Faster, Safer Joint Replacements

Elyas Bakhtiari, for HealthLeaders Magazine , June 11, 2009
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With demand for joint replacements set to skyrocket and a limited number of surgeons in the pipeline, hospitals are fine-tuning the surgical process from start to finish in order to replace joints faster and safer than ever before.

A severely arthritic knee or hip can be immobilizing and extremely painful, and in normal times, replacing the problematic joint can seem like a medical necessity. But as the economic recession has deepened, some patients have been rethinking elective surgeries, putting off expensive joint replacements until their finances are on surer footing.

In most cases, the surgeries are just postponed, not cancelled altogether. And the statistical and anecdotal evidence suggests the overall downtick in joint replacement surgeries has been very slight so far. In fact, the long-term demand for joint replacements is so strong that even a global economic slowdown will likely only cause a hiccup in its rapid growth phase.

The market has grown in more ways than one. The sheer volume of aging baby boomers has boosted demand as more hips and knees wear out. On top of that, obesity related joint problems are becoming more common in an increasingly overweight nation. Yet demographics alone can't account for growth in the field. The market has expanded through process improvement, as well. Joint replacement surgeries have a near 95% success rate, and with very little risk, the decision has become easier for patients of all ages.

"In the past, you wouldn't do a hip replacement on anyone under the age of 65 or 70. People who were 50 who had problems were told to stick with it until they were old enough to do this. That doesn't cut it anymore because people don't want to be in chronic pain, so they are more willing to have procedures at a younger age," says Mark Figgie, MD, chief of surgical arthritis services at Hospital for Special Surgery, a 162-licensed bed orthopedic hospital in New York. "Part of that is driven by the fact that the surgeries are more predictable and more durable, so that's allowed us to expand the use of joint replacement into a younger population."

Volume of joint replacements at Hospital for Special Surgery grew 11% between 2007 and 2008, and that type of double-digit growth has been common, year-over-year, for hospitals across the country. The growth in many regions isn't slowing down, and experts predict it will speed up in coming years. More than half of patients needing hip and knee replacements are projected to be under 65 by 2016.

That's good news for hospitals and physicians looking for a predictable income stream. But growth without limits isn't always a blessing. Keeping up with the demand can be a challenge and invoke a whole host of tough decisions. Hospitals may eventually need to expand facilities to make room for additional volume and, once built, maintain a minimum throughput to justify the investment and maintain margins in the face of rising costs and relatively stagnant reimbursements.

From the patient's perspective, joint replacement isn't like other types of care. Patients aren't seeking life-saving treatment or teaming with a physician for lifelong care coordination; they are in many ways buying a product—a new hip, knee, or shoulder. To truly differentiate their programs, providers have to deliver that end product quicker, safer, and more often than their competitors.

Service Line Success Key No. 1: Reduce variability
Most healthcare providers cringe at the thought of practicing assembly-line medicine. But if the analogy fits any sector of healthcare, it is joint replacement surgery. Despite the negative connotations of assembly lines in relation to healthcare, when it comes to manufacturing, assembly lines have many benefits—they can speed up a process, improve overall efficiency, and perhaps most important, reduce variability. The production process is broken down step by step, so that each widget is treated almost identically to its predecessors and successors.

Patients aren't identical, and neither are physicians, but reducing variability is an important goal for joint replacement centers looking to both improve quality and increase the volume of replacements that can be done in a given day.

"We try to manage variability down as much as possible so the experience the patients have and the experience the surgeons have is the same for each occurrence, all occurrences," says Robert Friedberg, vice president of operations at Central DuPage Hospital, a 313-staffed-bed hospital in Illinois. The idea is that repetition leads toward perfection, and the result is a smoother process from start to finish. And for providers, there are fewer surprises when paired with a different clinical team if everyone plays by the same rules.

Patients aren't literally put on assembly lines, of course, but they can be assigned clinical pathways, predetermined care routines that can be put in place for about 80% of the population. It is essentially a planning process. Multidisciplinary teams regularly review the routine care steps for an average patient—everything from preop education to the surgery itself and the postop recovery process—and develop best practices that are adhered to every time.

"We look at every element from the moment that a patient is diagnosed and put into an operating room schedule to the time they leave the last outpatient therapy visit two or three months post-op. We look at every element and make sure the processes we have in place are best options for patients and meet the needs of surgeons," says Friedberg.

If the remaining 20% of the population with unique care needs is identified well before surgery, physicians can efficiently concentrate on targeted care for these outliers while maximizing the care process for the average patient. The distinction between the two groups often comes down to age, not just chronological, but physiological age as affected by obesity and other medical history factors. Identifying these people early can save money and time later in the process, says Douglas Padgett, MD, chief of adult reconstruction and joint replacement services at Hospital for Special Surgery.

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