By Robert E. Booth Jr., MD
Surgical skills and the principles of efficient behavior are often formed very early in a clinical career. They are rarely consciously analyzed or critically evaluated thereafter. Indeed, it is fair to say that more surgeons have videotaped their golf swing than their surgical technique. Operative efficiency is a critical ingredient to surgical success. Efficiency creates speed and speed begets volume. Low complication rates are directly related to shortened surgical times and highly efficient operative procedures. The concept of creating "muscle memory" through repetitive tasks, thus eliminating costly gaps in surgical flow, and the willingness to analyze and alter even the most successful practices are the essence of personal improvement. While patterns of behavior in surgical experience vary enormously, the principles of expeditious surgeries include such mundane considerations as consistent staff, a simplified surgical system, extensive preoperative preparation, instruments that suit the surgeon more than the patient, and the innate desire to improve the result with every procedure. While rarely discussed, the concepts of appropriate volumes, outcomes oversight, and cost accountability will undoubtedly define the success of joint replacement centers in the twenty-first century.
Operating-room efficiency, which is usually the waist of the hourglass for any surgical system, begins in the clinic or office. The more a surgeon is able to focus on a specific spectrum of pathology, the more rewarding those hours will be in terms of conversion to surgical cases and successful outcomes. Preselected filtering of patient demographics (e.g., legal, compensation) and social issues is crucial. At the time of an initial patient encounter, whether a surgical commitment is made or not, the completion of a form detailing the probable equipment, resources, and components necessary for the ultimate surgery is optimal. Since the quality of orthopaedic radiology has been diluted by electronic systems (e.g., electronic and/or digital x-ray systems), a strong insistence on adequate radiographs—whether standing views, long films, or template-ready images—should be required at the initial evaluation. It is extremely worthwhile to devote at least one hour a week to reviewing the preadmission testing on patients, not for that week's surgery, but for the subsequent week's surgery. If properly performed, a cancellation rate of less than 1% should be expected. Perhaps one of the most effective methods of confirming this readiness as well as reassuring the patient is the preemptive nocturnal preoperative phone call. Anesthesia is typically the critical ingredient in an efficient program, and dedicated anesthesiologists who are designated as "orthopaedic specialists" are both appropriate and empowering. Even better, an induction room in close proximity to the operating suite allows regional anesthetic techniques to be performed at lower expense and greater reliability than in the operating room itself. It is absolutely critical that every surgeon desirous of efficiency or high volume have a reliable and committed operating-room team that specializes in those orthopaedic procedures. Other niceties, such as preprinted orders, case-cart instrument systems, and dedicated orthopaedic floors, serve to enhance the opportunity to increase efficiency.
Vlessides M. Epidural block room spares patients' pain, surgeons' time. Anesthesiology News. 2007;33.33
2007
Macario A, Dexter F, Traub RD. Hospital profitability per hour of operating room time can vary among surgeons. Anesth Analg. 2001:93:669-75.93669
2001
[PubMed][CrossRef]
Resnick AS, Corrigan D, Mullen JL, Kaiser LR. Surgeon contribution to hospital bottom line: not all are created equal. Ann Surg. 2005;242:530-9.242530
2005
Team-Building Basics
By David F. Dalury, MD
We are all aware of the anticipated increase in the demand for hip and knee arthroplasty in the near future1. The combination of the increase in volume and the specter of a further decrease in reimbursement means that orthopaedic surgeons are going to have to increase the efficiency of care of the adult patient undergoing reconstructive surgery. A successful practice depends on a team that will allow the surgeon to continue to provide excellent quality care in a more efficient manner2.
The team is composed of important members at every step of the process: in the office before the operation, in the operating room on the day of operation, during the patient's stay in the hospital, and after discharge. Secretaries, nurses, consultants, and therapists are all integral members of this team. Office secretarial support need to be familiar with the common medical and social issues of the typical patient undergoing joint replacement and able to deal with the large amount of paperwork that is involved in getting a patient to the hospital. Operating-room nursing staff need to be facile with the instrument systems in use. Scrub nurses need to anticipate broken or missing components; circulating nurses need to ready the next case. In-hospital nurses and therapists need to recognize the compressed hospital stays of the current patients and aggressively address pain, rehabilitation, and discharge issues. Discharge planners need to be able to help the patients and their families decide on discharge plans. Medical and cardiology consultants are frequently involved in the postoperative care of the joint replacement patient. Outpatient physical therapists need to be able to recognize what is considered to be an abnormal pace of progress or an abnormal wound and contact the surgeon appropriately.
It takes a large number of trained and experienced individuals to create a team that is capable of providing high-quality, efficient medical care to patients undergoing joint replacement. The surgeon is the captain of the team and has the responsibility of keeping the team together by rewarding loyalty with loyalty and by showing appropriate appreciation of good effort.
Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780-5.89780
2007
[PubMed][CrossRef]
Jackson DW. A team approach to orthopedics: hospitals and physicians need to work together. Orthop Today.2008;28:3.283
2008
The Economics of Total Joint Arthroplasty
By William L. Healy, MD
Total joint arthroplasty is a remarkably successful surgical treatment for painful arthritic hips and knees (the prevalence of which is increasing), but it is consuming an increasing proportion of health-care dollars. Payers, especially the Centers for Medicare and Medicaid Services (CMS), have targeted total joint arthroplasty for cost control.
Professional cost for joint replacement has been controlled by reducing the physician fee schedule through the Medicare Part-B Program. From 1991 although 2008, Medicare physician reimbursement for joint replacement was reduced by 20% to 39%1. The percentage of reduction and the current procedural terminology (CPT) code for the specific procedures are as follows:Hemiarthroplasty of the hip (CPT 27125)—20% reductionTotal hip arthroplasty (CPT 27130)—39% reductionRevision total hip arthroplasty (CPT 27134)—34% reductionTotal knee arthroplasty (CPT 27447)—36% reductionRevision total knee arthroplasty (CPT 27487)—39% reduction
Hemiarthroplasty of the hip (CPT 27125)—20% reduction
Total hip arthroplasty (CPT 27130)—39% reduction
Revision total hip arthroplasty (CPT 27134)—34% reduction
Total knee arthroplasty (CPT 27447)—36% reduction
Revision total knee arthroplasty (CPT 27487)—39% reduction
This erosion of professional reimbursement may be associated with fewer orthopaedic surgery residents choosing to specialize in adult reconstruction2.
Hospital cost for joint replacement has been controlled with the diagnosis-related group (DRG) payment system through the Medicare Part-A Program. DRG hospital reimbursement provides a fixed-case payment to cover all expenses for total joint arthroplasty—the operation, hospital care, and the joint replacement implant. From 1993 to 2008, Medicare reimbursement to hospitals for joint replacement operations increased 14.9%. During this interval, the consumer price index increased 49.5%. Hospital payment did not keep up with inflation. Furthermore, from 1991 to 2008, the average list price for a joint replacement implant increased 204% while the average selling price for joint implants increased 132%. The hospital margin of profitability for delivering joint replacement operations decreased considerably during the last fifteen years.
Hospitals are concerned about the economics of arthroplasty because the payments that are made to hospitals are not enough to keep up with inflation, joint implant costs are increasing and consuming a greater portion of hospital payment dollars each year, and implant selection can determine whether a hospital admission for joint replacement is an economic profit or loss. Hospitals want surgeons to reduce the cost associated with their preferred implants and/or use less expensive implants. This creates a conflict between the hospital and the surgeon because surgeons do not want restrictions placed on implant selection.
The economics of arthroplasty is a secondary concern for orthopaedic surgeons. Surgeons want to select the best implants possible to get the best patient outcome regardless of cost and without implant restrictions. This perspective creates a conflict between the surgeon and the hospital.
Management of joint replacement utilization must reconcile patient interests, surgeon interests, hospital interests, and economics. This process requires a consensus team approach and evidence-based information. During the last fifteen years, the orthopaedic literature has demonstrated that 70% of the hospital cost for joint replacement is generated in the operating room, in the recovery room, and on the medical-surgical floor and that 82% of the hospital cost is generated in the first two days of hospitalization3. Furthermore, the largest single expense for hip and knee replacement operations is implant cost4,5. Methods of controlling the cost of joint replacement implants include cost-awareness programs, vendor discounts, price caps, implant standardization, and competitive-bid purchasing. All methods of implant cost-reduction require cooperation between the hospital and the surgeon. One of the biggest hurdles in controlling the cost of joint replacement implants is creating incentives for surgeons to cooperate with hospitals. Gainsharing programs may help align the incentives of hospitals and surgeons relative to the selection and cost of implants.
Lahey Clinic implemented a Single Price/Case Price Purchasing Program with considerable savings with regard to the cost of implants and without adversely affecting patient outcome after total joint arthroplasty. This program reduced the cost of hip implants by 31.8% with a change of implant vendor and reduced the cost of knee implants by 23% without a change of implant vendor6.
The economics of arthroplasty is a critical issue for orthopaedic surgeons and hospitals. Professional payment for joint replacement has decreased to the point that the adult reconstruction workforce is dwindling; in the future, there may not be enough joint replacement surgeons to meet the rising demand for joint replacement2. Hospital payment for joint replacement is not keeping up with inflation, joint implant costs are rising, and implant costs can determine the profitability of a hospital admission for joint replacement. In order to enlist surgeon cooperation to reduce the cost of joint implants, hospitals must give physicians incentives to reduce implant costs. Concurrently, surgeons should use evidence-based medicine to select joint replacement implants that will give patients successful long-term outcomes. When implants with similar clinical performance have been identified, competitive-bid purchasing can be used to reduce the cost of the implants. Surgeons can and should help hospitals control implant costs. Surgeons and hospitals are partners in delivering joint replacement operations to patients, and, as always in health care, patients come first.
Mendenhall S. 2008 hip and knee implant review. Orthopaedic Network News Online. 2008 Jul. p 1.
2008
Iorio R, Robb WJ, Healy WL, Berry DJ, Hozack WJ, Kyle RF, Lewallen DG, Trousdale RT, Jiranek WA, Stamos VP, Parsley BS. Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: preparing for an epidemic. J Bone Joint Surg Am. 2008;90:1598-605.901598
2008
[PubMed][CrossRef]
Healy WL, Iorio R, Richards JA, Lucchesi C. Opportunities for control of hospital costs for total joint arthroplasty after initial cost containment. J Arthroplasty.1998;13:504-7.13504
1998
[CrossRef]
Barber TC, Healy WL. The hospital cost of total hip arthroplasty. A comparison between 1981 and 1990. J Bone Joint Surg Am. 1993;75:321-5.75321
1993
Healy WL, Finn D. The hospital cost and the cost of the implant for total knee arthroplasty. A comparison between 1983 and 1991 for one hospital. J Bone Joint Surg Am. 1994;76:801-6.76801
1994
Healy WL, Iorio R, Lemos MJ, Patch DA, Pfeifer BA, Smiley PM, Wilk RM. Single Price/Case Price Purchasing in orthopaedic surgery. Experience at the Lahey Clinic. J Bone Joint Surg Am. 2000;82:607-12. Erratum in: J Bone Joint Surg Am. 2000;82:1056.82607
2000
Outcomes Measures in Knee Arthroplasty
By Jess H. Lonner, MD
Total and partial knee arthroplasty are highly successful interventions for knee arthritis. However, despite "success" in more than 90% of patients at follow-up periods of ten to fifteen years, the outcomes will vary according to several parameters. First, perception of outcomes differs depending on whether objective or subjective measures are utilized, whether they are patient or clinician-derived, and according to the parameters that are being measured. For instance, if implant survivorship is the ultimate outcome measure, then success may be unparalleled. Alternatively, functional outcomes may tell a different story—patients may have pain and limitations in their ability to perform activities that are relevant in their lives, making outcomes less favorable despite radiographic success. Functional outcomes vary with demographic and patient characteristics such as body mass index, emotional health, sex, age, and severity of preoperative pain1. Furthermore, there is a poor correlation between objective physician-assessed knee scores and patient-derived satisfaction scores, highlighting a discrepancy between physicians and patients in the interpretation and prioritization of outcomes.
Several outcomes measures that are currently being utilized may be irrelevant for some patients or do not adequately capture the functional results. Critical components of a useful outcomes measurement system are validity (i.e., the test measures what it is designed to measure), reliability (i.e., the test consistently produces the same score given the equivalence of status of the element), and responsiveness (i.e., the test is able to assess changes in a particular parameter). The responsiveness of a test will allow it to detect early benefits and more subtle changes, which is particularly germane as we and our patients put a greater premium on the potential functional advances observed with minimally invasive techniques and partial knee resurfacing. Classic outcomes measures utilized in knee arthroplasty include, among others, the Knee Society clinical rating system, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, the Oxford knee score questionnaire, the Bristol knee score, and the Short Form-12 (SF-12) instrument. These instruments have variable correlation with each other, variable responsiveness, and variable relevance to contemporary patients.
The Knee Society clinical rating system, available since 1989, has been the preferred method of outcomes assessment after knee replacement surgery for many surgeons2. However, its reliability and responsiveness have been questioned3. The Knee Society score, which measures stair-climbing ability, walking (in terms of blocks), and use of assistive devices, is less applicable across the broad range of contemporary patients, who tend to be more active, to be younger, and to have different expectations and aspirations after joint replacement surgery in comparison with patients of the past.
The challenge, then, in measuring outcomes after knee replacement, is to develop a system that integrates patient and surgeon-derived outcomes assessments by means of validated measures that are relevant to contemporary patients. A new Knee Society clinical rating system is being validated and updated to reflect current trends in knee arthroplasty and contemporary expectations and activity levels that were not well addressed in earlier assessment models. It will include visual analog and pain assessment, as well as objective measures of knee motion and stability. The system will capture enhanced outcomes from "high-performance knees" and provide a level of responsiveness that will make it possible to track early outcomes. The functional component of the Knee Society score will be relevant to contemporary patients of any demographic background.
Franklin PD, Li W, Ayers DC. Functional outcome after total knee replacement varies with patient attributes. Clin Orthop Relat Res.2008;466:2597-604.4662597
2008
[PubMed][CrossRef]
Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res.1989;248:13-4.24813
1989
Lingard EA, Katz JN, Wright RJ, Wright EA, Sledge CB; Kinemax Outcomes Group. Validity and responsiveness of the Knee Society Clinical Rating System in comparison with the SF-36 and WOMAC. J Bone Joint Surg Am.2001;83:1856-64.831856
2001