CORR Insights®: Developing a Pathway for High-value, Patient-centered Total Joint Arthroplasty

Where Are We Now? The manuscript by Bozic and colleagues brings to mind Shouldice Hernia Center, a hospital located in Ontario, Canada. The hernia center is known for its specialization in external abdominal hernia operations. It epitomizes the goals we must reach to create affordable healthcare for total joint replacement patients. The complexity of total joint arthroplasty, and the partnership with many more entities, does not exactly line up with herniorrhaphy, a simple procedure under local anesthesia. Still, the systems-based principles in place at the Shouldice Hernia Center result in reduced costs and fewer recurrences, and they will be applied to the procedure of total joint arthroplasty. Using approaches along those advocated there, we should be able to coordinate the need for special components, as well as the elements of a hospitalization involving multiple doctors, analgesia, therapy, and pre and postsurgical care. But this will take dedicated physicians with an interest in creating such systems to guide the business of care. This is so much more than simply setting a low price and providing cut-rate services. Sun Tzu, author of The Art of War, brought us the strategy, “Every battle is won before it's ever fought.” This likely represents how the multidisciplinary clinical care pathway will succeed in clinical adaptation. Where Do We Need To Go? Before applying these multidisciplinary pathways, we will likely face a resistance from individuals entrenched in the older method. Taking control of the process may demonstrate that these healthcare workers do not possess the skill set to implement multidisciplinary approaches. Due to the Patient Protection and Affordable Care Act, there is a timeline that needs to be met. From the first visit, scheduling a total hip or knee arthroplasty begins a path that must be followed in order to keep a patient safe, and to instill an outcome that will satisfy the patient. This study succeeds across standardization and process improvement (avoids waste), interdisciplinary communication, and collaboration, identifying a role for accountability for care delivery. The challenge of this study is finding a practical way to connect hospitals, physicians, and therapy using different medical record software. It is also more difficult because it must be done in a secure HIPAA compliant method. The bungled launch of healthcare.gov demonstrated some of the potential issues of covering a large number of patients communicating via secure website. A surgeon and his or her colleagues planning a total joint arthroplasty have the advantage of a much smaller task. In order to financially withstand the comprehensive demands demonstrated in this paper, practitioners and medical colleagues would need the necessary funds to expand their own practices with physician assistants, nurse practitioners, and medical assistants. It may not be possible for one individual who performs a large surgical volume, to afford the human resources needed to achieve the required care and communication. One may state that this comprehensive system will save waste and result in better reimbursement to the surgeon. The problem is that this funnel of care comes to a single operation and a single surgeon, and not all surgeons are equally skilled. Postoperative care must continue as the surgery changes a patient's physiology. For example, while most distal deep vein thromboses do not pose serious risk to the patient, the less experienced physician might investigate for clots below the knee, and prescribe 6 to 12 weeks of anticoagulation. Fevers that are normal and expected in this population, sometimes are worked up to the hilt with chest CT scan looking for pulmonary embolism, pneumonia, or blood and urine cultures that rarely give helpful information. How Do We Get There? A solution starts with a National Personal Health Record that allows access to all caregivers involved with the patient's care. These physicians and caregivers should not be locked out by various healthcare systems using different software. This data will help determine the more healthy preoperative patients, and determine the costs we face treating patients with less robust health. It will eliminate repetition of tests and medications. Studies investigating expenditures from redundant testing or lack of use of generic medication should provide valuable information. There is a need to look at joint implants and determine whether a low-cost implant could provide an adequate service life. Finally, surveys should be performed to guide investigators directing the studies. These surveys will help us determine how much push back against change still exists within the healthcare community, as well as gauge the passion (for or against) the new pathways of care.

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