How Innovations in Orthopedics Can Enhance Patient-Centered Care

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Source: Stryker Instance


Total joint arthroplasties (TJA) have been shown to be highly safe and cost-effective procedures for patients with end-stage arthritis, which causes continuous pain, difficulties in functioning, and impaired quality of life.1,2 With nearly one million TJAs performed in the United States annually—and the number projected to triple by 2030—bundled payment models and other value-based measures are increasingly focused on containing costs and optimizing quality throughout the entire episode of care, including post-discharge.1,3 An integral aspect of these value-based measures is patient-centered care; a key component of the Triple Aims of Health Care Reform, which include improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.4 While evidence-based guidelines developed by organizations such as the American Academy of Orthopaedic Surgeons (AAOS) focus on specific standards of care for improving TJA safety, including venous thromboembolism (VTE) prophylaxis and surgical site infection prevention, there is wide variation in adherence to patient-centered pathways.3 Yet, such programs have been shown to improve patient satisfaction, shorten lengths of stay (LOS) and/or discharges, and promote more rapid rehabilitation and recovery in total knee arthroplasty (TKAs).5 In addition, comprehensive, patient-centered pathways and programs are well positioned to integrate the latest advances in surgical and communication technologies in order to further enhance the delivery of safe, effective, and efficient care in TJA procedures.3


Developing Patient-Centered Care Pathways

Based on a 2014 multistakeholder study on developing a generalizable clinical care pathway for TJA, as well as other studies of care pathways in TKA, best practices in pathway design includes processes that are organized by:

    1. The preoperative surgical visit; 2. Preparation and planning for surgery; 3. Hospital/surgical center admission through discharge; 4. Post-discharge care.3

These practices and processes can be applied across the continuum of care in TJA, based on principles of patient-centered care that include:

  • Multidisciplinary Care Coordination: An essential element of patient-centered care involves high-touch care coordination and collaboration among teams made up of primary care providers, specialists in areas such as anesthesiology and critical care, and perioperative care experts, including nursing, social work, physical therapy, and occupational therapy.5 Studies have shown that patients treated by such teams reported improvements in outcome measures and high satisfaction with their care, due to the organized approach, ease of communication, and availability of health care professionals.5 Coordination of care can also help reduce costs in the overall episode of care; for example, one study of clinical care pathways in TKA, demonstrated significant reductions in hospital costs after the implementation of a pathway program due to decreases in operating room time, improved resource utilization, and shortened LOS.5
  • Preoperative patient education programs (PPE): Such programs include web-based, print, and live initiatives structured to improve patient compliance and outcomes via instruction/information on self-care and rehabilitation, as well as helping the patient and clinician to set realistic expectations for the surgical process, recovery, and outcomes.3,5
  • Medical management: Beginning with the presurgical office visit and throughout the preoperative testing period, best practices in medical management involve a detailed planning process, developed by the physician in conjunction with the patient, in order to identify and mitigate surgical risk.3 Plans include an assessment of comorbid conditions and other risk factors, such as older age and obesity, that may increase complications, extend LOS, and/or discharge to an inpatient facility.3
  • Patient and family engagement: Patient engagement is critical to managing communication gaps in transitions in care and facilitating a critical information flow across the episode of care. Because families of TJA patients are often involved in post-discharge care, it is essential to include them in the patient education and communication process. Numerous studies have shown patient and family engagement can lead to improved TJA clinical outcomes.3
  • Shared decision-making (SDM): SDM is the delivery of accurate, clinically relevant information presented by the physician to the patient in an understandable and culturally sensitive format that describes the risks and benefits of the procedure and helps develop a treatment plan that aligns with the clinical goals and values of the patient.5 As part of the SDM process, physicians may also use standardized decision aids in helping patients to understand the benefits and risks of surgery. Multiple studies point to the role of SDM in improving patient engagement, as well as satisfaction scores following surgical procedures.5
  • Multimodal pain management: Studies have demonstrated that pain management programs that emphasize a multitargeted approach can promote postoperative rehabilitation and reduce LOS.5 The adoption of multimodal pain therapy that targets different aspects of pain at each phase of the preoperative, intraoperative, and postoperativestage of the TJA procedure has also been shown to:

            – Reduce opioid usage
            – Improve pain scores
            – Increase patient satisfaction
            – Enhance early recovery
            – Facilitate earlier discharge6

  • Innovative communications technologies: Online care coordination and patient engagement portals that provide ongoing information and alerts throughout the entire episode of care can assist the patient’s care team and family in helping patients comply with preoperative and postoperative discharge care and instructions.3 Other innovations, such as wearable devices with sensors, used in combination with questionnaires, may also assist health care providers by alerting clinicians of the status of patients’ rehabilitation progress.5


Combining Value and Advances in Technology with Patient-Centered Care

As value-based payment models continue to dominate the reimbursement landscape, many orthopedic practices and health systems are becoming more actively involved in testing and adopting patient-centered care initiatives to improve the delivery of high-value care.3 At the same time, as the pace of orthopaedic technology continues to advance, orthopedic surgeons are further tasked with incorporating new technologies into surgical practice while ensuring that are they delivering measurable value for their patients.2 Research has shown that patient-centered care, particularly the relationship between the patient, physician, and care team in ongoing engagement, communication, and shared decision-making, can impact treatment outcomes and lead to greater patient satisfaction.7 In fact, numerous studies have reported growing patient satisfaction following TKR, highlighting patient satisfaction as an important outcome measure in TKA that is most likely closely associated with patient-centered care and value-based initiatives.8

 


This material and/or presentation is provided for guidance and/or illustrative purposes only and should not be construed as a guarantee of future results or a substitution for legal advice and/or medical advice from a healthcare provider. Stryker Performance Solutions does not practice medicine and assumes no responsibility for the administration of patient care.


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References
  1. Projected Volume of Primary And Revision Total Joint Replacement in The U.S. 2030 to 2060 , American Academy of Orthopaedic Surgeons Research News, March, 2018, https://aaos-annualmeeting-presskit.org/2018/research-news/sloan_tjr/ Accessed April 27, 2019.
  2. Bundled Payments in Total Joint Replacement: Keeping Our Care Affordable and High in Quality, Current Reviews in Musculoskeletal Medicine, July, 2017. https://www.ncbi.nlm.nih.gov/pubmed/28741101 Accessed February, 2019.
  3. Developing a Pathway for High-value, Patient-centered Total Joint Arthroplasty, Clinical Orthopaedics Related Research, The Association of Bone and Joint Surgeons®,2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3971244/ Accessed April 28, 2019.
  4. Institute for Healthcare Improvement, IHI Triple Aim Initiative http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx Accessed February, 2019.
  5. Total Knee Arthroplasty: Improving Outcomes with a Multidisciplinary Approach., Journal of Multidisciplinary Healthcare, January, 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5790068/ Accessed April 27, 2019.
  6. Perioperative Pain Management in TJA: What Should Be in the Mix?, International Congress for Joint Reconstruction, March, 2018. https://icjr.net/articles/perioperative-pain-management-in-tja-what-should-be-in-the-mix Accessed April 28, 2019.
  7. How Patient-Centered Care is Changing Orthopaedics, Bone and Joint, February, 2014, https://online.boneandjoint.org.uk/doi/full/10.1302/2048-0105.31.360200?journalCode=bj360 Accessed April 30, 2019.
  8. Patient Satisfaction After Total Knee Replacement: A Systematic Review, HSS Journal, Musculoskeletal Journal of Hospital for Special Surgery, June, 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6031540/.Accessed April 28, 2019.