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1 Patient Optimization Improves Outcomes, Lowers Cost of Care > Consistent preoperative processes ensure better care for orthopedic patients The demand for primary total joint arthroplasty is projected to grow substantially over the next fifteen years. This expansive growth is accelerating the pressure on hospitals from the payer industry for improved patient outcomes at a lower total cost of care for a total joint replacement patient. National reporting agencies and organizations are increasingly focusing on the need to strengthen the surgical preparation of the patient. To that end, a large hospital system in the Midwest decided to incorporate a preoperative optimization and risk-reduction program as part of their joint replacement program. This paper details the preoperative process the hospital and Accelero Health Partners created and implemented to ensure all orthopedic patients have successful surgical outcomes

2 Introduction > By 2030, the demand for primary total hip arthroplasty is estimated to grow by 174% to 572,000. The demand for primary total knee arthroplasty is projected to grow by 673% to 3.48 million procedures 1. This expansive growth is accelerating the pressure on hospitals from the payer industry for improved patient outcomes at a lower total cost of care for a total joint replacement patient. Over 2,600 hospitals will be impacted financially for lower quality outcomes in one of three CMS programs this year (Figure 1). In fiscal year 2015, 1,360 hospitals are losing additional reimbursement under the Value-Based Purchasing (VBP) program, 724 hospitals will be penalized under the Hospital Acquired Conditions (HAC) Reduction Program and 2,639 hospitals will be penalized under the Readmissions Reduction Program. CMS Quality Program No. Hospitals Penalized Average Penalty Penalty Range VBP 1, % % Readmission 2, % % HAC % Figure 1 CMS quality penalties for hospitals Hospitals are under increased pressures from patients, the government and insurers to control costs and improve the quality of care. To do so often requires the hospital to partner with providers and services outside of their facility to ensure that patients are properly prepared to enter the hospital and are taken care of once they are discharged. One method for improving the quality of a total joint replacement program and the patient experience is including preoperative patient optimization into the preparatory phase of the process. Optimization can assist in preventing postoperative complications, decreasing unplanned readmissions after discharge, decreasing length of stay (LOS), and improving the overall health of the patient. National reporting agencies and organizations are increasingly focusing on the need to strengthen the surgical preparation of the patient. In the Agency for Healthcare Research and Quality s (AHRQ) Perioperative Protocol guideline, the organization recommends incorporating a preoperative basic health assessment and treating any pertinent medical conditions in order to: prevent delays or cancellations in surgery, ensure stable comorbidities are properly managed and minimize the potential for infections 2. Taking that recommendation one step further, the American Academy of Orthopedic Surgeons (AAOS) recommended specific preoperative riskstratification and risk reduction guidelines for total joint replacement patients at their 2014 national conference 3. Armed with these recommendations and guidelines, a large hospital system in the Midwestern region of the United States decided to create and incorporate a preoperative optimization and risk-reduction program as part of their joint replacement program. Figure 2 shows that those physicians that had their patients participate in the program more than 85% of the time saw fewer patients with in-hospital complications (i.e. acute renal failure, DVT/PE, acute respiratory failure), an increased percentage of patients discharged on day two or sooner, and discharged patients to home on a more consistent basis than their counterparts at the same facility. The hospital concentrated mainly on optimizing the following modifiable risk factors: BMI, blood pressure, HgA1c, obstructive sleep apnea, coronary 2 National Guidelines Clearinghouse (2014) Preoperative Protocol: Healthcare Protocol. 3 Ng, V. Y et al (2013) 1 Kurtz et al (2007)

3 Metric Physician Utilization of Patient Optimization Target <85% 85%+ Complication Rate % 0-6.7% 3.05% Length of Stay Two Days or Less 34-36% 42-58% 75% Discharge to Home or Home Health 79-90% 86-88% 86% Figure 2 Results by physician use of patient optimization artery disease, chronic obstructive pulmonary disorder and chronic pain issues. The goal of optimization for each patient is not just to survive surgery, but that the patient is in the best possible state to survive surgery, avoid complications and readmissions, and thrive after discharge. PREOPERATIVE OPTIMIZATION PROCESS Patient optimization is a multifaceted process involving the patient, the primary care physician, orthopedic surgeon, anesthesia and the surgical team/acute care facility. Accelero has defined the critical process steps to develop a successful optimization program which ensures: adequate time for scheduling, risk stratification, standardized preoperative process, surgical case reviews and the communication of findings. Adequate lead time prior to surgery Interventions are typically required to clear a patient preoperatively and fully optimize them medically prior to surgery. Therefore, Accelero recommends that surgery should be timed at least four to six weeks in advance, with some cases needing to be scheduled further out due to medical complexity. This allows the patient adequate time to see their primary care physician and any specialist for further evaluation such as cardiology or pulmonology. Defined risk stratification To initiate the medical optimization process, it is critical to have a plan to reduce postoperative medical complications by identifying and managing high risk patients prior to admission. This is accomplished through a preoperative optimization tool. Figure 3 depicts a portion of the preoperative treatment guidelines from a recent Accelero engagement. Figure 3 Preoperative risk factor grid for identifying and treating high risk patients

4 This tool was developed through a collaborative effort amongst orthopedic surgeons, anesthesiologists and hospitalists/primary care physicians. The team identified high risk comorbidities and recommendations for preoperative and postoperative management of these comorbidities. This group also established a prohibitive category for those patients that are not medically stable enough to be surgical candidates. The comorbidities and subsequent optimization are documented in the patient s chart and the tool continues to be utilized as a guide for providers throughout the entire care continuum to manage and optimize the patient s health. Standardized preoperative process To ensure the optimization tool is utilized properly and consistently, a program needs to develop a standardized preoperative process. Accelero has defined three models that can be used to implement this process (Figure 4). The first is managed collaboratively by the orthopedic surgeon and specialist--the patient goes to an established preoperative clinic. In the second model the patient is seen and cleared medically through a hospitalist or mid-level provider such as a nurse practitioner or physician assistant. The second model uses a two-tiered approach for the management of low and high risk patients. The high risk patient is sent to a specialist and is ultimately cleared medically though the preoperative clinic. The low risk patient is sent to their primary care physician for medical clearance. The last model utilizes the collaboration of the primary care physician and specialist. In all three of these models the preadmission testing (PAT) visit is accomplished along with a formal preoperative education session during a single visit. The specific model implemented requires the collective engagement of the surgeon, primary care physicians and key specialist to determine the best approach for each patient. Figure 4 Samples of three preoperative models

5 Accelero recommends that the preoperative clinic appointment include: standardized preadmission laboratory with diagnostic testing, a thorough nurse evaluation to assess the patient health history, a home health risk assessment and discharge planning, an evaluation by a physical therapist, and most importantly, a hands-on evaluation by both anesthesia and a physician. The patient will also attend a preoperative joint education class to address any questions and set expectations regarding preoperative and postoperative care. The patient will complete a preoperative assessment (patient reported outcome measure) to be compared against the six and twelve month postoperative time periods to measure the overall functional progression. Surgical case reviews A multidisciplinary case review should be conducted one week prior to surgery and requires the involvement of the surgeon, anesthesia, OR staff, case management, physical therapy, joint coordinator, home health and inpatient unit staff. The goal is to review each patient s past medical history as well as any anticipated needs within the operating room or the inpatient unit to ensure the best outcome for patient. The risk optimization assessment concluded during the preoperative clearance phase is utilized in this review to ensure all care providers understand each individual patient s needs. This review is paramount to link the entire care continuum from the preoperative process to the postoperative care for the patient. Communication of preoperative optimization The preoperative optimization tool is also utilized for the postoperative management of the patient during the inpatient stay. Further risk reduction strategies can be developed and implemented to care for the patient to avoid postoperative complications during the hospital stay. As an example, the patient that is prone to renal complications due to renal insufficiency/disease as a preexisting comorbidity would invoke a risk reduction strategy that focuses on close monitoring of hydration status and intake and output. SUMMARY The new paradigm of increased quality at lower costs is the new reality in joint replacement. Managing both of these facets effectively is predicated upon having a deliberate process on the front end of the episode of care. It requires the alignment of all necessary clinical resources to coordinate an effective plan to minimize a patient s risk factors. Accelero Health Partners has developed a preoperative optimization process that utilizes a collaborative approach to develop patientspecific care plans which can address medical issues that might adversely impact a successful surgical outcome. Accelero Health Partners, a subsidiary of Zimmer Holdings, Inc. 117 VIP Drive, Suite 320 I Wexford, PA Phone: I Accelero Health Partners

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