Two members of the collaborative—Dartmouth-Hitchcock and the Mayo Clinic, a Rochester, Minn.–based $8.5 billion international organization that treats 1 million patients a year—had set aside a morning when patients who wanted new knees could attend a presurgical class to learn a timetable for reasonable recovery expectations, and perhaps learn to use crutches, which some would need after discharge. That practice reduced length of stay, lowered costs, and improved patient experience scores, Weinstein says.
Much of the data is preliminary but shows solid trends toward improvement by multiple measures, he says.
For example, since October 2010, when Dartmouth-Hitchcock started working with the HVHC, through March 2012, it has decreased inpatient stay for total knee replacement from 3.5 days to 2.5 days. A contributing factor is the introduction in September 2011 of mobility assistants on the inpatient side, who would help patients move around, show them how to do basic exercises at home to keep the joint mobile, and answer questions
David Jevsevar, MD, medical director of the Intermountain Southwest Region orthopedic clinical program, says that when his team introduced that preoperative class "we reduced our length of stay by almost a full day."
Steven A. VanNorman, MD, chief medical officer for the Southwest Region of Intermountain, adds, "When you tell patients ahead of time that they'll be up walking on day one, they work toward that. And again, this doesn't cost more and most of it costs less, and we improve outcomes and patient experience at the same time."
Hospital officials say that for Intermountain, the education program highlighted the risks and benefits of skilled nursing facilities. "We saw a decrease of 30% in our SNF admissions," Jevsevar says. "We believe this is a critical factor in our infection reduction rate, which decreased over 50%."
An important element, Weinstein emphasizes, is that patients make an informed choice about whether to undergo the operation. And that means they hear honest assessments from an interdisciplinary team about negative side effects, the chance that it might not work, and the potential need for a redo, even before they are referred to the surgeon.
"That's a huge change, and we know it's threatening to the medical professions," says Weinstein, himself an orthopedic surgeon. "We know that the surgeon wants to operate. But the patient may not understand the risk of a blood clot, or an infection, or that there might be a problem with the device, which if they did understand, they might not want to go through with surgery."
Weinstein—who until November was director of the the Dartmouth Institute for Health Policy and Clinical Practice, a member of the HVHC—says the prevailing system now used in the country must change if providers are serious about improvement. "Now, patients are not informed and they're not given what they need."
The HVHC's leaders wrote up their findings of their first knee replacement sharing experience in a June issue of Health Affairs, saying that the many lessons learned are getting packaged in protocols and repeated, so all health systems can improve, too.