Carolinas HealthCare System
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Total Joint Replacement Program Focuses on Standardizing Care

As aging baby boomers drive increasing demand for total joint replacement of the hip and knee, patients at Carolinas HealthCare System stand to gain from vigorous ongoing efforts to standardize care, measure quality and minimize complications that reflect a system-wide approach.

A National trend in joint replacement This sustained focus by the System on quality control in total joint replacement echoes a national trend made even more pressing by the growing obesity epidemic, a public health issue that specifically fuels knee replacement procedures, explained orthopaedic surgeon David Mauerhan, MD, an adult reconstruction specialist for Carolinas HealthCare System. \

Fortunately, hip and knee replacement lend themselves well to a standardization of processes since factors such as type of implant, pain management used, physical therapy and patient education can readily be documented and compared. “There’s been a fairly large movement nationally – hip and knee replacement represents a significant and growing expenditure at the federal level, and even in private insurance plans it’s a big growth area,” Dr. Mauerhan said. “There’s a whole list of processes from A to Z – from the time a patient first sees a doctor to the time the patient leaves the hospital – that’s considered the episode of care.”

Payers at all levels, including the federal government, are considering bundled payment plans for total joint replacement that will offer providers a set fee to care Total Joint Replacement Program Focuses on Standardizing Care for each patient during an episode of care, he said. “So when you’re at significant risk like that as a System, you have to have processes in place to enable you to examine your efficiencies of care and offer the ability to document short- and long-term outcomes.”

System-Wide Steps

Steps Carolinas HealthCare System leaders have taken toward standardizing care within the total joint replacement program include participating in the American Joint Replacement Registry (AJRR) – a national center for data collection and research with potentially far-reaching benefits – as well as the American College of Surgeons’ National Safety Quality Improvement Project (NSQIP), an outcomesbased program to measure and improve the quality of surgical care in the private sector. “We’re putting in place many of these processes as a system,” Dr. Mauerhan said, “and then, as an orthopaedic service line in arthroplasty, we’re looking to improve and engage that effort.”

To better measure quality, Carolinas HealthCare System is also developing performance measures that will gather information both from inside and outside the system. Internal performance measures include factors such as appropriately screening patients before surgery, prescribing the optimal antibiotics to fight post-surgical infections and offering post-hospital support and standardized post-surgery physical therapy protocols. This information is already being integrated into electronic medical records, Dr. Mauerhan said.

External, outcome-based performance measurements will come from sources such as patients, who increasingly are being asked to rate their healthcare experiences using Internet-based technologies. “There’s a lot of technology that’s evolving around how we get this information reported,” Dr. Mauerhan said. “I expect over the next decade, we’ll see an evolution of more of what I call patient-centric reporting. But I think the sophistication of how it’s done will continue to evolve. That’s part of best practices, and we have the ability at Carolinas HealthCare System to share those best practices among multiple sites.”

Reducing Complications

The most common reasons for hospital readmissions following total joint replacement surgery include cardiac or pulmonary complications and wound-related problems such as bleeding or infection. Along with healthcare systems across the United States, Carolinas HealthCare System has halved those complication rates over the last decade by implementing measures such as immediate and repeated follow-up with patients after discharge and quick referrals for care when problems arise, Dr. Mauerhan said. “You’re never going to make the complication rate zero in surgery, no matter how hard you try,” he said. “So we make sure patients have appropriate medical clearance before surgery, which drives the complication rate down after surgery and then after they leave the hospital.”

Supporting Colleagues Around the World

Instead of competing with other institutions’ total joint replacement programs, Dr. Mauerhan espouses the belief that every program should want others to succeed for the good of both patients and healthcare providers.

One of the oldest joint replacement registries in the world, located in Sweden, has a “revolutionary” process that helps sub-par physicians and programs improve their skills and efficiency with an incentive-based approach, he said. “To me, that’s absolutely the way it should be done,” Dr. Mauerhan said. “I think of this as a national initiative, and those of us involved in hip and knee replacement want everyone to succeed. There has to be someone driving the change, and we’re in a community where we have thought leaders driving this change. We need to take those interested in arthroplasty and help them become as good as they can possibly be.”