Value In Shoulder Care VuMedi Webinar July 30, 2013 · PDF fileBFM to Mayo Brd of Gov, 2003 So, to simplify our question

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Hospital for Joint Diseases ● Department of Orthopaedic Surgery

Value In

Shoulder Care

VuMedi Webinar

July 30, 2013


Mark Frankle, M.D.- Tampa

Bernard Morrey, M.D.- Rochester

J.P. Warner, M.D.- Boston


•Health care delivery is

being redefined with a new

vocabulary for us to

understand and integrate

•Value

•Value-based purchasing

•Quality

•Clinical practice guidelines

•Appropriate use criteria

•ACOs

•Bundled payment systems

•Episodes of care

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Value = patient health outcomes

per dollar expended

Value = health outcomes

cost of delivering

the outcome

Requires us to measure outcomes

and understand costs


•Value-based purchasing: CMS program to

reward high performing institutions for

process of care and patient satisfaction

measurements

•Quality: being defined in many ways by

many organizations


•CPGs: a transparent, reproducible, systematic

evaluation of clinical evidence to assist the

practitioner and patient in making decisions

about appropriate health care for specific clinical

circumstances

•AUC: specifies when it is appropriate to use a

procedure by combining the best available

scientific evidence with the collective judgment of

physicians; derived from CPGs

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•ACOs: Responsible for quality, cost, and overall

care of a defined population of patients

•Bundled payment system/episodes of care:

CMS demonstration project that provides

payment for defined period of care regardless of

care provided


67 year-old male with significant shoulder

pain and disability


Evaluated by five orthopaedic surgeons

#1: Viscosupplementation injections

#2: Steroid injection

#3: arthrosopic debridement

#4: TSA

#5: Reverse TSA

Is this value-driven shoulder care?

VuMedi Webinar Logistics:

Value in Shoulder Care

Bernard F Morrey, M.D.

Mayo Clinic, Rochester, MN

U of Texas, San Antonio

Best Practice and Value Where is the Evidence?

Disclosure – none

• Value committee ASES

• Voting member of AAOS

AUC: rotator cuff


1995

10

12

14

2005 2010

Health cost = 13% GDP: ‘do the math’

Why Important


Goal

Assess as to whether:

There is evidence that

• Evidence based practice

• Improves care and

• Is not more expensive than poorer care


Terms, definitions, and concepts

• Value

• Evidence

- Practice guidelines

- Appropriate use criteria


What are we talking about?

Best practice –

“The use of current best evidence

in making decisions about the care of patients”

i.e. Evidence based clinical practice


Evidence Based – Cost Effective Medicine

Where is the Evidence?

Levels of Evidence (1979)

I. Random controlled

II. Cohort, case controlled

III. Case series – 0 control

IV. Expert opinion

Value: what are we talking about?

Value = quality/cost

Where

Quality = optimization of risk/benefit

Cost = total cost of encounter

includes managing complications

So “value” = cost effectiveness


So best practice and value is

“evidence based - cost effective “


Evidence is used to define guidelines

Guidelines (CPG) are used to define

optimum (best) practice

Appropriate use criteria (AUC) used to

define appropriate indications

• Considers patient input

• Allows for expert experience

Evidence is incorporated in practice

through the development of guidelines


Variation Arbitrary choice

Excessive costs Decreased quality

Solution

Standardize Practice - Evidence Based Guideline

CP1189516-11

Hypothesis:

BFM to Mayo Brd of Gov, 2003

So, to simplify our question

If so, have they affected cost of care?


Have orthopedic clinical practice guidelines

(N = 14) improved the quality of care ?

So to simplify the question

Have orthopedic guidelines (N=14)

improved orthopedic practice?

guidelines improve any practice?

If so, have they decreased cost of care?


Coronary artery disease:

“Improved process and structure.

No evidence of improved care”

Lugtenbery, et al. Effects of Evidence Based Clinical Practice Guidelines on Quality

of Care Quality Studies of Health Care: 18, 385, 2009

Guidelines proven to improve process

Little evidence they improve practice


Coronary artery disease:

“Improved process and structure.

No evidence of improved care”

Lugtenbery, et al. Effects of Evidence Based Clinical Practice Guidelines on Quality

of Care Quality Studies of Health Care: 18, 385, 2009




“No evidence of successful transfer of evidence guidelines to

improved practice”

“Guideline based performance should be carefully evaluated

before implementation to avoid incorrect assessment of

quality of care.”

Lin, et al Impact of Changes in Clinical Practice Guidelines on Assessment of Quality

Of Care Med Care: 48, 733, 2010

Guidelines shown to improve process


NEJM, 2000, Lancet, 2003


Evidence for the impact of quality

improvement collaboratives: systemic review

“… have only modest impact on outcomes”

Schouten, et al, BMJ, 2008




Effect / Impact / Relevance

To date questionable -

2008 – Congress engaged Institute of Medicine to assess

reason for poor adoption

Answer – Effective?

- ‘not trustworthy’


Cost effective?

Little progress

“ ..unable to calculate a cost per quality adjusted life year”

Health Policy, 1999


Evidence based effectiveness

• Process well defined

• Incorporation limited to date

Assessing true cost effectiveness is in future

Driven by irreversible trends

Impact +/- will increase with time

Summary –Conclusion


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Effects of Morbid Obesity on RSA

Mark Frankle, MD

Value in Shoulder Care Tuesday, July 30, 2013

A case control study on outcomes,

complications, disposition and cost

Disclosures

Dr. Frankle receives royalites, research support, and consulting fees

from DJO Surgical

• ↑ Obesity incidence and prevalence in US

• 2005 U.S. prevalence: 3-5%

• 2003-2010 incidence in 1˚ RSA (our patients)

= 21/765 (3%)

• Inferior outcomes generally in THA, TKA,

TSA

• No literature on RSA

Background

Morbid Obesity: BMI > 40

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Morbidly obese patients will have…

• inferior clinical outcomes

• greater cost

• more post-discharge needs

• higher complication rates

…when compared to non-obese patients

Hypothesis

To compare RSA in

BMI ≥ 40 to BMI < 30

• Clinical and

radiographic outcomes

• Disposition,

complications and

hospital cost

Purpose

• STrengthening the Reporting of OBservational studies in Epidemiology (STROBE)

• Case control 1:3

• Matched age, sex, Dx, f/u

Study Design

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• Inclusion

◦ 1˚ RSA between 2003 and 2010

◦ Min 24 months of f/u

◦ Dx: CTA, MRCT, RA

• Exclusion

◦ Infection, neurologic injury, fracture and revisions

Study Design

• Uniform, previously described

• DP approach, single experienced surgeon

• Consistent team

• 2nd generation baseplate, lag screw, locking screws

• Cemented humeral component

Surgical Technique

• Existing data used to calculate

• Δ ASES 10 -> 84pts with 1:3 case control

• ΔSST 2 → 42 pts

• 10% higher complication rate

◦ Major 760 pts

◦ Minor 584 pts

Primary Outcome

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Study Demographics

Males

(4)

Females

(17)

Males

(13)

Females

(50)

Study Group

Control Group

Study Group

Control Group

43.2 (40.3-48.9)

27.1 (18.9-30.0) p<0.05

Study Demographics

Study Group

Control Group

248.8 (196-300)

156.4 (100-225)

Study: 69.2

Control: 71.1

Study: 45.0

Control: 48.2

p<0.05

Study Demographics

Study Group Control Group

CTA (17) CTA (51)

MCT (2) MCT (6) RA (6) RA (2)

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Total Comorbidities Cancer

CAD

CHF

CRF

CVA

COPD

Corticosteroids

Dementia

Diabetes

DM

HLD

HTN

Narcotic use

Liver Disorder

Obesity

Osteoporosis

OSA

PUD

PAD

RA

Tobacco

Other (i.e.

Parkinson’s, NM

disease)

Phases of Care Preoperative Intraoperative Postoperative

Preop Hospital Visit

Holding Room

OR in

OR out

PACU

WARD

ICU

Excluded post-hospitalization cost (variable)

• Line item costs for goods and services for each patient

• Provided by TGH Decision Support Department

• Incorporates effort and time spent with each patient by staff, resource utilization and dispensables

• Hospital cost ONLY

Cost Collection Method

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Preoperative Cost

LABS PREOP

MICRO PREOP

CXR PREOP

EKG PREOP

HOLDING ROOM

SURGICAL PREPARATION

Intraoperative Cost

SURGICAL SUITE USAGE

ANESTHESIA SERVICES

IMPLANTS

DISPOSABLE SURGICAL INSTRUMENTS

REUSABLE SURGICAL INSTRUMENTS

DISPOSABLE SURGICAL SUPPLIES

Postoperative Cost

PACU PT WARD POST RESPIRATORY TELEMETRY PHARMACY ORTHOTICS DRESSING SUPPLIES LABS TOTAL ALL OTHER SUPPLIES

SHOULDER FILMS MICRO CXR PATH

PORTABLE SERVICES CARDIAC STUDIES OT

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• ASES

• SST

• VAS Pain

• VAS Function

• Satisfaction

Outcomes Measured

• Motion

• Radiographs

Outcomes

6.6

2.1

1.1

2.2

6.9 7.0

8.9

6.2

3.6

2.1

1.3

7.8 8.3

9.3

0

1

2

3

4

5

6

7

8

9

10

VAS Pain VAS Function SST Satisfaction

Obese-Pre Obese-Post Control-Post Control-Pre

p<0.05

Outcomes

17.1 14.8

32

38.8

31.4

69.0

19.3 20.5

39.9 43.3

34.9

78.2

0

10

20

30

40

50

60

70

80

90

100

ASES Pain ASES Function ASES Total

Study-Pre Study-Post Control-Post Control-Pre

p<0.05

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• Both improved significantly pre→post

• Improvement:

◦ VAS pain 3x

◦ VAS function 3.5x

◦ SST 6x vs 4x

◦ ASES 2x

• Obese more impaired at baseline for VAS Function, SST and ASES function

• Increment was similar

Results

Motion

61 56

11

139

125

54

74 68

26

153

138

55

0

20

40

60

80

100

120

140

160

180

Forward Flexion Abduction External Rotation Internal Rotation

T12 T12

S1

L4

Study-Pre Study-Post Control-Post Control-Pre

p<0.05

• Both improved significantly pre→post

• Motion increased: ◦ 2x FF, ABD, & IR

◦ ER 5x vs 2x

• Obese more impaired at baseline for ER and IR

• Increment was similar

Results

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Comorbidities Obese Control ∆

Co

mo

rbid

itie

s

Total 6 4

OSA 10/21 2/63

Steroid use 4/21 5/63

p < 0.05

Surgical Data

Obese Control ∆

EBL (ml) 237 197 40

Skin to Skin 118’ 109’ 9’

Total OR Time 185’ 172’ 13’

Rest Time in OR 68’ 63’ 5’

40

13’ p<0.05

p<0.05

LOS, Disposition, Readmissions

Obese Control

LOS (days) 3.1 2.6

Home dc 15 60

Readmission 2 0

ED Visit 1 1

15/21 60/63 p<0.05

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Radiographs and Complications

Obese Control

Notching 1 - G1 3 – G1 2 – G2

Reactive Bone 7 16

Stem Loosening 0 2

Baseplate Failure 0 0

Dissociation 0 0

Other Mechanical 0 0

Cost Analysis

Obese: $24,467 (18,790-57,649)

Δ $2,958

Controls: $21,509 (15,864 - 29,773) p<0.05

Cost Analysis by Care Phase

Study Group

Control Group

∆

Pre-operative $ 322 $ 315 $ 7

Intra-operative $ 18,757 $ 17,864 $ 893

Post-operative $ 5388 $ 3329 $ 2058 $ 2058

p<0.05

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Cost Analysis

Post-Op $5,388 (22%)

Pre-Op $322 (1%)

Intra-Op $17,864 (83%)

Obese $24,467

Post-Op $3,329 (16%)

Pre-Op $315 (1%)

Intra-Op $18,757 (77%)

Control $21,509

◦ ↑ Holding Room Time ($18)

◦ ↑ OR Time ($242)

◦ ↑ Orthotics ($95)

◦ ↑ Respiratory services ($130)

◦ ↑ Labs ($32)

◦ ICU

Significant Line Item Costs

p<0.05

Complications

Major

Reoperation

Hospital Readmission

Treatment >1month

Minor

Everything Else

Obese: 4 in 3 patients

Controls: 8 in 8 patients p = 0.479 Obese: 3 in 3 patients

Controls: 14 in 12 patients p = 0.440

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Major Complications Obese Controls

1. COPD exacerbation Readmission

2. V-tach postop ICU, cath

3. Acromial base fx sling

4. Acromial fracture (3) sling

1. Acromion fx sling

2. Scapular spine fx (3) sling

3. Postop pain ED visit

4. Dislocation 2-3 yr, self-reduced

5. Wound drainage POD10 outside ID, iv Dapto

6. Humeral loosening Revision @ 75 m

Minor Complications

Mo

rbid

ly

Ob

ese

1. SWI (Keflex)

2. Ankle gout & neck arthritis flare up (NSAID’s),

3. RVR (Rate Meds-chronic A-fib)

Controls

1. Wound drainage wound care and Augmentin

2. Wound erythema Keflex

3. RVR postop Rate meds, (chronic known A-fib)

4. Neck pain spine, conservative Tx (pt 3)

5. C6 radiculopathy exacerbation resolved

6. Postop nausea head CT

7. New atrial flutter outpt f/u

8. Hypoxia/hemidiaphragm paralysis (block) Telemetry, fever w/u, atelectasis

9. UTI antibiotics

10. Anemia 2 units PRBC transfused

11. Hyponatremia (Na+ 120) Free H2O restriction

12. Atelectasis fever workup

13. Oral herpes flare-up acyclovir (pt 12)

14. GI virus dehydration, oral + iv hydration

• Novel but consistent

• Difficult to isolate effect of morbidy obesity alone

• Cost outlier: consistent with literature

• Can anticipate 5% ICU for morbidly obese

Discussion

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• Generic concept: Value= Outcome / cost

• Hard to measure objectively

• Hard to put value on patients’ symptoms

• Patients at risk for lower value

Our study helps define the value of RSA in morbidly obese patients

Discussion

Conclusions

• Era of finite and decreasing resources

• Increased pressure, P4P

• Similar studies useful

• Shoulder surgery equally successful

• More comorbidities, higher cost and more post discharge needs

Thank

You

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Jon J.P. Warner, MD Chief, The MGH Shoulder Service

Professor of Orthopaedic Surgery

Harvard Medical School

Massachusetts General Hospital

Laurence D. Higgins, M.D. Chief, Sports Medicine & Shoulder Service

Brigham and Women’s Hospital Eric Black, M.D. Resident, Harvard Combined Ortho. Program

Jon J.P. Warner, MD

Chief, The MGH Shoulder Service

Professor of Orthopaedic Surgery

Harvard Medical School

Co-Director, Boston Shoulder Institute

Fellowship Support: Arthrex Mitek Smith & Nephew Breg DJO Royalty:

$ Tornier- RCR device

Consulting (Lecture honorarium): $ Tornier, Mitek

Equity: $ Orthospace Co.

$ Vumedi

Conflict of Ego - Past President ASES

- Current work with HBS

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What is Value? Its personal...

–The Patient = Outcome

– Insurers/Hospital:

–Cost ?

–Time?

–Resources?

•- The Surgeon:

» Outcome

» Income

Competitive Strategy in Healthcare?

(Alignment)

• Zero-sum competition

– Compete to shift costs

• Positive-sum competition

– Compete towards net gain

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2008

Reference: National Ambulatory Medical Care survey, 2010

ss

Top 20 Reasons for Office Visits in USA, 2010

Shoulder Symptoms 11.5 Million

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How important is Shoulder Care at our

hospitals

“The current system of health care payment is not

Value based”

“…health care providers are compensated at

widely different rates for providing similar quality

and complexity of services.”

(…in Massachusetts)

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The Four Major Hip/Knee manurfacurers paid physicians:

$800,000,000 in consulting, royalties & equity

…in 65,000 agreements

- Assistant Attorney General Report to the Senate

In Massachusetts In Massachusetts

Enquist M, Bosco JA, Pazand, L, Habibi, KA, Donohue, RJ, Zuckerman, JD: Managing Episodes of Care: Strategies for Orthopaedic Surgeons in the Era of Reform. J Bone Joint Surg. Am. 2011; 93:1-7.

•“In the last twenty years…surgeon payments for total hip

and knee replacement have decreased 69% and 66%

respectively.” (Medicare data)

•Sixty-three percent of U.S. hospital have negative Margins

on Medicare patients, with one-quarter sustaining inpatient

margins of -20% or lower.”

Enquist M, et al: Managing Episodes of Care: Strategies for Orthopaedic Surgeons in the Era of Reform. J Bone Joint Surg. Am. 2011; 93:1-7.

Patient Protection and Affordable Care Act

(PPACA): references the word quality 906 times

“ but does not “clearly define this in the legislation.”

Who Will Define “Quality” and “How” will quality be defined?

Patient Protection and Affordable Care Act (PPACA): “Orthopaedic surgeons

will need to identify ways to cut costs, maintain quality measures, and manage

post-acute care to survive in a changing marketplace”

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- R. Herzlinger

Medicare: Fixed pricing which pays equal for good & poor outcomes

P4P: Incentivizes practice not outcome (not quality)

03 2 3 5 4 5

15

22

55

0

10

20

30

40

50

60

1960 1964 1968 1990 1992 1994 1996 1998 2000 2002

Year

# o

f A

rtic

les

1960

1964

1968

1990

1992

1994

1996

1998

2000

2002

ERRORS IN MEDICAL LITERTURE

What does this cost???

Poor documentation

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0

100

200

300

400

500

600

700

800

900

0 20 40 60 80 100 120

TTD

Day

s

Physical Therapy Visits (post shoulder procedure)

Shoulder Procedures

How Insurer’s see us

No Correlation between the number of P.T. visits and TTD!!!!!!!

-Insurance Companies Practice Medicine: “Managed care results in a top-down health care system which

impedes any potential for innovation which improves care of patients.”

-- Herzlinger

Who are our allies?: The Hospital… - R. Herzlinger:

Hospitals: “…when it comes to supply, hospitals suppress competition and innovation, and health care’s key suppliers, the physicians, are marginalized.”

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•Most experts favor “vertical integration” of large physician groups”…

•”the larger the scale, the larger the problems encountered”

- Herzlinger

Diminishing Margin

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___________

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Shoulder Care

50%

18%

40%

10% 11%

5% 8%

0% 0%

10%

20%

30%

40%

50%

60%

2004 2005 2006 2007 2008 2009 2010 2011

Complication Rates Each Year for Reverse Arthroplasty

Department of Orthopedics

DRG 209 - Total Hip Arthroplasty (Primary)

Cost per Case by Surgeon

RP

MDCAR

MD 1

MD 2

MD 3

MD 4

MD 5

MD 6

MD 7

MD 8

MD 9

MD 1

0

MD 1

1

MD 1

2

MD 1

3

MD 1

4

MD 1

5

ANAT PATHO

CRITICAL C

RADIOLOGY

CENTRAL SU

INTERNAL M

PHARMACY

LAB MEDICI

MEDICAL SP

ANESTHESIA

SURG SUBSP

PT CARE SE

HOSP SURG

Mayo Clinic Resource Utilization for THR

30% Variation by Physician

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Imaging Utilization (Medicare)

Reference: Iglehart. NEJM; 2009: 1030-37

We order these tests….and create costs…..

Department of Orthopedics

DRG 209 - Total Hip Arthroplasty (Primary)

Margin % by Surgeon

ALL

CASES

MD 1

MD 2

MD 3

MD 4

MD 5

MD 6

MD 7

MD 8

MD 9

MD 1

0

MD 1

1

MD 1

2

MD 1

3

MD 1

4

MD 1

5

Surgeon

Marg

in %

Margin = Reimbursement – cost cost

Complication rate = NS

MAYO PRIMARY THR MARGIN BY SURGEON

Linear Decrease in Hospital Cost of Hemiarthroplasty (n=8,115)

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-

3

4

Shoulder Pain

PCP

Orthopaedic Surgeon

MRI PT

Shoulder

Sports

Hand

Repeat Imaging?

PT

Surgery

Open

Arthroscopic

Anchors

Bone tunnels

Rehab?

The formula for cost effective care

VARIATION: Arbitrary Choice

Excessive Costs Decreased Quality

Solution

Standardize Practice Evidence Based

Status quo

• Lack of Incentives

• Failure of Alignment

• Poor Consensus on

Outcomes Measures

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37

• Actual Costs

• Allocated Costs

What’s it really cost?

37

• Resource Capacity

Capacity Cost Rate

Alternative Payment Models in the Private Sector The Future Awaits!

• Patient-Centered Medical Home • Accountable Care Organizations • Bundled Payments • Global Capitation

An Old Model?

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Documents

Value In Shoulder Care VuMedi Webinar July 30, 2013 · PDF fileBFM to Mayo Brd of Gov, 2003 So, to simplify our question