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Nov 03, 2022 335 likes •494 views

Evolving Technique Update: Patient Selection and Optimization: Coordinating Care for Total Hip Replacement the Bundle William A. Jiranek MD, FACS Professor and Vice Chair Duke University Orthopaedic Summit 2017 Las Vegas, Nev. Dec. 6-9,

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Adult Reconstruction

Evolving Technique Update: Patient Selection and Optimization: Coordinating Care for Total Hip Replacement – the Bundle

William A. Jiranek MD, FACS Professor and Vice Chair Duke University Orthopaedic Summit 2017 Las Vegas, Nev.

Dec. 6-9, 2017

SLIDE 2

Disclosure

Personal

– Royalties

Depuy

– Consultant

Depuy

– BOD and Committee

AAHK

S, Hip Society

Institution

– Research and clinical support:

Depuy
Stryker

SLIDE 3

The AAHKS (Fehring) 11 (Voss, Halsey)

Clinical Risk Factor ICD9 Code15 Descriptor

Morbid obesity BMI >40 278.01 Morbid Obesity Smoking 305.1 Tobacco use disorder

Chronic anticoagulant use V58.61 Long‐term (current) use of anticoagulants. Chronic narcotic use 305.51 Opioid abuse, continuous Workmen’s compensation case V62.1 Adverse effects of work environment Previous intra‐articular infection 139.8 Late effect of other and unspecified infectious and parasitic diseases Congenital hip deformity 755.63 Other congenital deformity of hip Angular knee deformity >15 degrees 736.6 Other acquired deformity of knee16 Previous ORIF hip 716.15 Traumatic arthropathy, pelvic region and thigh Previous ORIF knee 716.16 Traumatic arthropathy, lower leg Depression/psychiatric disease 300.9 Unspecified nonpsychotic mental disorder

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What has helped Duke?

A preop committee that has power, and expertise,

to delay surgery to optimize patients

– Anesthesia (combined with preanesthesia testing) – APP staff trained in optimization

Developing systems to modify risks factors that are

identified

Identifying a discharge plan preoperatively

– This includes convincing the patient

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CJR – Risk Stratification Guidelines for Elective Primary Total Knee, Hip, Ankle Replacements- Duke Health System Consensus or Evidence Based- 2016

1. BMI 40 or greater
2. Active smoker- must begin cessation program
3. HgA1C > 7.5% (>8%?)
4. Albumin of 3 or less (?3.4 or less)
5. Anemia - Hgb less than 11
6. Thrombocytopenia- platelets less than 50k
7. ESRD on dialysis
8. Coronary stenting with or without AMI within the past 6 months (?12 months)
9. Stroke or TIA within previous 6 months
10. Any active infections; any open wounds on the lower extremity posted for

surgery

11. Other significant issues- e.g. uncontrolled hypo-hyper thyroidism/

hyperparathyroidism, ASA 4, COPD on oxygen, etc.

12. Chronic high dose narcotic use (addiction)

Patients that do not meet these criteria may occasionally receive surgery if reviewed and approved by a faculty panel at Preoperative Conference.

Current Practice at Duke

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Scheduling note

Procedure plan
TXA plan
Antibiotic Plan
Anticoag Plan
Therapy Plan
Discharge Plan
Risk Factor assessment

– BMI >40 – Tobacco Presence – H/H (anemia) >12 – Hgb A1C <8.5 – Albumin > 3.5 – Opioid Use < 30 MSO4 equivalalents

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Duke Bundle Busters

Recognize

– Obesity – Nutrition – Nicotine – A1C – Narcotics – Psychosocial

Catastrophising
No support structure

– Cardiac

Optimize

– Patient buy-in – A system to deal with each of these risk factors – A committee that will review the patient – The will to delay surgery

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Sicker patients cost more – but which are the worst?

There are limits to optimization
Some comorbidities will lead to

increased cost, you need to know that

Have a system to identify

comorbid conditions accurately

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How should we track risk factors ? N= 693 Duke 2012-14

CMS data from surgery + 90 days inc. payments made to outside institutions

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Duke University Medical Center

Focus on the results that pertain to your purpose and

hypothesis. Let us know the

statistical significance of your most important findings. Give us the "meat" of your findings.

Results

Reddit.com

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Results

Medicare payments increased with increasing number of

comorbidities (p<0.05)

Bundled payment remains static

20,000 22,000 24,000 26,000 28,000 30,000 32,000 1 2 3 4 5 6 7 8 9 10 TOTAL MEDICARE COST NUMBER OF COMORBIDITIES

MEDICARE PAYMENT INCREASE WITH COMORBIDITY

Cost Bundle Target Payment

Expon. (Cost)

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Complications : Decrease SSI and Dislocation – the most bang for the buck!

Mean overall total CMS payment

was $23,046.40 (n=693)

1. surgical site infection was $27,765 (n=15). 2. Dislocation was associated with an increase of $25,983 (n=3) 3. Deep vein thrombosis $15,141 (n=7) 4. fracture $10,504 (n=5) 5. pulmonary embolism $3,978 (n=14)

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Conclusion

Hospital needs to set up pre anesthesia/ optimization clinic

– Staffed by people who specialize on perioperative home

Program must optimize preop and minimize complications postop

– Clear guidelines and programs for high risk comorbidities – An active communication system that monitors their progress.

Optimizing patients draws them into their care
Document clearly the patients at increased risk
Track your most common and expensive complications

– Develop a plan to decrease them (for Duke it was SSI and dislocation)

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Moving forward. Climbing higher. Moving forward. Climbing higher.