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Consultancy Smith & Nephew Medtronic Research Support Smith & Nephew Hatton Research Institute GSH IDEs Bayer Boehringer Cadence Co-management Arrangements.

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Presentation on theme: "Consultancy Smith & Nephew Medtronic Research Support Smith & Nephew Hatton Research Institute GSH IDEs Bayer Boehringer Cadence Co-management Arrangements."— Presentation transcript:

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2 Consultancy Smith & Nephew Medtronic Research Support Smith & Nephew Hatton Research Institute GSH IDEs Bayer Boehringer Cadence Co-management Arrangements Good Samaritan Hospital Consultancy Smith & Nephew Medtronic Research Support Smith & Nephew Hatton Research Institute GSH IDEs Bayer Boehringer Cadence Co-management Arrangements Good Samaritan Hospital

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5 The Solution: Consumer (patient)-Driven Care Consumer-driven insurers Consumer-friendly hospitals Consumer-friendly employers Consumer-supportive laws Consumer-driven market Americans Favor Transparency in Medicare, Physician Changes, May 2, 2006,

6 How physicians can change the future of health care. Porter ME, Teisberg EO. JAMA 2007;297(10):1103. PRINCIPLES: *Goal is value for patients *Organization around conditions and cycles of care *Measuring of results, risk- adjusted outcomes, and costs Returning medicine to its proper focus: Enabling health and providing effective care. * * *

7 Adverse events are associated with significantly increased hospitalization costs and appropriate evidence-based interventions are justified to minimize AEs. Kondalsamy-Chennakesavan S, et al. Gynecol Oncol. 2011;121(1):70 Risk-adjusted total, Medicare, and beneficiary healthcare costs were significantly higher for both THR and TKR patients with VTE. Boser O, et al. Curr Med Res Opin. 2011;27(2):423 Radically reduce adverse events! Invest in initiatives to apply best evidence literature to care processes. Believe that real change can happen and that it is good for all stakeholders!

8 Error type % of injuries that are errors Count of injuries (2008) Count of Errors (2008) Medical cost per Error In Hospital Mortality Cost per Error STD Cost Error Total Cost per Error Total Cost of Error Millions Pressure Ulcer (Medicare Never Event) >90%394,669374,964$8,730$1,133$425$10,288$3858 Postoperative infection >90% 265,995252,695$13,312$-$1,236$14,548$3,676 Mechanical complication of device, implant or graft 10-35%268,35360,380$17,709$426$636$18,771$1,133 Postlaminectomy syndrome 10-35%505,881113,823$8,739$-$1,124$9,8631,123 Hemorrhage complicating a procedure 35-65%156,43378,216$8,665$2,838$778$12,272$960 Infection following infusion, injection, transfusion, vacc >90% 9,3218,855$63,911$14,172$-$78,083$691 Pneumothorax 35-65% 51,11925,256$22,256$-$1,876$24,132$617 Infection due to central venous catheter >90%7,4347,062$83,365$- $83,365$589 Other complications of internal biological, synthetic <10%535,66626,783$14,851$1,768$614$17,233$462 Ventral hernia w/o mention of obstruction or gangrene 10-35%239,15653,810$6,359$260$1,559$8,178$440

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10 CMS in cooperation with the AAOS Dry-run September 2012 National transparency 2013 via compare.gov RSCR and RARR What are the targets? Mechanical complication readmission 90 days PJI 90 days SSI 90 days Surgical site bleeding, PE, death 30 days AMI, pneumonia, sepsis/septicemia 7 days

11 RARR 5.7% national RSCR 3.6% GSH 5.0% and 3.6% respectively Years 2008 to 2010

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13 No silver bullet Mountain climbing

14 Causal analysis Heget JR, et al. Jt Comm J Qual Improv 2002;28(12):660 Nicolini D, et al. J Health Serv Res Policy 2011;16 Suppl 1:34 BEFORE…DURING…AFTER Randomized clinical trials Meta-analyses Cochrane reviews Available clinical practice guidelines (CPG) BEST PRACTICE PROPOSALS (BPP) Barbieri A, et al. BMC Med 2009;7:32 Rotter T, et al. Cochrane Database Syst Rev 2010;(3):CD006632

15 BEFORE: uncorrected pre-op anemia DURING: unfettered bleeding and no inhibition of fibrinolysis AFTER: mandated strong VTE chemoprophylaxis Evidence: STRONG, MODERATE, WEAK, INCONCLUSIVE

16 BEFOREDURINGAFTER Recognition of anemia with CBC more than 4 weeks prior to surgery (S) Regional anesthesia (M)Avoidance of strong VTE chemoprophylaxis in low risk TKA patients (S) Correction of HgB <13 in males and <12 in females with erythropoietin and iron supplements (S) Hypotensive anesthesia for those requiring GA Lovenox 40 mg daily in TKA. INR targets near 1.5 for coumadinized patients (M) Referral to hematology if HgB < 10 Pre-op TXA given 15 mg/kg 15 minutes before incision (S) Transfusion triggers 7/21 unless cardiac symptoms unstable (S) Avoidance of autologous donation (M) Decreased tourniquet time, bipolar cautery (I) IV fluid correction of hypotension and mild postural changes (I) Drain avoidance (M)

17 Teamwork is required to enable Zero in on Zero Surgeons Staff Administration Patients and family

18 Get broad buy-in Collegially help everyone move in the same direction to achieve a solution! Hospital credentialing: Docs must participate in the Registry Docs may use the OCE marketing plan IF they follow established CPGs and new BPP protocols where CPGs do not yet exist While docs must decide what is best for their individual patients, disagreements with CPGs and BPP protocols must be in writing

19 Blood Transfusions

20 Salida JA, et al. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: predictive factors. JBJS :216 Bong MR, et al. Risks associated with blood transfusion after total knee arthroplasty. J Arthroplasty 2004;19:281

21 < 13 gm/L for men and < 12 gm/L for women Patients unaware of anemia since fatigue is the predominant symptom. PCP acceptance of anemia since surgical options not in their usual treatment algorithms. Patients with severe OA of the hip and/or knee are more likely to undergo TJA if this option is discussed with their PCP, but few patients experience this conversation! Schonberg MA, et al. J Am Geriatr Soc 2009;57(1):82

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24 In 2010, transfusion cost for 321 allogenic and autologous units was $321,000. In 2011 and 2012, we have already saved over$500,000! Shander A, et al. Transfusion 2010;50(4):753

25 Collaborative group with strong leadership Supportive multidisciplinary team Zero in on Zero initiative with strong body of evidence to support best practice initiatives High usage of blood products Wide variation in blood management practices

26 Example of physician blinding for elective total hip arthroplasties

27 Blinded physician-specific transfusion data Presented at Section meeting Extensive literature review for evidence based best practice New practice initiatives for pre, intra, and post-operative conservation Amended order sets to reflect changes Established Anemia Clinic Orthopedic Center of Excellence (OCE) Quality measure: Preoperative anemia Established metrics Posted on OCE dashboard

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29 Anemia Clinic with automatic treatment of patients by hematologist Education of residents, and individual services Go to each section meeting and deliver the message that is pertinent to their practice Let other services know about the successes gained by others Empower staff nurses as your advocates

30 Lack of knowledge about anemia Overwhelmed when notified of anemic status Feared surgery cancelation Did not want to travel for additional doctor visits

31 Orthopedic surgeons tried to treat patients on a case by case basis only to meet resistance from PCP and third party payers. PCPs feared loss of control over patient care if patients were referred to a hematologist for mild anemia. Speculation that the new process would delay surgery. Communication gaps

32 Ownership of clinic process Clinical exam space Departments wanted new business but sometimes resisted implementation Multi dept involvement Verbal and electronic communication gaps between departments

33 Prospective, consecutive tracking of all total hip and knee arthroplasties enables physicians to see their own results in comparison with blood conservation best practices, and then choose to change their own practices. The registry has before/during/after data that enables problem solving.

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39 August 1, 2011 to Sept 21, TJA Total AE 1.73% Transfusion 0% SSI 0% RSCR 0.49% RARR 0.49%

40 BEFORE Anemia detection Anemia correction DURING Novel blood loss prevention TXA administration Avoidance of surgical drains AFTER TXA effect Transfusion criteria 7/21 IV saline for minor postural hypotension and lack if vigor

41 TAKE HOME MESSAGES Part of a regional solution for an upcoming patient access crisis Stellar safety and quality are win-wins for patients, providers, hospitals and society. Physician leadership is critical to creating and sustaining patient- centered solutions for adverse event challenges in hip and knee replacement. THE PATH Center of Excellence Zero in on Zero safety and quality initiative Initiative deployment Physician credentialing agreement Registry

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