Vanderbilt Orthopaedics: Value, Quality & Safety January 2014
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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 Orthopaedics: Value, Quality & Safety 2014
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.
Vanderbilt Orthopaedics: Value, Quality & Safety 2014
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.
Vanderbilt Orthopaedics: Value, Quality & Safety 2014
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
Vanderbilt Orthopaedics: Value, Quality & Safety 2014
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
Vanderbilt Orthopaedics: Value, Quality & Safety 2014
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
Vanderbilt Orthopaedics: Value, Quality & Safety 2014
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.
Vanderbilt Orthopaedics: Value, Quality & Safety 2014
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
Vanderbilt Orthopaedics: Value, Quality & Safety 2014
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)
Vanderbilt Orthopaedics: Value, Quality & Safety 2014
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)