Implementation at a single institution of a multidisciplinary rapid recovery care pathway has led to improved value-based care.
According to a recent study, patients undergoing primary total knee arthroplasty under the perioperative surgical home (PSH) model had decreased hospital length of stay (LOS) and costs compared with those managed in a traditional fashion. In addition, more patients in the PSH model were discharged to home without an increase in complications or 30-day readmissions.
“Our PSH model has led to improvements in clinical outcomes and costs while helping us achieve our triple aim,” said Richard Robertson Jr., MD, an anesthesiology resident at Ochsner Health System, in New Orleans. “Patients coming to our hospital recognize the difference in care and see the value in what we’re doing.”
As Dr. Robertson reported, with the repeal of the sustainable growth rate formula and implementation of the Medicare Access and CHIP Reauthorization Act of 2015, the ability to provide value-based care is now directly linked to hospital reimbursement. With this in mind, the PSH model was developed to deliver patient-centered care, improving the patient experience while reducing the cost of care.
“The care team is composed of orthopedic and anesthesia services, which basically provide comanagement of patients,” he explained. “Along with a multimodal approach to pain management, there is rapid progression of mobilization. All of our patients are working with physical therapy while they’re in recovery on the day of surgery.”
In addition, providers use a standardized de-escalation of care and hold weekly meetings to discuss discharge planning.
“These meetings are a critical aspect of the model,” Dr. Robertson said. “We discuss our patients, evaluate their frailty scores and determine what type of issues we can expect.”
Primary Total Knee Arthroplasty
For this study, Dr. Robertson and his colleagues prospectively followed patients undergoing primary total knee arthroplasty before and after implementation of the rapid recovery pathway. In 2014, a total of 453 patients were operated on using the traditional care model. In 2015, following implementation of the PSH model, 373 patients were treated and evaluated.
The researchers used the Wilcoxon signed-rank test, chi square and multivariate regression analysis to compare the groups for age, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status score, Charlson Comorbidity Index, LOS, total direct cost, complications, 30-day readmissions and discharge location.
As Dr. Robertson reported at the 2017 annual meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 3675), the investigators observed no difference between the groups in age, BMI and ASA physical score.
After implementation of the PSH model, however, hospital LOS fell from 2.86 to 1.91 days (P<0.001). In addition, when compared with patients receiving traditional care, significantly more patients were discharged to home in the PSH group (71% vs. 80%, respectively; P=0.0009). Average total direct costs also were significantly lower in the PSH group ($10,702 vs. $11,126; P<0.0001). Most importantly, Dr. Robertson said, an increase in the speed of care did not compromise efficacy; investigators observed no difference in complications or 30-day readmissions between the two groups.
“We were able to save several hundred dollars per patient in total direct costs, but by discharging patients quickly, we were also able to get more patients into the hospital,” Dr. Robertson said. “We’re improving our value by decreasing total direct costs and increasing economic efficiency.”
Despite these successes, however, the hospital continues to look for ways to optimize the PSH model in all facets of care.
“It starts with preoperative management, where we now have patients rehab prior to surgery, but we’re always looking for ways to enhance intraoperative and postoperative management, as well,” Dr. Robertson said. “As we continue to look at these data, I think the PSH model will continue to provide value not only to our patients but to our hospital systems and the country as a whole.”
Christopher Wu, MD, professor of anesthesiology and critical care medicine and gynecology and obstetrics at the Johns Hopkins University School of Medicine, in Baltimore, commented, “The holy grail of medicine is to improve patient care while spending less, but there can be challenges in measuring the total cost of care delivery.”
“Total direct costs to the hospital was one of our measures, but we also had our economic team look for indirect associations,” Dr. Robertson said. “Backfilling was one of the major ways the hospital was able to save money, because we’re no longer keeping those beds occupied with patients that we have a capped cost on; we’re able to get those patients in and out of the hospital faster—without compromising care.
“We also send our patients home with paperwork that allows them to call our orthopedic service if they’re having any issues,” Dr. Robertson added. “So, instead of patients going directly to the ER, we’re able to address those complaints without having readmission issues.”