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Bryan Springer, M.D. with Cuban patient, Paula post-knee surgery. / Courtesy of Operation Walk Carolinas

OpWalk Carolinas Heads to Cuba; U.S.TKA Cost Varies Wildly; Capsular Repair Cuts Conversion to Hip Replacement

Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, June 7th, 2017

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Operation Walk Carolinas Heads to Cuba

Operation Walk marked its 20th year of providing knee replacements and education in Cuba, this time with the Carolina team, now 60 members strong, leading the way and managing a monumental logistical task.

First-timers OpWalk Carolinas brought to Cuba four tons of cargo…suction tips, tubing, disposable retractors, gloves, cement mixing devices, drapes, gowns, caps, syringes, disposable surgical instruments and more.

Bryan Springer, M.D., orthopedic surgeon with OrthoCarolina Hip and Knee Center and medical director and co-founder of Operation Walk Carolinas described how he and his team were able to pull off such an impressive logistical feat, “Rick Hendrick of Hendrick Automotive & Hendrick Motorsports graciously donated the use of his planes to transport cargo and our team. We also had to operate without some of the supplies and technology we have at home. One of the most difficult parts of the trip was turning down people for very specialized operations for which we did not have the right equipment or implants.”

For about half of the team, this was their first mission trip. OpWalk Carolinas funds are raised mostly by the participating medical providers, who volunteer their time for the cause. Carolinas Healthcare and Novant Health provided funds, while Stryker Orthopaedics donated implants.

Dr. Springer told OTW, “Operation Walk Carolinas’ mission is to provide free hip and knee replacement surgeries to patients in developing countries who would otherwise have no access to these life-changing operations. This was our inaugural mission as a chapter of Operation Walk. We chose Cuba because there is a huge need there.”

“While Cuba does have excellent doctors and free healthcare, they simply lack the resources to provide this operation. In addition, on an average salary of 20 Cuban pesos a month, they can’t afford to travel elsewhere. We could perform 51 joint replacements over 3 days of operations. In addition, we taught doctors, nurses and residents. Our team was amazing. All the pieces of the puzzle came together perfectly. We had an all-star team. I know the trip was successful because everyone was exhausted physically and emotionally.”

“It is true that there is a need for joint replacement in the U.S.,” says Dr. Springer, “Operation Walk is a U.S. organization that provides this care to American citizens every year. However, in the U.S., there is always access to this surgery. In addition, we believe in serving people no matter the country or circumstance they were born into. People in countries like Cuba live in a non-democratic environment and don't have access to many of the basic things we have in America, leaving them hopeless. Even if they wanted to leave the country it's generally too expensive for them to afford to do so, and after a certain period they won't be allowed back. Patient in need are patients in need, no matter where they live.”

Walter Beaver, M.D., also with OrthoCarolina Hip and Knee Center, is a co-founder of Operation Walk Carolinas. Dr. Beaver told OTW, “We in the United States and other developed countries are very fortunate to have access to all areas of health care. Others in underdeveloped countries do not have that opportunity. Operation Walk Carolinas has a voluntary group that covers the best of what health care should be. The willingness of these health care experts to take time away from family and work makes the work of correcting deformed and arthritic hips and knees an easy task.”

“Cuba is a country that doesn’t perform joint replacements. The people who received a hip or knee replacement felt very fortunate to have their procedure. Otherwise they would live a life of pain and suffering. It truly takes a village to have the success we achieved while in Cuba. Without each person performing in their area of expertise this would not be possible.”

“Several members of our team have been on other Operation Walk trips with different groups to Panama and Nicaragua,” adds Dr. Springer. “Cuba is a wholly different environment that's hard to understand unless you see it in person. The medical staff there are eager to learn but don't have the training or technology. They are incredibly devoted to their patients. The patients in Cuba are tremendously gracious. Working condition can be difficult, but our team was focused. We are eagerly awaiting our next mission trip.”

Harvard Study: Enormous Nationwide Variations in TKA Cost

Derek A. Haas, M.B.A. and Robert S. Kaplan, Ph.D. are with Harvard Business School in Boston, Massachusetts.

Their work, “Variation in the cost of care for primary total knee arthroplasties,” was published in the March 2017 edition of Arthroplasty Today.

According to the authors: “Despite there being similar patient demographics, readmission rates, and complication rates across the hospitals, the cost of care varied by about 2 to 1 from the hospital at the 10th percentile of spend to the one at the 90th percentile of spend.”

Furthermore, as authors Haas and Dr. Kaplan told OTW, “Much of the variation could be reduced quite quickly by having the high-cost hospitals adopt the practices of the low-cost hospitals, such as through better patient counseling, improved purchasing of implants and other supplies, new pain management approaches, faster access to physical therapy, more attention to discharge disposition, and better monitoring of patients post-discharge. We were also excited to learn that all the organizations could complete their cost measurements within three months, showing how the methodology can be easily adopted.”

“We were most surprised by the more than 2:1 variation in costs across 29 high-volume hospitals performing a fairly standard medical procedure. No hospital was in the lowest 10% of costs across all the processes in a complete care cycle. So, every facility learned important lessons from the benchmarking and best practice sharing in the project.”

The study emerged from work Haas and Dr. Kaplan were doing with activity costing. “We had been working 1:1 with leading providers to implement time-driven activity-based costing (TDABC). We wanted to demonstrate that we could scale TDABC to a large number of high-volume health care providers simultaneously and then to compare and benchmark costs across them so they could learn how to deliver higher quality and more cost-effective care.”

“We chose to focus on TKAs [total knee arthroplasty] for three reasons: 1) Joint replacements are the single biggest episode of care expense for Medicare, 2) We already had a good base of experience and templates for analyzing TKAs, and 3) joint replacements are one of the first procedures that are shifting toward bundled payments.

“We were able to use TDABC to measure the true costs for TKAs for 29 hospitals and their affiliated orthopedic surgeons. This was one of the first studies to measure costs across a complete cycle of care, including the costs of surgeons, hospital personnel, other physicians, implants, supplies, and post-acute care. In addition to being far more accurate than traditional health care costing, TDABC allowed us to adjust for differences in wage rates across providers so we could make true apples-to-apples comparisons across the organizations on productivity. This allowed us to identify and share best practices for lowering total costs of care while maintaining and often improving the quality of patient care.”

“The prosthetic implant was the most expensive supply item. We wrote a related article using the data from this study in which we analyzed the drivers of the variation in implant purchase prices across hospitals, which had the unexpected result that patient volume and number of vendors mattered far less in determining pricing than the extent of physician-hospital alignment during the purchasing process.”

“It is both important and possible to understand your total costs for treating patients over complete cycles of care, and the opportunities for improving the quality and lowering the costs of your care regardless of your employment/practice model. Using TDABC to understand and improve your costs will be a critical success factor as reimbursement for orthopedic surgeries moves to value-based payment models, especially bundled payments. We have continued to refine and improve the value-based care analytics toolkit since the article, and we would be delighted to connect with surgeons who are interested in applying it.”

Capsular Repair Cuts Rate of Conversion to Hip Replacement Compared to Unrepaired Capsulotomy

Should the capsule be closed in hip arthroscopy, or should you leave it open? If you take either route, what happens at the five-year follow-up mark?

Benjamin Domb, M.D., an orthopedic surgeon and founder of the American Hip Institute, undertook a matched cohort study to examine just that topic.

Dr. Domb told OTW, “Hip dysplasia has traditionally been treated with periacetabular osteotomy (PAO), a major surgery involving significant blood loss and hospitalization. Approximately 10 years ago some surgeons began doing arthroscopy in these patients, however it was often unclear what was done with capsule. The outcomes were disastrous, possibly because the static stabilizers of the hip had been compromised.”

“My colleagues and I devised a technique involving labral repair and capsular plication with inferior shift, first published in 2013. We began using the technique in patients with borderline dysplasia with a lateral center edge angle (LCEA) between 20 and 25 degrees, a patient group that had experienced poor outcomes with arthroscopy in the past. The outcomes were excellent, and we published these in a pilot study on 22 patients.”

The initial success of the arthroscopic approach only raised more questions, however. “We then wanted to study what would happen in a longer follow-up period with a larger sample. And what about patients with no dysplasia? Should you routinely close the capsule in those cases? Many arthroscopists have routinely left the capsulotomy unrepaired, or shaved out part of the capsule. Biomechanical studies show the importance of the iliofemoral ligament to the mechanics of the joint. In 2013, we theorized that a repair was needed to restore the mechanics of a normal joint; subsequent biomechanical studies confirmed that to be correct. Over time we evolved to routine capsular closure after hip arthroscopy. The question to be answered then became, ‘In the non-dysplasia population, does it matter if you close the capsule?’”

Dr. Domb and his team set out to prospectively collect data on hip arthroscopy patients, eventually obtaining five-year follow-up information on 287 (82.5%) of 348 hips that met the inclusion criteria. Dr. Domb commented to OTW, “We matched patients for age, gender, body mass index, Workman’s Compensation, and acetabular coverage. All throughout the study period we collected data on patient-reported outcome scores (PROs) including modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-sport specific subscale (HOS-SSS) and Visual Analogue Score for pain (VAS).”

“Out of the 287 hips,” says Dr. Domb, “172 underwent unrepaired capsulotomy and 115 underwent capsular repair. We found that both groups significantly improved from the preoperative period through the last follow-up—this was true of all patient reported outcomes. In the unrepaired group, we found a significant decrease in mHHS and patient satisfaction between two and five-year follow-up. The most dramatic finding was that more patients in the unrepaired group required conversion to hip replacement than in the repair group (18% versus 10.8%, respectively).”

“I advise my colleagues to consider routinely repairing the capsule and to only consider leaving the capsulotomy unrepaired when there is a specific reason to do so, such as in extreme stiffness.”

“We at The American Hip Institute are now collaborating with Mayo Clinic on a randomized controlled trial looking at capsular repair versus unrepaired capsulotomy. We hope this will provide the Level I evidence we need to have definitive proof.”

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