Walking Lessons Compliments of AAOS
Learning to walk usually takes place early on. Who knew that one day the average person would need to relearn this skill?
With the rise in cell phone use amongst pedestrians—and the consequent rise in accidents—the American Academy of Orthopaedic Surgeons (AAOS) has taken the lead in addressing this issue. Alan Hilibrand, M.D. is the Joseph and Marie Field Professor of Spinal Surgery and professor of neurological surgery at the Rothman Institute in Philadelphia. He is also the Vice Chair of Academic Affairs and Faculty Development for the Department of Orthopaedic Surgery at the Rothman Institute and Jefferson Medical College.
Dr. Hilibrand, who Chairs the AAOS Communications Cabinet and leads its efforts to reign in this problem, tells OTW, “According to the Consumer Product Safety Commission, in 2013 more than 1, 200 people were treated for distracted walking-related injuries received while using electronic devices. This is happening across all age groups and it’s not something you’re going to make laws against because it is not enforceable. The only solution is to raise public awareness.”
“We want people to know, for example, that a 2004 study of hospital emergency departments found that 559 pedestrians were injured; in 2010 that number was up to more than 1, 500 pedestrians. As you might expect, people ages 16 to 25 were most likely to be injured as distracted pedestrians, and most were hurt while talking rather than texting. Talking on the phone accounted for 69% of injuries between 2004 and 2010; texting accounted for 9% of the injuries.”
“In Philadelphia, the city buses are now equipped with automated warning systems saying, ‘Pedestrians, be aware that this bus is making a turn.’ We are hoping that over the next year more American cities recognize this problem, and install similar mechanisms to warn pedestrians of the risks of ‘digital dead walking.’ As for the AAOS effort, we are doing public service ads on radio and television, as well as in print. The AAOS would like to encourage the public to remain engaged with their surroundings when in crowded public spaces. We want to keep everyone in our nation in motion with healthy bones!”
Compression Devices Trump Warfarin in Patient Satisfaction
When portable compression devices square off against warfarin, who wins?
That’s what a team of researchers from the University of Washington School of Medicine in St. Louis wanted to know. Leading the team was Ryan M. Nunley, M.D., associate professor of orthopedic surgery at that institution. He tells OTW, “One of the most serious challenges for surgeons performing total joint surgery are blood clots. To prevent these events, you can either use a chemical prophylaxis like Coumadin, aspirin or one of the newer blood thinners—or you can use one of the recently approved mobile compression devices (MCDs). Using ActiveCare (manufactured by Medical Compression Systems, Inc.), we set out to examine the differences in complication rates and patient satisfaction of those on warfarin and those on a MCD.”
“Those labeled as ‘standard risk’ wore MCDs for 10 days and took aspirin for 6 weeks post-operatively (1, 888 patients). Those at high risk of a thromboembolic event received adjusted-dose warfarin for 4 weeks and wore compression stockings for 6 weeks post-operatively (834 patients).”
This research, selected as the best poster in the adult reconstruction category by the American Academy of Orthopaedic Surgeons, may make payers stand up and take notice. “Our results indicated that in combination with aspirin, the MCDs provided results that were equivalent to the results seen with warfarin as far as reducing deep vein thrombosis and pulmonary embolism.”
“Also, the MCD patients had a significant reduction in days of drainage, bleeding events, reoperation, and readmission…and the overall level of patient satisfaction was higher. Now that patient satisfaction is such an important CMS [Centers for Medicare and Medicaid Services} metric, this is critical. The fact that these devices are portable makes people very happy; they can just put it on and walk around the house and charge the battery before they leave the house.”
“The biggest downside is that Medicare has a written policy saying that they don’t pay for preventive measures when it comes to DVT [deep vein thrombosis] and PE [pulmonary embolism]. Thus, because this is not a pharmacologic agent Medicare patients may have pay something out of pocket. Now that many physicians and hospitals are entering into bundled payment programs the issue of Medicare covering these devices could be less of an issue because they would be covered by the bundled payment. There is certainly a significant interest in DVT/PE prophylactic measures that are simple to institute, have improved patient satisfaction, and reduce complications like readmissions and reoperations that would also have significant financial implications for people participating in the bundled payment program.”
Note: The University of Washington School of Medicine in St. Louis received research funding from Medical Compression Systems, Inc. to perform this study.
Thursday, Friday Surgery Increases LOS, Cost in TJA
In the effort to drive down costs, researchers often examine length of stay (LOS) as a variable that might be open to adjustment. Carlos Higuera-Rueda, M.D., Trevor Murray, M.D. and Robert Molloy, M.D., orthopedic surgeons at the Cleveland Clinic in Ohio, decided to look at the specific day of the week as it affects cost and length of stay of patients undergoing hip and knee arthroplasty (TJA = total joint arthroplasty).
Dr. Higuera-Rueda tells OTW, “Bundled payments are here to stay and will set the tone for hip and knee arthroplasty. One of the variables included on these bundles is LOS; in our practice we found that LOS is the most important driver for cost.”
“We reviewed data from 11 Cleveland Clinic system hospital sites for all primary total knee and total hip admissions performed between January 1, 2010 and December 31, 2012 (a total of 14, 800 surgeries). What we found was truly eye opening.”
“Those surgeries done late in the week (Thursday and Friday versus Monday and Tuesday) lead to increased LOS and increased charges. Specifically, the mean LOS for late versus early week arthroplasty admissions was 4.01 vs. 3.61 days for knees and 3.7 vs. 3.4 for hips. The total charges for late versus early week arthroplasty admissions were $44, 319 vs. $43, 522). In addition, after a univariate statistical analysis we found that older patients, as well as those with severe illnesses, were more likely to have a longer LOS.”
“While there is a Medicare study that recently reported similar results, we believe that our study provides more accuracy because with very large datasets there are often inaccuracies (up to 30%). Our data is more refined because it is from a single health care system; we think it is especially detailed and reliable.”
“Given these findings, we are beginning to explore something new in our practice. We are hoping that patients within the bundled payment system (primary cases) are now going to have surgery on a Monday or Tuesday. While this will require a change in infrastructure, it will ultimately save money and will most likely increase patient satisfaction.”
“The primary message to my colleagues is that they need to be aware that unless you have a system in place to deal with this discrepancy between early and late week surgery, even if you have the best preoperative planning and infrastructure support from case management standpoint, insurance companies don’t work over the weekend and paper work and authorizations are not made delaying patients discharge. Sometimes that results in an extra day LOS. If we keep a patient for three days instead of two we are not necessarily providing better care, we may just be wasting resources. Our advice is to change the scheduling and do all of these cases at the beginning of the week and more revisions and other cases at the end of the week—those do not involve bundled payments.”
