How to Cut 1 Hospital Day in Revision TKA/THA Cases

Surgeons from Florida have come up with some specific suggestions as to how their colleagues can improve treatment metrics for arthroplasty revision patients.

Their work, “Bundled Payment “Creep”: Institutional Redesign for Primary Arthroplasty Positively Affects Revision Arthroplasty,” was published in the February 2019 edition of The Journal of Arthroplasty.

Chancellor Gray, M.D., an orthopedic surgeon at the University of Florida College of Medicine in Gainesville and co-author on the work, told OTW, “We found that the overall environment and culture of care in our health system was improving, favoring increased value for our total joint arthroplasty [TJA] patients, in the wake of our Comprehensive Care for Joint Replacement (CJR) inspired redesign of our total joint program.”

“We were seeing improved quality metrics for our revision patients, though they were not explicitly targeted by our intervention, and wanted to examine the effect of the redesign for these patients in particular. Prior work we published showed the efficacy of the intervention on the intended group, so we were quite curious to see the effect on this other group (the revision patients).”

“We compared quality metrics for all revision TJA patients including readmission rate, use of post–acute care facility after discharge, length of stay, and cost, between the year leading up to the redesign and the two years following its implementation. Changes in the primary TJA group over the same time period were also assessed for comparison.”

Dr. Gray explained to OTW the most surprising results from the study. “The most important results are that, despite no targeting of revision patients, complex revision THA [total hip arthroplasty]/TKA [total knee arthroplasty] patients can see an improvement in length of stay, readmission rate, and home discharge rate largely through a culture change coming from care improvements for primary THA/TKA patients.”

“For instance, we improved length of stay by nearly a day (from 4.8 to 3.9 days) and were able to make a nearly 25% improvement in patients going to home instead of to a facility.”

“Surgeons have an opportunity to improve care for their patients through culture change in their hospital/ practice. We found the key elements of the culture change to stem from a monthly multi-disciplinary meeting where the surgeon group: a) controlled the messaging by being the foremost presenting group, b) was a fully invested group willing to share and compare data, and c) was willing to take ownership over the whole patient-care episode, both before, during, and after the hospital surgical experience.”

“Despite putting surgeons in what may, at first, feel like an uncomfortable position, bundled payment programs may offer real opportunities for care alignment and improvement of value in what is a very common and very expensive operation. In fact, handled correctly, these programs give surgeons an opportunity to reassert ownership over the care episode for the benefit of their patients and their health system.”