NYU Langone Reduces Referrals to Rehab Facilities, Decreases Costs
They dreamt: “Just what would the ideal patient experience look like?” And then they got down to work. The team at NYU Langone Medical Center set out to create a long-term care plan for their hip and knee replacement patients…one that would drive down postop referrals to acute care facilities. Joseph Zuckerman, M.D., the Walter A.L. Thompson Professor of Orthopaedic Surgery and chair of the department of orthopaedic surgery at NYU Langone, told OTW, “We knew there must be a way to reduce the number of patients who were discharged to acute care facilities. In 2012 (when it was voluntary), we began participating in the Medicare Bundled Payment for Care Improvement program. NYU Langone put together the necessary resources and created not just a 2-3 day in-hospital plan but a 90 day care plan for our joint replacement patients.”
So what did they come up with as their ideal? “Patients were prepared ahead of time for surgery and rehabilitation. They were actively supported before surgery by our clinical care coordinators (CCCs). Working with our surgeons, the CCCs developed comprehensive care plans with the goal of discharge to home with appropriate home care services. In the past, due to the nature of healthcare in New York, many patients were discharged to other health care facilities. One of the problems with this is that when patients are in your facility you can control the quality, but when they go elsewhere you have no control. We began working closely with a few carefully selected home care services and instituted a program in which a physical therapist visits the patient four to six times a week and the nurse twice a week. This is a true extension of our high quality hospital care.”
The results, which appear in the November 23 edition of JAMA Internal Medicine, were great news for patients, says Dr. Zuckerman. “We were thrilled to see that we achieved a drop of 34 percentage points for those undergoing lower extremity joint replacement surgery—and with no increase in readmission rates. These patients were able to recuperate in the comfort and familiarity of their own homes with no increased risk of medical complications.”
Asked about the particular challenges of implementing their program, Dr. Zuckerman told OTW, “There are many situations where patients with significant medical issues require more care, but not necessarily acute care. Ours is no longer a country of extended families and social issues are a factor. To address this, patients are contacted ahead of time by a clinical care coordinator, they are assessed for readmission and if they score below the threshold then we do plan on discharge to a rehabilitation facility for a shot stay in order to minimize the risk of readmission.”
This kind of preparation must start from the initial meeting with the patient, says Dr. Zuckerman. “From the very first visit I tell my patients that they will be in the hospital for two days and then they will go home. They are often surprised because they assume they will have to go to a sub-acute facility. I tell them, ‘That’s just another hospital. And our goal is to get you out of the hospital and back home’ It is important that they get the message that they can go home directly from their physician.”
“My key message to administrators is that you must have physician/institutional alignment in order for a program like ours to succeed. If you attempt to implement such a program without this alignment, then it will not be successful because it will lack the through and through support it requires. One way to look at this program is that it expands the ‘care umbrella’ of the doctor. This way you can be confident that the care you deliver and expect continues once the patient is out of your direct contact. We have essentially established a 90 day care umbrella.”
Study: Obese Patients Who Drop Weight Can Protect Knee Joint
According to a new study from the University of California, San Francisco (UCSF), if obese patients can lose weight they can slow the degeneration of their knee cartilage. The team, led by Alexandra S. Gersing, M.D. of the Department of Radiology and Biomedical Imaging at UCSF, looked at degrees of weight loss and knee cartilage degeneration in 506 overweight and obese patients from the nationwide Osteoarthritis Initiative.
Dr. Gersing told OTW, “This study is part of a larger NIH-funded project focusing on the effects of weight change in individuals at risk for and with osteoarthritis. Our group has previously shown that weight gain causes substantial worsening of knee joint degeneration in patients with risk factors for osteoarthritis and now we aimed to show that weight loss can protect the knee joint from degeneration and osteoarthritis. Osteoarthritis is one of the major causes of pain and disability worldwide; and cartilage plays a central role in the development of joint degeneration. Since cartilage loss is irreversible, we wanted to assess whether lifestyle interventions, such as weight loss, could make a difference at a very early, potentially reversible stage of cartilage degradation and whether a certain amount of weight loss is more beneficial to prevent cartilage deterioration.”
“The most relevant finding of this study is that patients with more that 10% of weight loss benefited significantly more from losing weight compared to the obese controls that did not lose weight or only lost little weight. Moreover, the clinical symptoms also improved significantly more in the group with more than 10% weight loss compared to the obese groups with no or only little weight loss.”
Regarding their future research, Dr. Gersing noted, “Systemic metabolic disorders are known to have an impact on many different organs and tissues in the human body, and they also affect cartilage and bone health. Our initial work has suggested that diabetes and metabolic syndrome has a negative impact on cartilage health and now we want to investigate whether patients with diabetes are at a higher risk for early cartilage degeneration compared to healthy controls, and whether we are able to detect those abnormalities at an early stage using our molecular T2 mapping MRI technique.”
Ultra-Marathoners: Brain Shrinks, But Cartilage Rebounds Nicely
Uwe Schütz, M.D. is a radiologist and specialist in orthopedics and trauma surgery at the University Hospital of Ulm in Germany. He and his colleagues traipsed around Europe following 44 runners on a 9 week race across Europe. Dr. Schütz tells OTW, “In this study, which is a small part of the TEFR-project [Trans Europe Foot Race], we investigated the question, what happens to the joints, in detail to the joint cartilage of the lower extremities, when running 4500 km without any day rest for nearly 10 weeks. Is there really a risk for developing an arthrosis when doing this, like some researches and many physicians postulate?”
“Well, what we found when accompanying 44 ultra-athletes with a modern 1.5 Tesla MRI mounted on a custom made 38 ton truck trailer over 64 days on their way throughout Europe is that the joint cartilage is initially altered by this running burden: it shows signals of cartilage matrix degradation beneath the first 1000 to 1500 km of running. But then the situation changes. When further running occurs, then the cartilage shows the ability to partially regenerate under the ongoing running burden. This is a pretty new and astonishing finding; it is first time it has been measured and observed in the human joint in vivo. Scandinavian animal studies show the same results in dog cartilage.”
“So what we find is very interesting for every orthopedic surgeon, sports physician and athlete. There seems to be no distance limit for running in those with healthy cartilage (flat ground running). If you have a healthy joint in the legs, no obesity, leg deformities or other injuries in the lower extremities, you should begin running step by step, give yourself enough time to increase the distance…and there might be no limit regarding the risk of developing joint degeneration.”
“We hope that our colleagues pick up our results and conduct new research protocols regarding our hypothesis: that cartilage develops a kind of equilibrium between the degradation processes and regeneration processes during an ongoing running burden over more than the 4500 km. We think that there will be a plateau reached which will show such a steady state in normal flat ground running without distance limit. What we also have seen is that there is a leg difference between left and right MRI signal and therefore the cartilage behaves as a response to running forces (even in highly trained ultra-runners). We think these athletes have a leg preference (like all of us). This is a future research question for sport medicine physicians and neurophysiologists.”
“Last but not least, we opened the door for future research in the extreme poles of human performance with a new way of setting when taking high end research machines like an MRI out of the laboratory directly to the object into reality. We hope that our success encourages other research colleagues for similar ideas. There is a risk of failure when doing this, but without this risk the may be no success.”
