Vanderbilt Department of Orthopaedics

Transcription

1 Vanderbilt Orthopaedics: Value, Quality & Safety January VanderbiltHealth.com/Orthopaedics () 93-ORTHO

2 VANDERBILT ORTHOPAEDICS: VALUE, QUALITY & SAFETY A Message from the Chairman, Herbert Schwartz, M.D. The compelling need for a good definition of health care value highlights a fundamental challenge. We have not yet developed scientifically sound or accepted approaches to defining or measuring either patient centered outcomes of care, or the costs of producing those outcomes. The scientific hurdles to defining patient centered outcomes are numerous. Outcomes can be subtle and multidimensional, involving not only physiological and functional results, but also patients perceptions and valuations of their care and health status. The ability of health care organizations to measure costs is primitive at best and doesn t meet the standards used in many other advanced industries. Equally challenging is the lack of data systems to support outcome measurement. The (VDO) presents this compilation of Value, Quality and Safety as testimony to our mission, accomplishments and culture. The Divisions within VDO have proudly displayed some examples of the programs conducted in 3 which document our commitment to value in health care. Value can be defined as: Quality Patient Outcomes, Safety and Satisfaction divided by Cost, Waste Reduction and Operational Redesign. We strive to deliver the very best care for our patients, as per our credo of putting the patient first, by performing evidence based medicine whenever appropriate and setting examples of that behavior for our residents, alumni and colleagues. At Vanderbilt, the promise of discovery is our passion. Teamwork within VDO is fundamental and each team member is critical in facilitating a constantly evolving and improved product. We emphasize patient s rights and the sanctity and privacy of the patient-doctor relationship. We use our data management systems to support our discovery of best practices and apply them to the individual based upon their needs. Our team tries to focus on optimal access and care delivery while minimizing the distractions of poor metric proxies of performance. We must be mindful in our changing healthcare environment that we maintain our focus on delivering the care to our patients that they need. Please enjoy reviewing our march toward delivering value based health care. If you have any questions regarding the outcomes report, please feel free to contact me directly at: () 3-3. Best Wishes in the New Year, Herbert S. Schwartz, M.D. Professor and Chairman Vanderbilt Orthopaedic Institute MCE South Tower, Suite Nashville, TN Phone: () 3-3, Fax: () 7-79 herbert.s.schwartz@vanderbilt.edu

3 SPINE SURGERY OUTCOMES REPORT 3 Total Number of Patients Enrolled from October April 3 Oct - Dec 3 Jan - Dec Jan - Dec 9 Jan - April 3 37 Total,3 Anatomical Region Type of Surgery Cervical 3% Revision.% Lumbar 9% Primary 7.% Types of Lumbar Surgeries Types of Cervical Surgeries 7% 7% % % % % % 7% % % 3% % % % % % 3% % % % 33% Microdiskectomy Laminectomy Laminectomy + Fusion Laminectomy Anterior Cervical Diskectomy + Fusion and Fusion

4 SPINE SURGERY OUTCOMES REPORT 3 Outcomes Reported by Our Patients Lumbar Surgery Back Pain Baseline -Month Leg Pain 3 Back-Related Disability General Health State... Quality of Life 3.. Baseline -Month Baseline -Month Baseline -Month Baseline -Month Cervical Surgery Neck Pain Arm Pain 3 Neck-Related Disability. Baseline -Month Baseline -Month Baseline -Month Baseline -Month Baseline -Month 3 General Health State.... Quality of Life Return to Work Lumbar Surgery Return to Work Cervical Surgery Percent Lumbar Non-Fusion 97% returned to work Lumbar Fusion 9% returned to work Percent 9% returned to work 3 Time (months) 3 Time (months) Patient Satisfaction with Care % 9% % 97% 9% 97% 99% 7% % % Satisfaction with Surgeon Satisfaction with Nursing Staff Lumbar Cervical

5 JOINT REPLACEMENT OUTCOMES REPORT 3 Primary total knee replacement remains the most common procedure performed by the Joint Replacement Center, while primary hip replacement volume continues to grow. Our center has remained a strong referral center for revision hip and knee replacements, as well as infected joint replacements. Surgery Volume Due to Infection 9 Component Removal 3 7% 9 Joint Irrigation and Debridement Surgery Volume by Surgical Procedure 3 9 Total Knee Replacement 9 Total Hip Replacement Revised Total Knee Replacement Revised Total Hip Replacement Unicondylars Hip Resurfacing Infection and complication rates after total joint replacements continue to remain below national standards, as compared to other large, tertiary centers (de identified) as seen in the data obtained from University HealthSystem Consortium (UHC). Readmission Rate After Total Joint Replacement Readmission Rate % % % % % % % % % Q 9 A H B I C J D K E Vanderbilt F G Complication Rate After Total Joint Replacement Complication Rate % % % % % % % Q 9 A H B I C J D K E Vanderbilt F G

6 BONE AND JOINT OUTCOMES REPORT 3 Core Principles Patient Education Multimodal Pain Management Early Mobilization Inpatient Assessments (x day) Innovative Discharge Planning Telephone Follow up with Patient After Discharge from Hospital Length of Stay Due to Accelerated Recovery Program (ARP) Days Primary Primary Total Primary Joint Total Hip Arthroplasty Replacement Arthroplasty (TKA) (THA and TKA) (THA Peer Group (3.) National Benchmark (3.) Jan-Sept Nov - Jan 3 Accelerated Recovery Pathway Trial Length of Stay Reduction Savings (Eight-week period) Projected savings = $/day/patient Conservative estimate = days reduced Savings = $, in hospital costs The average length of stay following a primary joint replacement following the accelerated recovery pathway program was. days between November and January 3. This average includes patients who chose inpatient rehabilitation which requires at minimum a 3 night hospital stay. Average Patient-controlled Analgesia Usage Average Oral Pain Tablets Usage 3 Milligrams 3 9 Number of Pain Tablets. ARP Non ARP ARP Non ARP The average patient controlled analgesia (pain medication usage) among patients participating in the Accelerated Recovery Program (ARP) was nearly half that of the group not participating in ARP. The average number of oral pain tablets (taken as needed for pain) per visit using a random sample of 3 patients. The total overall average of tablets taken per visit for all of the ARP patients was 7 per patient.

7 CHILDREN S ORTHOPAEDICS OUTCOMES REPORT 3 Pediatric Spinal Fusion Surgical Site Infection (SSI) Improvements Procedure: Pediatric Spinal Fusion Infection Rate per Procedures % % % % % % Q3 Q Q Q Q3 Q 3 Q 3 Q 3 Q3 Infections Procedure Inf Rate*.7%.%.% 3.7%.3%.%.7%.%.% Surgical site infection rates for patients receiving spinal fusions continues to decrease. In Quarter 3 of there were 7 surgical site infections for every procedures completed. That number has been reduced to surgical site infections for every procedures completed in Quarter 3 of 3. Pediatric Fusion SSI Standardized Infection Ratio (SIR) 3 Q Q3 SIRAII Q CDC Benchmark Linear (SIRAII) Q Q Q3 Q 3 Q Q 3 Q3 Spinal Fusion Surgery Protocol Prior to Surgery Skin Assesment Bath Using Antiseptic Wipes Antibiotic Selection Implants and Surgical Instruments are Present Hours Before Surgery During Surgery Administer Antibiotics Prior to Incision Hair Removal Prepare Skin Perform Hand Hygiene Procedures Gloves for Surgical Staff Proper Surgical Attire Limit Personnel Antibiotics Every Hours Wound Irrigation Antibiotic Power After Surgery Antibiotic Regimen Dressing Changes Patient and Family Education

8 CHILDREN S ORTHOPAEDICS OUTCOMES REPORT 3 Pediatric Spinal Fusion Length of Stay Improvements Procedure: Pediatric Spinal Fusion Average length of Stay January-3 February-3 March-3 April-3 May-3 June-3 The length of stay for patients undergoing a spinal fusion has been reduced from. days prior to the postoperative pathway modifications to.3 days. This is. days below the national average of.9 (as indicated by black bar on table above). Benefits of a shorter length of stay: Patients are able to recover quicker and return to school/activities sooner Families face less of a socioeconomic burden (lower cost, less time off of work) Hospitals have increased open beds, available staff for new patients, and reduced costs. Postoperative Pathway Modifications Previously Occured on PostOp Day Now Occurs On on PostOp Day Patient is ordered to be out of the bed 3x/day Discontinue patient or 3 controlled analgesia Pain medication or 3 taken by mouth IV fluids stopped 3 Patient ambulates 3 (moves) 3x/day Hemovac drain removal 3

9 BONE HAND AND SURGERY JOINT OUTCOMES REPORT 3 Vanderbilt Department of of Orthopaedics Outcomes of Hook of the Hamate Fracture Excision in High Level Athletes Demographics Sport Age Range Level of Play at Time of Injury 9% % 3% Baseball Football Golf # of Participants in Age Group Age 9 College Rising Junior College College Outcomes Patient Satisfaction Patients Satisfaction was based on a score of (not satisfied) to (very satisfied). Pain s Pain Preoperative Postoperative Patients Pain was based on a score of (no pain) to (worst possible pain). Return to Sport Performance s # of Patients Weeks Performance Patients Left Right Preinjury Postinjury Postoperative DASH s Patients DASH DASH Sports All patients successfully returned to full participation in their sport an average of weeks after surgery. Performance in the patient s respective sport was measured on a scale of (worst possible performance) to (best possible performance). A patient s functional outcome was measured using the DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire and DASH Sports module which uses a scale of (no difficulty doing specific function) and (unable to do specific function).

10 ORTHOPAEDIC ONCOLOGY OUTCOMES REPORT 3 Surgical Site Infections and Resected Soft Tissue Sarcomas Wound Complication and Local Recurrence Rates Patient % 9 Toronto (n=) Boston (n=3) Nagoya (n=) Vanderbilt 3 (n=9) Wound Complication Rate Local Recurrence Rate % of patients (n=9) who underwent preoperative radiation prior to the operative procedure to resect their soft tissue sarcoma did not suffer any wound complications. In addition, % of the patients did not have a local reoccurrence. Management of Obese Patients with Extremity Soft Tissue Sarcomas Wound Complication and the Obese Patient Hazard Ratio Obesity Wound Complications Sarcoma-Specific Death.. Distant Metastatis.. Local Recurrence.. The Vanderbilt Sarcoma Service is able to achieve the same overall survival, local recurrence rates, and wound healing in obese (Body Mass Index > 3) and non obese (BMI < 3) patients in contrast to other orthopaedic and general surgery literature.

11 BONE ORTHOPAEDIC AND JOINT ONCOLOGY OUTCOMES OUTCOMES REPORT REPORT 3 3 Vanderbilt Department of of Orthopaedics Quality Projects on Incomplete Excisions of Soft Tissue Sarcomas Patient Distance Insurance Status Miles (Median) Primary Reexcision Excision (n=3) (n=7) Primary Excision (n=3) Reexcision (n=7) % of Patients % % % 3% % % % None Public Private Primary Excision (n=3) Reexcision (n=7) Type of Surgery Type of Insurance Difference in Charges Between Primary and Reexcision Cost ($),,,,, Indirect Professional Technical Type of Charges Primary Excision (n=3) Reexcision (n=7) INSURANCE AND DISTANCE ANALYSIS: Insurance status and patient distance from the treatment center were not significantly different between patients who underwent primary excision and reexcision of a soft tissue sarcoma. However, large and deep tumors and certain histology types predicted appropriate referrals. COST ANALYSIS: The average professional charge was $99 for a primary excision and $9 for a reexcision. After adjusting for variables such as: tumor size, grade, and site, patients undergoing reexcision saw an increase of $3,99 in professional charges more than those with a primary excision. Proposed Flowchart for Avoiding Unplanned Resections of Wrist Sarcomas Chief Complaint: Dorsal Wrist Mass Atypical Features Ulnar sided Symptoms < months Lack of function Rapid growth Proximal-distal to wrist Yes. Proceed with caution. Consider MRI 3. Consider longitudinal incision No No Aspirate = No Transilluminate viscous jelly/ Yes Treat as dorsal ganglion cyst honey Yes Treat as dorsal ganglion cyst MRI Flowchart of purposed algorithm of diagnostic steps () and treatment recommendations () for patients presenting with dorsal wrist mass. This algorithm was created to help surgeons avoid treating malignant tumors thought to be dorsal ganglion cysts.

12 ORTHOPAEDIC TRAUMA OUTCOMES REPORT 3 Relationship of Hyperglycemia and Surgical Site Infection (SSI) Rates Review of 79 Non Diabetic Orthopaedic Trauma Patients Requiring Surgery Blood Glucose Levels and Surgical-Site Infections Hyperglycemic Index (HGI) and Surgical-Site Infections % % 3% % % 3% % % % 37%.%.% More than Less than Blood Glucose Level mg Number of Patients Thirty-day Surgical- Site Infection (SSI) Rate % % % % 7% 7.%.7% HGI.7 HGI <.7 Number of Patients Thirty-day Surgical- Site Infection (SSI) Rate Of the 79 patients, 9 had more than one glucose value of mg. This factor was associated with thirty day SSIs, with.% of the 9 patients with that indication of hyperglycemia having a surgical site infection versus.% of the 9 patients without more than one glucose value of mg. Hyperglycemia was an independent risk factor for thirty day SSIs in orthopaedic trauma patients without a history of diabetes. We now closely monitor and control glucose levels perioperatively. Stress Induced Hyperglycemia as a Risk Factor for Surgical Site Infection (SSI) Rates Review of 7 Non Diabetic Orthopaedic Trauma Patients Admitted to the Intensive Care Unit (ICU) Average Length of Stay Injury Type Infection Rates Day Average length of Stay ICU Hospital 3 Upper Extremity Pelvic or Acetabular Femur Tibia Foot % % % % % %.% 3% Surgical- Site Infections Infections Hyperglycemic Index (HGI) and Surgical-Site Infections Blood Transfusion Units and Surgical-Site Infections..... Average HGI Level Patients without an SSI Patients with an SSI Units.9.9 Average Blood Transfusion Patients without an SSI Patients with an SSI Stress induced hyperglycemia demonstrated a signifiicant independent association with surgical site infections in a nondiabetic orthopaedic trauma patients who were admitted to the ICU. In addition, patients with an SSI received a greater amount of blood transfusions. We also closely monitor and control glucose values in severely injured patients.

13 ORTHOPAEDIC TRAUMA OUTCOMES REPORT 3 Health Literacy in Orthopaedic Trauma Patients Implementation of Program to Improve Patient's Understanding of Injuries Patient Assessment. What bone did you break?. How was the bone fixed? 3. How much weight can you put on the extremity?. How long until your bone is healed?. Are you supposed to be on medicine for blood clots? Provided M.D. Information to Patient Hometown Residency Program Fellowship Program Medical Interests Professional Memberships Name Overall Patient Performance on Comprehension Questions 9% % 7% % % % 3% % % % Q Q Q3 Q Q Pre-Intervention (N=) Post-Intervention (N=3) Patient Satisfaction % 7% % % % 3% % % % Poor Fair Good Very Good Excellent Patients with Intervention (N=3) Patients with no Intervention (N=3) All patients receive plain language information on their injury, surgery and follow up.

14 REHABILITATION ORTHOPAEDICS OUTCOMES REPORT 3 The Worker s Compensation Patient Number of Days Restricted to Light Duty Number of Patients >9 Cervical 3 3 Lumbar Shoulder Hand Knee 3 Foot/Ankle Average Days on Light Duty Cervical Lumbar Shoulder Hand Knee Foot/Ankle Over half (%) of the sampled worker s compensation population (n=) were restricted to light duty for less than 3 days. % of the patients were restricted to light duty for days or less. The average number of days a worker s compensation patient was restricted to light duty ranged from 9 days for patients with foot and ankle injuries to days for patients suffering from hand injuries. % of 9 worker s compensation patients sampled were able to return to work following treatment. Over 7% of lumbar spine injury patients and % of amputation patients were able to return to work. Return to Work Number of Patients Lumbar Paraplegia Pelvic Extremity Amputations Cervical Thoracic Multiple Spine Injuries Injuries Spine Spine Traumas (No Injury Injuries Injuries Fractures) Returned to Work Did Not Return to Work Total Patients 3 3

15 SPORTS MEDICINE OUTCOMES REPORT 3 Value Based Treatment of Atraumatic Rotator Cuff Tears MOON (Multicenter Orthopaedics Outcomes Network) Physical Therapy Program for Atraumatic Rotator Cuff Tears Physical Therapy ( weeks) Daily Range of Motion Exercises Daily Flexibility Exercises Strengthening Exercises (3x/week) Heat/Cold Therapy Home Therapy Program Further Treatment Determined Patient "cured" No Further Treatment Patient "improved" Physical Therapy for More Weeks Patient "no better" Could Elect to Have Surgery Outcomes Patient-completed Survey s Range of Motion Measurements Baseline Weeks Weeks SF- MCS SF- PCS ASES WORC SANE Marks Acivity Scale Degrees Baseline Weeks Weeks Forward Elevation Abduction External Rotation at Side Internal Rotation at Side External Rotation at 9º of Abduction Marks Acivity Scale Week Week Year Year % 9% % % % % % % 9% % 79% 7% Nonoperative Treatment Patient did not Follow-up Surgical Treatment Surgery Free Probability Nonoperative treatment using the MOON physical therapy program was found to be effective for treating atraumatic rotator cuff tears in approximately 7% of the patients that were followed for years. Patient reported outcomes improved significantly at and weeks. If patients did fail the therapy program it was usually within the first three months. 7% Cost Savings (Between patients undergoing surgery for rotator cuff tear and patients treated successfully using MOON physical therapy program) Realized Costs Savings = $ million/per year