Vanderbilt Department of Orthopaedics...Vanderbilt Orthopaedics: Value, Quality & Safety January 2014 A Message from the Chairman, Herbert Schwartz, MD The compelling need for a good

Vanderbilt Orthopaedics: Value, Quality & Safety January 2014

VanderbiltHealth.com/Orthopaedics(615) 93-ORTHO

Vanderbilt Department of Orthopaedics

Vanderbilt Orthopaedics: Value, Quality & Safety January 2014

A Message from the Chairman, Herbert Schwartz, MDThe compelling need for a good definition of health care value highlights a fundamentalchallenge. We have not yet developed scientifically sound or accepted approaches todefining or measuring either patient centered outcomes of care, or the costs ofproducing those outcomes. The scientific hurdles to defining patient centered outcomesare numerous. Outcomes can be subtle and multidimensional, involving not onlyphysiological and functional results, but also patients’ perceptions and valuations oftheir care and health status. The ability of health care organizations to measure costs isprimitive at best and doesn’t meet the standards used in many other advancedindustries. Equally challenging is the lack of data systems to support outcomemeasurement.

The Vanderbilt Department of Orthopaedics (VDO) presents this compilation of Value, Quality and Safety astestimony to our mission, accomplishments and culture. The Divisions within VDO have proudly displayedsome examples of the programs conducted in 2013 which document our commitment to value in health care.Value can be defined as: Quality Patient Outcomes, Safety and Satisfaction divided by Cost, Waste Reductionand Operational Redesign. We strive to deliver the very best care for our patients, as per our credo of puttingthe patient first, by performing evidence based medicine whenever appropriate and setting examples of thatbehavior for our residents, alumni and colleagues.

At Vanderbilt, the promise of discovery is our passion. Teamwork within VDO is fundamental and each teammember is critical in facilitating a constantly evolving and improved product. We emphasize patient’s rightsand the sanctity and privacy of the patient – doctor relationship. We use our data management systems tosupport our discovery of best practices and apply them to the individual based upon their needs. Our teamtries to focus on optimal access and care delivery while minimizing the distractions of poor metric proxies ofperformance. We must be mindful in our changing healthcare environment that we maintain our focus ondelivering the care to our patients that they need.

Please enjoy reviewing our march toward delivering value based health care.

Best Wishes in the New Year,

Herbert S. Schwartz MDProfessor and ChairmanVanderbilt Department of OrthopaedicsMCE South Tower, Suite 4200Nashville, TN 37232 8774Phone: 615.322 0543, Fax: 615.875 [email protected]

Vanderbilt Orthopaedics: Value, Quality & Safety 2014

Joint Replacement Outcomes Report 2013

Total Joint ReplacementsInfec on and complica on rates a er total joint replacements con nue to remain below na onal standards, as compared to other

large, ter ary centers (de iden fied) as seen in the data obtained from University HealthSystem Consor um (UHC).

Primary total knee replacement remains the most commonprocedure performed by the Joint Replacement Center,

while primary hip replacement volume con nues to grow.Our center has remained a strong referral center for revision

hip and knee replacements, as well as infected jointreplacements.


Vanderbilt Bone and Joint Outcomes Report 2013

The average length of stay following aprimary joint replacement following the

accelerated recovery pathway program was2.18 days between November 2012 andJanuary 2013. This average includes 6

pa ents who chose inpa ent rehabilita onwhich requires at minimum a 3 night

hospital stay.

The average pa ent controlled analgesia (pain medica on usage)among pa ents par cipa ng in the Accelerated Recovery Program(ARP) was nearly half that of the group not par cipa ng in ARP.

The average number of oral pain tablets (taken as needed for pain) pervisit using a random sample of 30 pa ents. The total overall averageof tablets taken per visit for all of the ARP pa ents was 7 per pa ent.


Children’s Orthopaedics Outcomes Report 2013

Pediatric Spinal Fusion Surgical Site Infection (SSI) Improvements

Surgical site infec on rates for pa ents receiving spinal fusions con nues to decrease. InQuarter 3 of 2011 there were 7 surgical site infec ons for every 100 procedures completed.That number has been reduced to 0 surgical site infec ons for every 100 procedures com-

pleted in Quarter 3 of 2013.


Children’s Orthopaedics Outcomes Report 2013

Pediatric Spinal Fusion Length of Stay Improvements

Bene its of a shorter length of stay:

Previously Occurred OnPostop Day:

Now Occurs On PostopDay:

Patient is Ordered to BeOut of the Bed 3x/Day

2 1

Discontinue patientcontrolled analgesia

2 or 3 1

Pain medication taken byMouth

2 or 3 1

IV fluids stopped 3 2

Patients ambulates(moves) 3x/Day

3 2

Hemovac drain removal 3 2

Postoperative Pathway Modifications


Hand Surgery Outcomes Report 2013

Outcomes of Hook of the Hamate Fracture Excision in High Level Athletes

Level of Playat Time of InjurySport

0

1

2

3

4

5

3 4 5 6 7 8

#of

Patie

nts

Weeks

Return to Sport

0

1

2

3

0 1 2 3 4 5 6 7 8 9 1011

Score

Patients

PostoperativeDASH Scores

DASH Score

DASH Sports Score

0

2

4

6

8

10

0 1 2 3 4 5 6 7 8 9 10 11

Pain

(010

)

Patients

Pain Scores

Preoperative

Postoperative

02468

10

1 2 3 5 67Left

7Right 8 9 10 11

Perfo

rmance

Score

Patients

PerformanceScores

Preinjury

Postinjury

0123456789

10

1 2 3 4 5 6 7 8 9 10 11

Satisfaction

Score(0

10)

Patients

Patient Satisfaction

Demographics

Outcomes

Pain was based on a scale of 0 (no pain) to 10 (worst possible pain).Sa sfac on was based on a score of 1 (not sa sfied) to 10 (very sa sfied).

All pa ents successfully returned to full par cipa on in theirsport an average of 6 weeks a er surgery. Performance inthe pa ent’s respec ve sport was measured on a scale of 1

(worst possible performance) to 10 (best possibleperformance). A pa ent’s func onal outcome was measuredusing the DASH (Disabili es of the Arm, Shoulder, and Hand)ques onnaire and DASH Sports module which uses a scale of1 (no di culty doing specific func on) and 5 (unable to do

specific func on).

1 1

5

2 2

0

1

2

3

4

5

6

17 18 19 20 21#of

Patie

ntsin

AgeG

roup

Age

Age Range


Orthopaedic Oncology Outcomes Report 2013

Surgical Site Infections and Resected Soft Tissue Sarcomas

Management of Obese Patients with Extremity Soft Tissue Sarcomas

35

10

35

10

2215

19125

10

15

20

25

30

35

40

Wound Complication Rate Local Recurrence Rate

Patient%

Wound Complicationand Local RecurrenceRates

Toronto 2002 (n=88)

Boston 2012 (n=103)

Nagoya 2010 (n=126)

Vanderbilt 2013 (n=91)

Obesity WoundComplicationsSarcoma Specific

Death 1.4 1.28

Distant Metastatis 0.82 1.11Local Recurrence 0.6 1.42

00.20.40.60.81

1.21.41.61.82

HazardRa

tio

Wound Complications and the Obese Patient


Orthopaedic Oncology Outcomes Report 2013

Quality Projects on Incomplete Excisions of Soft Tissue Sarcomas

INSURANCE AND DISTANCE ANALYSIS: Insurance statusand pa ent distance from the treatment center were notsignificantly di erent between pa ents who underwentprimary excision and reexcision of a so ssue sarcoma.However, large and deep tumors and certain histology

types predicted appropriate referrals.

COST ANALYSIS: The average professional charge was$9694 for a primary excision and $12896 for a reexcision.A er adjus ng for variables such as: tumor size, grade, andsite, pa ents undergoing reexcision saw an increase of$3,699 in professional charges more than those with a

primary excision.

Proposed Flowchart for Avoiding Unplanned Resections of Wrist Sarcomas

Flowchart of purposed algorithmof diagnos c steps (diamonds)

and treatment recommenda ons(rectangles) for pa ents

presen ng with dorsal wrist mass.This algorithm was created tohelp surgeons avoid trea ng

malignant tumors thought to bedorsal ganglion cysts.


Orthopaedic Trauma Outcomes Report 2013

Relationship of Hyperglycemia and Surgical Site Infection (SSI) Rates

Stress Induced Hyperglycemia as a Risk Factor for Surgical Site Infection (SSI) Rates

4

10

0

2

4

6

8

10

12

Average Length of Stay

Day

Average Length of Stay

ICU

Hospital

8.6%

23%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Infection Rates

Surgical SiteInfections

Infections

37%

63%

4.4% 1.6%0%

20%

40%

60%

80%

More than 1 Less than 1Blood Glucose Level 200mg

BloodGlucose Levels andSurgical SiteInfections

Number of Patients

Thirty day SurgicalSite Infection (SSI)Rate

17%

83%

7.5%1.7%

0%

20%

40%

60%

80%

100%

HGI 1.76 HGI < 1.76

Hyperglycemic Index (HGI)and Surgical Site Infections

Number of Patients

Thirty day SurgicalSite Infection (SSI)Rate

62

36

86

56

20

Injury TypeUpper Extremity

Pelvic or Acetabular

Femur

Tibia

Foot

4.9

14.9

02468

10121416

Average Blood Transfusion

Units

BloodTransfusionUnits and Surgical SiteInfections

Patients without an SSI

Patients with an SSI1.2

2.1

0

0.5

1

1.5

2

2.5

Average HGI Level

Hyperglycemic (HGI) andSurgical Site Infections

Patients without an SSI

Patients with an SSI


Orthopaedic Trauma Outcomes Report 2013

Health Literacy in Orthopaedic Trauma Patients

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Q1 Q2 Q3 Q4 Q5

Overall Patient PerformanceonComphrensionQuestions

Pre Intervention (N=146)

Post Intervention (N=153)

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%

Patient Satisfaction

Patients withIntervention (N=34)

Patients with NoIntervention (N=153)


Rehabilitation Orthopaedics Outcomes Report 2013

Over half (56%) of the sampled worker’s compensa onpopula on (n=50) were restricted to light duty for less than 30days. 84% of the pa ents were restricted to light duty for 60

days or less. The average number of days a worker’scompensa on pa ent was restricted to light duty ranged from19 days for pa ents with foot and ankle injuries to 50 days for

pa ents su ering from hand injuries.

51% of 29 worker’s compensa on pa ents sampled were able to return to work following treatment. Over 67% oflumbar spine injury pa ents and 100% of amputa on pa ents were able to return to work.

The Worker’s Compensation Patient

0 30 31 60 60 90 >90Cervical 3 3 1 0Lumbar 12 4 2 0Shoulder 0 2 1 0Hand 5 1 2 2Knee 4 3 0 0Foot/Ankle 4 1 0 0

3 31 0

12

42

002 1 0

5

1 2 24 3

0 0

4

1 0 002468

101214

Numbe

rofP

atients

Days on Light Duty

# of Days Restricted to Light Duty

LumbarSpine Injury Paraplegia

PelvicInjuries

ExtremityInjuries Amputations

CervicalSpineInjuries

ThoracicSpineInjuries

MultipleTraumas (NoFractures)

Returned to Work 4 1 1 5 4 0 0 0Did Not Return to Work 2 2 2 5 0 1 1 1Total Patients 6 3 3 10 4 1 1 1

41 1

5 4

0 0 02 2 2

5

0 1 1 1

63 3

10

41 1 1

02468

1012

NumberofPatients

Return to WorkReturned to Work Did Not Return to Work Total Patients

34

27

48

50

24

19

Average Days on Light Duty

Cervical

Lumbar

Shoulder

Hand

Knee

Foot/Ankle

Vanderbilt Orthopaedics: Value, Quality, & Safety 2014

Sports Medicine Outcomes Report 2013

Value–Based Treatment of Atraumatic Rotator Cu Tears

Outcomes

0102030405060708090

Baseline 6 Weeks 12 Weeks

Patient completed Survey Scores

SF 12 MCS

SF 12 PCS

ASES

WORC

SANE

Marks Activity Scale0

20406080

100120140160180

Baseline 6 Weeks 12 Weeks

Degrees

Range of Motion MeasurementsForward Elevation

Abduction

External Rotation atSide

Internal Rotation atSide

External Rotation at90° of Abduction

Nonoperative treatment using the MOON physical therapy program wasfound to be effective for treating atraumatic rotator cuff tears in

approximately 75% of the 452 patients that were followed for 2 years.Patient reported outcomes improved signi icantly at 6 and 12 weeks. Ifpatients did fail the therapy program it was usually within the irst

three months.

Final Cover 12-12-13.pdfWords From The Chairman 12-12-13Spine 12-10-13 (Including Smartart)Page 1Page 2.pdf

Joints 12-12-13 (Option 2- Rectangles)VBJ 12-10-13 (Updated footers)Pediatrics- Version 6 12-11-13 (Updated V leaf footer)Hand 12-12-13Oncology 12-10-13Oncology 12-9-13 (1st Page)Oncology 12-9-13 (2nd Page).pdf

Trauma 12-12-13General 12-11-13 (Updated header)Sports 12-10-13 (Update footer)

Documents

Vanderbilt Department of Orthopaedics...Vanderbilt Orthopaedics: Value, Quality & Safety January 2014 A Message from the Chairman, Herbert Schwartz, MD The compelling need for a good