Making great strides. OrthoPedics

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1 OrthoPedics provided by New Hanover regional medical center Physicians at New Hanover Regional Medical Center Orthopedic Hospital in Wilmington perform about 2,500 total-joint replacements annually. Making great strides Orthopedic physicians in North Carolina are changing treatment tactics to improve surgical outcomes, decrease recovery times and lower costs. A graduate of the U.S. Military Academy, Dr. Joseph Hsu trained in Italy and Russia and served as an orthopedic surgeon in the military, reconstructing the limbs of wounded soldiers. The interest for me is to help the body regenerate its own tissue, Hsu says. Dr. Brian Brighton, who completed his residency at the Cleveland Clinic in Ohio, is a pediatric orthopedic surgeon focused on scoliosis and spinal deformity, pediatric trauma and improving quality indicators in health care. Together, they are developing a limb-lengthening and -deformity center at Carolinas HealthCare System in Charlotte, combining skills to treat limb injuries from traumatic events or genetic conditions. They recently completed Charlotte s first remotecontrolled internal-limb-lengthening procedure. A magnetic implant run by an external remote control gradually extends the rod, lengthening the bone. Before Hsu and Brighton started offering such specialized procedures, a North Carolina patient would likely 66 B u s i n e s s N o r t h C a r o l i n a

2 NOT THAT YOU WOULD, BUT WHAT IF YOU COULD? NO MATTER WHAT YOU DO, OUR ORTHOPEDIC EXPERTS CAN HELP YOU GET BACK TO IT So maybe you won t take up wakeboarding, zip lining or extreme rock climbing. But what if we could help you get back to everyday living, without pain? Imagine being able to take a walk, do some yard work, or play a round of golf without having to think about your hip, knee or shoulder. At Vidant Health, we can get you there. Our expert orthopedic surgeons perform complex reconstructive surgery and we offer post-operative rehabilitation. Isn t it time you took yourself off the sidelines and got back to doing what you love? Call MyVidant for more information or to schedule an initial consultation.

3 Provided by First Health of the Carolinas David Casey of Pinehurst Surgical focuses on treating the patient, not just body parts. have had to travel to New York or Baltimore for such treatment. The next step for the center is to educate other orthopedists, physical therapists, nurse practitioners and the public about its offerings. We already started treating patients, Hsu says. Now we re getting the word out that we re here and have the expertise. That s just one of the innovations setting North Carolina orthopedics apart. Baby boomers are driving major advancements and not all of them are technological. Orthopedic practices in North Carolina are creating patient-centric, cost-effective solutions for those facing surgery on joints or spines, which experience more stress as a person ages. Many people are maintaining high levels of activity into their 70s, says Dr. Jonathan Chappell, an orthopedic surgeon at Wake Orthopaedics specializing in sports medicine. In addition to being more fragile, older patients don t heal as fast as younger ones. The goal of orthopedists, however, is to get people back to their daily activities. When Dr. Gurvinder Deol was 10 years old, his grandfather had knee-replacement surgery. The surgery changed his grandfather s life. From that point forward, Deol knew he wanted to be a surgeon. By the time he was a second-year surgical resident, he realized spinal orthopedics was an area with exceptional growth opportunity. In 1996, we were still doing kind of archaic spine surgery, Deol says. There s a lot of room for improvement here. He has made great strides in improving his field. Now an orthopedic spine surgeon with Wake Orthopaedics, which has offices in Raleigh and Cary, he has jointly patented NuVasive Inc. s Maximum Access Surgery Posterior Lumbar Interbody Fusion procedure, which allows surgeons maximum access through a smaller incision, reducing a patient s postoperative pain and recovery time. The biggest push in spine now is minimally invasive spine surgery, Deol says. He estimates that about 25% of Triangle surgeons perform minimally invasive spine surgeries, similar to the national average. MAS PLIF is just one example. The learning curve is steep for these newer surgical techniques, Deol says, but orthopedic residents from UNC School of Medicine rotate within Wake Orthopaedics. Those spending 10 weeks with Deol get extensive experience with minimally invasive techniques. The minimally invasive movement is also occurring in other areas, such as hip, knee and rotator cuff. As with spinal surgery, smaller incisions lessen blood loss, muscle trauma and postoperative pain. Improvements in pain management also support rapid recovery while reducing the length of hospital stays. Instead of patient-controlled pain pumps, physicians and health-care centers use pain-management techniques, including providing medication ahead of surgery to reduce inflammation, spinal blocks that provide relief throughout the surgery and immediately afterward and long-lasting medications injected into tissues around the joint to provide relief for up to four days. Joint replacements have come a long way in what materials are used, says Dr. J. Bohannon Mason, an orthopedic surgeon with OrthoCarolina in Charlotte. Advancements in polyethylene make for tougher, longer-lasting replacement hips and knees. A newer generation of ceramic implants has also seen success. Better metrics, another advancement, helps surgeons determine what type of implant best suits patients. However, all of these efforts come at a time when health-care providers are working to reduce costs while maintaining or increasing the quality of care and responding to the demands of an aging population. Dr. Timothy Harris of Wake Orthopaedics now replaces 90% to 95% of hips using the direct anterior approach, positioning the replacement from the front, rather than the back or side. The approach produces the same long-term result as traditional methods, but involves less muscle trauma in the short term. Within three to four hours of the surgery s completion, a physical therapist is able to get the 68 B u s i n e s s N o r t h C a r o l i n a

4 Special ad Section patient out of bed. Two-thirds of Harris anterior-hip-replacement patients go home the following day. New Hanover Regional Medical Center Orthopedic Hospital in Wilmington performs 2,500 total-joint replacements a year. Seventy-five percent of its hip replacements are done using the direct anterior approach. The average hospital stay for those patients is about two days. We re getting all of our hips up on the day of surgery, and we re incorporating knees as we speak, says John Michael Eargle, the hospital s orthopedic service line director. One reason for the postoperative success is the preoperative measures the hospital has in place. Prior to surgery, a hospitalist reviews all orthopedic joint-replacement patients at the testing clinic. The hospitalist also checks for anemia, which occurs when a patient has a lower than normal amount of healthy red blood cells. Anemic patients are more likely to require blood transfusions, increasing the risk for complications that lengthen recovery time and increase costs. New Hanover Regional Medical Center Orthopedic Hospital has an anemia clinic for treatment prior to surgery. It has contributed to the hospital s 600% reduction in blood utilization for knee replacements and a 150% reduction for hip replacements. Patients are also educated beforehand, with orthopedic nurses preparing them and answering questions. If there s a standardized way to prep a patient for surgery and standardized care they use post-surgery, it greatly improves outcomes, Eargle says. Other hospitals are also focused on improving operative care. Mike Riley, president of Novant Health s Charlotte Orthopedic Hospital, says his hospital has modified practices to keep pace with improving treatment plans. Historically, Novant Health and all health care, you were on your own for pre- and postop. Now there s a concerted effort to make sure they [follow through]. Health-care systems will soon be responsible for the entire continuum of care and wellness. The average length of hospital stay for a joint-replacement procedure in the U.S. is Making Great Strides Through Advanced Orthopaedic Solutions Minimally Invasive Spine Surgery Microvascular & Reconstructive Hand Surgery Total Ankle Replacement Outpatient Partial Knee Replacement OrthoWilmington specialists are at the forefront of improving outcomes including advancements in pain control for joint replacement patients. This results in signifi cantly lowered self-reported pain scores, reduced length of hospital stays, and much quicker recoveries. Innovations and advanced care help our patients move better and live better OrthoWilmington.com Advanced Approaches in Joint Replacement Spine Sports Medicine Joint Replacement & Reconstruction Hand & Upper Extremity Foot & Ankle Trauma Physical Medicine & Rehabilitation 2014 OrthoWilmington ow great strides ad-buisness nc.indd 1 8/7/14 5:09 PM

5 3.4 to 3.8 days. At the end of 2013, jointreplacement patients at Charlotte Orthopedic Hospital stayed an average of 3.1 days. This year, that s down to 2.8 days, Riley says. Shorter stays mean less expense for the hospital and patient. In addition, recent health-care reforms will eliminate payments to hospitals when patients are readmitted, an effort to ensure that quality of care is top-notch. Charlotte Orthopedic Hospital has developed a plan to decrease the likelihood of readmissions and support long-term positive surgical outcomes. If a patient is not ready to go home after the third day, but no longer needs acute care, the hospital offers transitional care for five to seven days. In the past, such patients would have been transferred to a community-rehabilitation center. In the transitional-care unit, patients get orthopedic-specific physical therapy, and surgeons remain involved through the course of care. That s just one cog in improving wellness after operations. Patient education plays an important role, too. The Program for Early Recovery from Knee Surgery or PERKS at Mission Health in Asheville is a comprehensive program designed to support recovery. It combines preoperative education, patient motivation, early physical-therapy evaluation and swelling reduction to help patients recover sooner. Erica Arndt, a patient educator with Mission Orthopedics, teaches a preoperative class that outlines the upcoming procedure. I think that they need to know ahead of time how important it is that they are engaged patients, Arndt says. They have to take ownership of this joint. Since PERKS was implemented about two years ago, Mission has reduced the length of stay for such patients by one day, which saves about $900 per patient. Shorter hospital stays also reduce the risk of infection, and, if the patient recovers quickly, he can return to work faster. The key to PERKS is coordination. It began with four participating physicians, and three more are in the process of joining. Mission Health is discussing expanding the program to hip-replacement patients. It s the physician s job, says Dr. David Casey, an orthopedic surgeon at Pinehurst Surgical and FirstHealth of the Carolinas, to educate patients about the most effective treatment for specific cases. Direct-marketing campaigns and word-of-mouth often leave patients believing they know what treatment is right for them. Casey goes through all of the options before surgery, such as creating an exercise and stretching regimen or modifying an existing routine. Too many times we just become the technician or surgeon, Casey says. It s important to remember, it s the whole person in front of you. It s the skeleton. You have to see the whole person, not just the right knee. He adds that, You can t undo an operation you don t like. Many times, surgery should be a last resort. FirstHealth orthopedics performs about 1,400 hip and knee replacements a

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7 Sometimes it s good to follow the crowd! year. The region s abundance of retirees and proximity to Fort Bragg, with its active population of military personnel and contract workers, contribute to the high volume. Once a month, the orthopedic department meets to discuss protocols and review data. Such appraisals are common in academia, Casey says, but less common in a private practice. They help physicians and health-care centers maintain consistency and improve practices, and collaboration leads to financial efficiency. Pinehurst Surgical, a clinic in Moore County, works with FirstHealth in a bundled-payment initiative through the Centers for Medicare and Medicaid Services. The plan consolidates a patient s multiple payments for surgery into one bill. It also collects performance data to ensure a high level of care. We re trying to be cost-conscious, Casey says, but Award-Winning Orthopaedic Team Fellowship-Trained Surgeons 1400 Joint Replacements Annually For more information, call (800) or visit we can never be perceived as doing something cheap. We have to get the best results. OrthoCarolina, in Charlotte, is also working to make the health-care system easier to navigate, says Steve Hendrick, chief operating officer. Its coordinatedcare program offers clinical navigators who assist patients with scheduling appointments, explain results and plans to caregivers, answer questions and communicate expectations. OrthoCarolina worked with Chapel Hill-based Blue Cross and Blue Shield of North Carolina, as well as other insurers and employers, to develop a bundled payment plan. It s trying to get more hospitals on board. Before OrthoCarolina introduced the bundled plan, procedures had to be itemized. The process revealed that an average joint replacement in Charlotte can cost between $40,000 and $50,000. The surgeon s portion accounts for 6% to 8%, while the majority goes to the hospital. In an effort to reduce that total, OrthoCarolina developed protocols for items doctors order for surgeries and postoperative treatments to get patients up, moving and ready to go home sooner. That allowed OrthoCarolina to approach hospitals with suggestions on how to lower rates. Standard protocols help reduce surgeon variability, Mason says. An inverse correlation exists between the number of surgeries performed and adverse outcomes. Mason recommends patients seek out surgeons performing more than 200 joint replacements a year. Physicians at OrthoCarolina s Hip & Knee Center in Charlotte perform about 3,500 procedures annually. A collaborative approach involves more than physicians. At New Hanover Regional, a board meets monthly to review data and monitor progress in the hope of decreasing inconsistencies for better recovery results. If you have less variability in delivering that procedure, then you ll have less variability in your outcome, Eargle says