Project Goals
The overall goals are to improve care, health, and cost of care for patients with hip or knee osteoarthritis by implementing patient engagement interventions including shared decision making, expectation management for length of stay, patient education for discharge to self-care, and interdisciplinary pre-operative clinics.
Improve care: >50% eligible patients referred to patient engagement interventions and >50% of referred patients/families participate in interventions
Improve health: Improve health status measures (function, pain) for > 50% of patients considering hip and knee surgery at one year
Reduce costs: Reduce rates of hip & knee surgeries and episode costs resulting in 5% total cost reduction (aggregate relative rate)
Background
The lifetime risk of symptomatic knee osteoarthritis is estimated to be nearly 50 percent, and the two major risk factors are aging and obesity.1 In 2008, total knee replacement inpatient costs exceeded $9 billion—the highest aggregate cost among the ten procedures for which demand is growing the fastest.2 Between 2005 and 2030, the demand for primary knee arthroplasty in the United States is projected to grow by 673 percent to 3.48 million procedures annually. More resource-intensive total knee revisions — a procedure that repairs or replaces a previous replacement — are projected to grow by 601 percent between 2005 and 2030.3 In 2005, medical expenditures for the treatment of arthritis were $353 billion, and they are expected to rise because of increases in the number of people with osteoarthritis.4
Total knee replacement (TKR) is one of the most successful surgical procedures ever studied and is highly effective at restoring mobility and reducing pain when nonsurgical options fail.5 Current evidence suggests that medical management, although reasonably effective in treating mild to moderate osteoarthritis, is much less effective than surgery in treating severe knee disease.6 Despite the evidence of its efficacy, the wide variation in TKR rates among HVHC members highlights the opportunity to work together to process and determine the right rate of surgery.
Patient Engagement Interventions
Based on comparative analysis of the co-lead member data, the Hip & Knee Team identified care models associated with those members with better performance around specific metrics. The following patient engagement interventions were prioritized for implementation
at pilot member sites:
- Shared Decision Making (SDM): Based largely on the Dartmouth-Hitchcock care model, the SDM intervention offers patients “decision aid” videos describing the risks and benefits of hip or knee surgery versus non-surgical treatments; utilizes web-based tools to assess patients’ preferences, values, and knowledge about their decision; and engages health coaches to assist patients with their treatment decision.
- Length of Stay (LOS) Expectation Management: Length of Stay expectation management was proposed by Mayo Clinic as a way to prepare patients for discharge from the hospital. They had found that the messaging from staff to patients about the availability of post-operative rehabilitation or physical therapy provided a disincentive for patients to push themselves to be mobile enough for discharge. This intervention provides education and consistent messaging from all members of the care team that healthy patients (defined as having <2 co-conditions) will be discharged from the hospital 2-3 days after their surgery.
- Discharge to Self-Care: Planning and training healthy patients to be discharged to self-care (with no home health visits) was developed by Mayo Clinic as a way to get their healthy patients home safely after total knee or hip replacement. Prior to admission, patients and a primary relative are taught what to expect after discharge and the physical exercises they are expected to perform. Mayo has been able to discharge their patients to self-care with no current evidence of negative outcomes.
- Pre-operative Clinic: Interdisciplinary pre-operative clinics were proposed as a method to streamline the post-operative care of patients by engaging the caregivers early in the pre-operative process. Hospitalists or internists engage early in preparation for the patient’s surgery and are better prepared to care for the patient post-operatively, reducing complications and costs by avoiding clinical mistakes or mismanagement. This intervention provides patient education, discharge planning and risk assessment prior to surgery.
Beyond these patient engagement interventions, another pilot project being considered is the consistent operating room team model identified as a potential reason for Intermountain’s shorter operating times.
Standard metrics are being used across all pilots, including: length of stay, discharge disposition, operating room time, inpatient complications, post-op complications, readmissions, and patient-reported outcomes such as pain, function, and quality of life.