Managing Care Variation: Optimizing Total Joint Replacement Bundle

With the Center for Medicare & Medicaid Services’ May 19 final rule delaying the expansion of its Comprehensive Care for Joint Replacement (CJR) bundled payment model, many providers now have more time to prepare for taking on orthopedic bundles. For many, this is welcome news because bundled payment brings greater complexity to the imperative to improve and align cost and quality performance. It necessitates not only refining and furthering current tactics aimed at improving inpatient care efficiency, but also expanding care standardization efforts across the continuum.

One approach to identifying priorities for improvement is to break down the bundle both horizontally (“Do we understand and address every step of the patient journey from pre-admission to post-acute care?”) and vertically (“For the performance measures that show the greatest variation, how can we design and implement consistent, better clinical processes to improve outcomes?”).

Manage the Full Patient Journey

Although many hospitals already have developed standard clinical pathways for joint replacement, many organizations also are expanding their view horizontally across the continuum to address the full spectrum of opportunities to streamline care and discharge total joint replacement patients more quickly. This effort includes moving beyond routine diagnostic testing and basic questioning to conducting an assessment of patients’ home environments and support systems to minimize the potential for accidents and readmissions.

These organizations also are going much deeper to ensure that patients—especially those with physical or environmental risk factors (e.g., obesity, poor mobility, multiple chronic conditions)—are maintaining better physical conditioning through exercise and physical therapy designed to improve strength and mobility, thereby promoting faster and more successful recovery.

It’s not just about soliciting better information from patients; the information sharing is a two-way street. Some organizations employ patient navigators who hold presurgical education sessions in which they introduce the care team, teach patients about the procedure and recovery process, and help patients set appropriate expectations. These patient navigators often continue to engage patients across the full episode, ensuring adherence to protocols and processes during the inpatient stay, and even acting as a resource after discharge to address patient questions and concerns and prevent unnecessary emergency department visits and readmissions.

Dive Deep on Variation

In addition to taking a broader, “horizontal” view of patient care across the full episode, it’s important to look closely at the “vertical” opportunities and specific drivers of variation. By understanding the differences in how individual physicians and other staff provide care to similar patients, especially during the inpatient stay, health systems gain insight into which areas their efforts to redesign and standardize clinical processes around best practice care standards can have the greatest impact.

It is essential then also to drill down on the variation in quality and outcomes measures across orthopedic surgeons and their support teams and understand how these variances affect cost. Although negotiating better prices with vendors on implants is important for reining in costs in the inpatient setting (especially in the short term) organizations are taking a much deeper look at the total direct variable costs and new quality metrics, including the percentage of patients who are transferred to home or home health and the rate of deep vein thrombosis, among others.

Organizations that succeed at reducing these variances identify data sharing and transparency as key to building physician awareness and effecting change. At one institution, leadership began sharing data on intraoperative costs per case, including line-item detail of supply costs, with their orthopedic surgeons. There was a variance exceeding $3,000 per case across the patient population. When presented with the data, surgeons discussed among themselves how their practices differed from those of their peers, and they saw opportunities to learn from one another and adopt best practices. As a first step, they agreed to make changes in their supply utilization, which decreased the variance by more than $400 per case by reducing the quantity of bone cement, the amount of sealant, usage of antibiotic bone cement, and even supplies that were opened and unused during a case. This success set the stage for further discussions on how to standardize processes for better cost and quality outcomes.

Taken together, the horizontal and vertical approaches uncover new and meaningful opportunities to reduce care variation and cost and quality outcomes for patients, and help organizations move forward toward succeeding under bundled payment. 

Sean Angert, MBA, is national partner and senior vice president at Advisory Board, Washington, D.C.