Fuente: http://www.medscape.com/viewarticle/763746

From Medscape Medical News

Total Knee Replacement Improved by 3 Strategies

Janis C. Kelly

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May 12, 2011 — Eleven leading US healthcare systems, working together as the High Value Healthcare Collaborative, have found significant variation in total knee replacement (TKR) surgery times, hospital stays, discharge dispositions, and complication rates. Patients whose surgeons did large numbers of TKRs had shorter operating times and lengths of stay and fewer complications.

In their article, published online May 9 in Health Affairs, Ivan M. Tomek, MD, an orthopedic surgeon at Dartmouth-Hitchcock Medical Center and an assistant professor of orthopedic surgery at both the Geisel School of Medicine at Dartmouth and the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, New Hampshire, and colleagues write that 3 strategies improve TKR delivery:

multispeciality presurgery evaluation of TKR candidates and inpatient management teams including anesthesia, internal medicine, and orthopedic surgery;
dedicated operating room teams in which TKR surgeons work with the same group of specialized arthroplasty scrub technicians and nurses; and
involving patients in discharge planning before admission to better manage patient expectations.

The initial report on TKR delivery is meant to provide "benchmark data against which other health care systems might measure themselves," the authors write.

The analysis of single primary TKR data for 10,910 patients showed that mean lengths of stay varied from 3.0 to 4.2 days, operating time varied from 80 to 105 minutes, percentage discharged to self-care varied from 5.2% to 88.6%, and complication rates during admission varied from 0.2% to 1.6%. The 3 proposed strategies are meant to help improve all of these areas by developing "replicable and exportable innovations to spread best practices and thereby increase health care value," according to the authors.

Coauthor and collaborative cofounder James N. Weinstein, DO, president and chief executive officer of the Dartmouth-Hitchcock Health System, told Medscape Medical News, "Regular conferences among the members of the team involved in the total knee replacement project have revealed tremendous enthusiasm among surgeons for working together both within institutions and across institutions to identify approaches that work best and to apply those in their own practices. Of course, this does carry some administrative costs, but it is likely to be the most effective way to both improve care and reduce unnecessary healthcare expenditures."

Dr. Weinstein continued, "For the first time, the people who actually take care of patients are taking on the work of improving quality while reducing cost, and that has unleashed a lot of energy. The collaborative now includes many of the top health systems in the country and over 50 million patients. I think that together we can figure out how to fix many of the problems in the American healthcare system."

The expanded collaborative has begun monitoring the effectiveness of the 3 proposed strategies and plans further work on the influence of physician compensation models, academic orientation, and hospital type.

Dr. Weinstein said that the 3-part approach to TKR as originally proposed has been tried by the original members of the collaborative, that modifications have already been made, and that new member institutions are taking up the TKR project as they come on board. A second set of data has already been collected and will be analyzed later this month to determine effectiveness.

"We see this as an approach of continuous improvement," Dr. Weinstein said.

Edward H. Yelin, PhD, professor in residence of medicine and health policy. Division of Rheumatology and Institute for Health Policy Studies, University of California, San Francisco, reviewed the study for Medscape Medical News.

Do High Volumes Cause Good Outcomes, or Vice Versa?

Dr. Yelin said, "In total joint replacement, other studies show both hospital and surgeon effects and, I believe, synergies. High-volume hospitals and high-volume surgeons have better results than high-volume hospitals/low-volume surgeons or than low-volume hospitals/high-volume surgeons. Why this is so is still open to question, but the 'practice makes perfect' argument seems compelling. For the record, there are researchers who claim also that the causal direction runs from good outcomes to high volumes; that is, successful surgeons/hospitals get reputations for excellence, which draws patients. I don't think one explanation precludes the other."

Dr. Yelin added, "Because we don't yet know how to bottle the combination of hospitals and surgeons or, better, to unbundle them to see whether you can do well without dedicated teams, the argument in favor of dedicated teams within hospitals has a compelling logic. We are not ever going to have randomized trials to dispel this belief. That being so, the first 2 proposals seem to hold water for me until the notion that you can unbundle the care is proven."

Dr. Yelin also noted that health plan contracts with a delimited number of hospitals may preclude getting care at the hospitals with the best track records. He said, "Similarly, many hospitals either outright exclude Medicaid patients (let alone those without insurance) or make it difficult for such patients to get access due to factors like limiting admitting privileges to physicians who practice in low-income neighborhoods under the guise of, 'they didn't train here at the mountaintop, so we don't know them.' "

Jeffrey N. Katz, MD, professor of medicine and orthopedic surgery, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, agreed with Dr. Yelin, adding, "It appears that having a critical pathway that specifies the way care is delivered has a protective effect on complication rates, even after taking volume into account. This suggests that there are probably specific processes of care that help improve outcomes. We don't know exactly what these processes are, and it would take lots of trials to investigate them all."

The High Value Healthcare Collaborative has been self-funded by the participating institutions for the last 5 years and has now applied for additional funding from the Center for Medicare and Medicaid Innovation. "We calculate that we need about $6 million/year (a total of about $30 million) to fully implement this approach across the 9 health conditions and procedures most important in terms of national prevalence and societal expense. These include primary total knee replacement, diabetes, heart failure, asthma, weight loss surgery, labor and delivery, spine surgery, and depression," Dr. Weinstein said.

The founders of the collaborative are the Cleveland Clinic, Denver Health, Dartmouth-Hitchcock Medical Center, the Dartmouth Institute for Health Policy and Clinical Practice, Intermountain Healthcare, and the Mayo Clinic. The collaborative now also includes the Baylor Health Care System; Beaumont Health System; Beth Israel Deaconess Medical Center; North Shore–Long Island Jewish Health System; MaineHealth; Providence Health and Services; Scott and White Healthcare; Sutter Health; University of California, Los Angeles, Health System; University of Iowa Health Care; and Virginia Mason Medical Center.

Dr. Weinstein, Dr. Yelin, and Dr. Katz have disclosed no relevant financial relationships.

Health Aff. Published online May 9, 2012. Full text