidence for the impact of quality improvement collaboratives: systemic review have only modest impact on outcomes Schouten, et al, BMJ, 2008 Best Practice and Value Effect / Impact / Relevance To date questionable Congress engaged Institute of Medicine to assess reason for poor adoption Answer Effective? - not trustworthy

10 Best Practice and Value Cost effective? Little progress..unable to calculate a cost per quality adjusted life year Health Policy, 1999 Best Practice and Value Summary Conclusion Evidence based effectiveness Process well defined Incorporation limited to date Assessing true cost effectiveness is in future Driven by irreversible trends Impact +/- will increase with time

11 Effects of Morbid Obesity on RSA A case control study on outcomes, complications, disposition and cost Mark Frankle, MD Value in Shoulder Care Tuesday, July 30, 2013 Disclosures Dr. Frankle receives royalites, research support, and consulting fees from DJO Surgical Background Obesity incidence and prevalence in US Morbid Obesity: BMI > U.S. prevalence: 3-5% incidence in 1 RSA (our patients) = 21/765 (3%) Inferior outcomes generally in THA, TKA, TSA No literature on RSA 1

12 Hypothesis Morbidly obese patients will have inferior clinical outcomes greater cost more post-discharge needs higher complication rates when compared to non-obese patients Purpose To compare RSA in BMI 40 to BMI < 30 Clinical and radiographic outcomes Disposition, complications and hospital cost Study Design STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) Case control 1:3 Matched age, sex, Dx, f/u 2

13 Inclusion Study Design 1 RSA between 2003 and 2010 Min 24 months of f/u Dx: CTA, MRCT, RA Exclusion Infection, neurologic injury, fracture and revisions Surgical Technique Uniform, previously described DP approach, single experienced surgeon Consistent team 2nd generation baseplate, lag screw, locking screws Cemented humeral component Primary Outcome Existing data used to calculate Δ ASES 10 -> 84pts with 1:3 case control ΔSST 2 42 pts 10% higher complication rate Major 760 pts Minor 584 pts 3

14 Study Demographics Study Group Control Group Females (17) Females (50) Males (4) Males (13) Study Group Control Group 43.2 ( ) 27.1 ( ) p<0.05 Study Demographics Study Group Control Group ( ) ( ) p<0.05 Study: 69.2 Control: 71.1 Study: 45.0 Control: 48.2 Study Demographics Study Group Control Group MCT (2) MCT (6) RA (2) RA (6) CTA (17) CTA (51) 4

15 Total Comorbidities Cancer Diabetes OSA CAD CHF CRF CVA COPD Corticosteroids Dementia DM HLD HTN Narcotic use Liver Disorder Obesity Osteoporosis PUD PAD RA Tobacco Other (i.e. Parkinson s, NM disease) Phases of Care Preoperative Intraoperative Postoperative Preop Hospital Visit OR in PACU WARD Holding Room OR out ICU Excluded post-hospitalization cost (variable) Cost Collection Method Line item costs for goods and services for each patient Provided by TGH Decision Support Department Incorporates effort and time spent with each patient by staff, resource utilization and dispensables Hospital cost ONLY 5

16 Preoperative Cost LABS PREOP MICRO PREOP CXR PREOP EKG PREOP HOLDING ROOM SURGICAL PREPARATION Intraoperative Cost SURGICAL SUITE USAGE ANESTHESIA SERVICES IMPLANTS DISPOSABLE SURGICAL INSTRUMENTS REUSABLE SURGICAL INSTRUMENTS DISPOSABLE SURGICAL SUPPLIES Postoperative Cost PACU WARD POST TELEMETRY ORTHOTICS LABS TOTAL SHOULDER FILMS CXR PORTABLE SERVICES OT PT RESPIRATORY PHARMACY DRESSING SUPPLIES ALL OTHER SUPPLIES MICRO PATH CARDIAC STUDIES 6

17 Outcomes Measured ASES SST VAS Pain VAS Function Satisfaction Motion Radiographs Outcomes Obese-Pre Obese-Post Control-Pre Control-Post p< VAS Pain VAS Function SST Satisfaction Outcomes Study-Pre Study-Post Control-Pre Control-Post p< ASES Pain ASES Function ASES Total 7

18 Results Both improved significantly pre post Improvement: VAS pain 3x VAS function 3.5x SST 6x vs 4x ASES 2x Obese more impaired at baseline for VAS Function, SST and ASES function Increment was similar Motion Study-Pre Study-Post Control-Pre Control-Post 125 p< T12 T S1 L Forward Flexion Abduction External Rotation Internal Rotation Results Both improved significantly pre post Motion increased: 2x FF, ABD, & IR ER 5x vs 2x Obese more impaired at baseline for ER and IR Increment was similar 8

19 Comorbidities 7/29/2013 Comorbidities Obese Control Total 6 4 OSA 10/21 2/63 p < 0.05 Steroid use 4/21 5/63 Surgical Data Obese Control EBL (ml) Skin to Skin Total OR Time Rest Time in OR p< p<0.05 LOS, Disposition, Readmissions Obese Control LOS (days) Home dc 15/21 60/63 p<0.05 Readmission 2 0 ED Visit 1 1 9

20 Radiographs and Complications Obese Control Notching 1 - G1 3 G1 2 G2 Reactive Bone 7 16 Stem Loosening 0 2 Baseplate Failure 0 0 Dissociation 0 0 Other Mechanical 0 0 Cost Analysis Obese: $24,467 (18,790-57,649) Controls: $21,509 (15,864-29,773) Δ $2,958 p<0.05 Cost Analysis by Care Phase Study Group Control Group Pre-operative $ 322 $ 315 $ 7 Intra-operative $ 18,757 $ 17,864 $ 893 Post-operative $ 5388 $ 3329 $ 2058 p<

21 Cost Analysis Post-Op $5,388 (22%) Pre-Op $322 (1%) Post-Op $3,329 (16%) Pre-Op $315 (1%) Intra-Op $18,757 (77%) Intra-Op $17,864 (83%) Obese $24,467 Control $21,509 Significant Line Item Costs Holding Room Time ($18) OR Time ($242) Orthotics ($95) Respiratory services ($130) Labs ($32) ICU p<0.05 Complications Major Reoperation Hospital Readmission Treatment >1month Minor Everything Else Obese: 4 in 3 patients Controls: 8 in 8 patients p = Obese: 3 in 3 patients Controls: 14 in 12 patients p =

22 Morbidly Obese 7/29/2013 Major Complications Obese 1. COPD exacerbation Readmission 2. V-tach postop ICU, cath 3. Acromial base fx sling 4. Acromial fracture (3) sling Controls 1. Acromion fx sling 2. Scapular spine fx (3) sling 3. Postop pain ED visit 4. Dislocation 2-3 yr, self-reduced 5. Wound drainage POD10 outside ID, iv Dapto 6. Humeral loosening 75 m Minor Complications 1. SWI (Keflex) 2. Ankle gout & neck arthritis flare up (NSAID s), 3. RVR (Rate Meds-chronic A-fib) 1. Wound drainage wound care and Augmentin 2. Wound erythema Keflex 3. RVR postop Rate meds, (chronic known A-fib) 4. Neck pain spine, conservative Tx (pt 3) 5. C6 radiculopathy exacerbation resolved 6. Postop nausea head CT 7. New atrial flutter outpt f/u Controls 8. Hypoxia/hemidiaphragm paralysis (block) Telemetry, fever w/u, atelectasis 9. UTI antibiotics 10. Anemia 2 units PRBC transfused 11. Hyponatremia (Na+ 120) Free H2O restriction 12. Atelectasis fever workup 13. Oral herpes flare-up acyclovir (pt 12) 14. GI virus dehydration, oral + iv hydration Discussion Novel but consistent Difficult to isolate effect of morbidy obesity alone Cost outlier: consistent with literature Can anticipate 5% ICU for morbidly obese 12

23 Discussion Generic concept: Value= Outcome / cost Hard to measure objectively Hard to put value on patients symptoms Patients at risk for lower value Our study helps define the value of RSA in morbidly obese patients Conclusions Era of finite and decreasing resources Increased pressure, P4P Similar studies useful Shoulder surgery equally successful More comorbidities, higher cost and more post discharge needs Thank You 13

24 Jon J.P. Warner, MD Chief, The MGH Shoulder Service Professor of Orthopaedic Surgery Harvard Medical School Massachusetts General Hospital Laurence D. Higgins, M.D. Chief, Sports Medicine & Shoulder Service Brigham and Women s Hospital Eric Black, M.D. Resident, Harvard Combined Ortho. Program Jon J.P. Warner, MD Chief, The MGH Shoulder Service Professor of Orthopaedic Surgery Harvard Medical School Co-Director, Boston Shoulder Institute Conflict of Ego - Past President ASES - Current work with HBS Fellowship Support: Arthrex Mitek Smith & Nephew Breg DJO Royalty: $ Tornier- RCR device Consulting (Lecture honorarium): $ Tornier, Mitek Equity: $ Orthospace Co. $ Vumedi 1

25 What is Value? Its personal... The Patient = Outcome Insurers/Hospital: Cost? Time? Resources? - The Surgeon:» Outcome» Income Competitive Strategy in Healthcare? (Alignment) Zero-sum competition Compete to shift costs Positive-sum competition Compete towards net gain 2

26 2008 Top 20 Reasons for Office Visits in USA, 2010 Shoulder Symptoms ss 11.5 Million Reference: National Ambulatory Medical Care survey,

27 How important is Shoulder Care at our hospitals ( in Massachusetts) The current system of health care payment is not Value based health care providers are compensated at widely different rates for providing similar quality and complexity of services. 4

28 In Massachusetts In Massachusetts The Four Major Hip/Knee manurfacurers paid physicians: $800,000,000 in consulting, royalties & equity in 65,000 agreements - Assistant Attorney General Report to the Senate In Sixty-three the last percent twenty years surgeon of U.S. hospital payments have negative for total Margins hip Enquist M, Bosco JA, Pazand, L, Habibi, KA, Donohue, RJ, Zuckerman, JD: and on Managing Medicare knee replacement Episodes patients, of Care: with have Strategies one-quarter decreased for Orthopaedic 69% sustaining Surgeons and 66% inpatient the Era of respectively. margins Reform. J of Bone -20% Joint (Medicare Surg. or lower. Am. data) 2011; 93:1-7. Patient Protection and Affordable Care Act (PPACA): Orthopaedic surgeons will need to identify ways to cut costs, maintain quality measures, and manage post-acute care to survive in a changing marketplace Patient Protection and Affordable Care Act (PPACA): references the word quality 906 times but does not clearly define this in the legislation. Who Will Define Quality and How will quality be defined? Enquist M, et al: Managing Episodes of Care: Strategies for Orthopaedic Surgeons in the Era of Reform. J Bone Joint Surg. Am. 2011; 93:1-7. 5

29 # of Articles 7/29/2013 Medicare: Fixed pricing which pays equal for good & poor outcomes P4P: Incentivizes practice not outcome (not quality) - R. Herzlinger What does this cost??? ERRORS IN MEDICAL LITERTURE Year Poor documentation 6

30 TTD Days 7/29/2013 How Insurer s see us 900 Shoulder Procedures Physical Therapy Visits (post shoulder procedure) No Correlation between the number of P.T. visits and TTD!!!!!!! -Insurance Companies Practice Medicine: Managed care results in a top-down health care system which impedes any potential for innovation which improves care of patients. -- Herzlinger Who are our allies?: The Hospital - R. Herzlinger: Hospitals: when it comes to supply, hospitals suppress competition and innovation, and health care s key suppliers, the physicians, are marginalized. 7

31 Most experts favor vertical integration of large physician groups the larger the scale, the larger the problems encountered - Herzlinger Diminishing Margin 8

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33 Shoulder Care 60% Complication Rates Each Year for Reverse Arthroplasty 50% 50% 40% 40% 30% 20% 10% 0% 18% 10% 11% 8% 5% 0% Mayo Clinic Resource Utilization for THR Department of Orthopedics DRG Total Hip Arthroplasty (Primary) Cost per Case by Surgeon 30% Variation by Physician ANAT PATHO CRITICAL C RADIOLOGY CENTRAL SU INTERNAL M PHARMACY LAB MEDICI MEDICAL SP ANESTHESIA SURG SUBSP PT CARE SE HOSP SURG RP MDCAR MD 1 MD 2 MD 3 MD 4 MD 5 MD 6 MD 7 MD 8 MD 9 MD 10 MD 11 MD 12 MD 13 MD 14 MD 15 10

34 Margin % 7/29/2013 Imaging Utilization (Medicare) Reference: Iglehart. NEJM; 2009: We order these tests.and create costs.. MAYO PRIMARY THR MARGIN BY SURGEON Department of Orthopedics DRG Total Hip Arthroplasty (Primary) Margin % by Surgeon Margin = Reimbursement cost cost ALL CASES MD 1 MD 2 MD 3 MD 4 MD 5 MD 6 MD 7 MD 8 MD 9 MD 10 MD 11 MD 12 MD 13 MD 14 MD 15 Complication rate = NS Surgeon Linear Decrease in Hospital Cost of Hemiarthroplasty (n=8,115) 11

35 Shoulder Pain PCP Orthopaedic Surgeon Shoulder Sports Repeat Imaging? MRI PT Hand PT Rehab? Anchors Bone tunnels Open Arthroscopic Surgery The formula for cost effective care VARIATION: Arbitrary Choice Excessive Costs Decreased Quality Solution Standardize Practice Evidence Based Status quo Lack of Incentives Failure of Alignment Poor Consensus on Outcomes Measures 12

36 What s it really cost? Actual Costs Allocated Costs Resource Capacity Capacity Cost Rate Alternative Payment Models in the Private Sector The Future Awaits! Patient-Centered Medical Home Accountable Care Organizations Bundled Payments Global Capitation An Old Model? 13

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