Total!Knee!and!Hip!Replacement!(TKR/THR)!Surgery! !Bundled ... · CycleIII:StandardforSurgery!...

A Community Standard for Quality

Total Knee and Hip Replacement (TKR/THR) Surgery

Bundled Payment Model

Accountable Payment Model Workgroup Robert Bree Collabora9ve

September 25, 2013

Workgroup Tasks ü Develop a warranty for TKR/THR surgery

a.  Warranty approved by Bree at 7/18 mee9ng and formally submiNed to HCA Director on 9/10

b.  Financial accountability for nine complica9ons spread over 7, 30, and 90-‐day post-‐op periods

c.  Terms only apply to complica9ons treated in the hospital that performed the TKR/THR surgery

d.  Warranty does not apply to implantable devices ü Develop a bundled payment model for TKR/THR surgery (today’s topic)

2

Members of Workgroup Staffed by Rachel Quinn and Kathryn Downie

Purchasers

Kerry Schaefer: King County

Jay Tihinen: Costco

Providers

Gary McLaughlin: Overlake

Bob Mecklenburg, Lyle Sorensen: Virginia Mason

Joe Gifford: Providence

Tom Hutchinson: WSMA/WSMGMA

Quality organiza9ons

Susie Dade: Puget Sound Health

Alliance

Julie Sylvester: Qualis

Health plans

Bob Herr, Bob Manley: Regence

Dan Kent, JeaneNe Mansell, Rich

Maturi: Premera

3

Overview of Bundle

Process • Standardized & transparent evidence appraisal process to develop/support the bundle

• Market-‐relevant quality measures selected with strong input by purchasers

Contents • Appropriateness standards are embedded in the 1st and 2nd cycles • Includes complete cycle of care from pa9ent perspec9ve, including return to func9on

Providers are accountable for measuring and repor9ng quality

4

Process

Scope Uncomplicated total joint replacement

Create Preliminary four-‐cycle value stream

Populate Cycles with candidate interven9ons

Appraise Evidence to ensure value of each

5

Cycle I: Standard for Disability First Appropriateness Standard

A.  Document disability of pa9ent with KOOS/HOOS*, a validated disability scale

B.  Document osteoarthri9s with standard x-‐ray scale C.  Document conserva9ve therapy for at least 3

months with physical therapy and medica9on

D.  Document failure of conserva9ve therapy with KOOS/HOOS disability scale and x-‐ray findings

*KOOS/HOOS: Knee/Hip Osteoarthri9s Outcome Score

6

Cycle II: Standard for Fitness for Surgery Second Appropriateness Standard

A.  Document requirements related to pa9ent safety such as BMI, tobacco, alcohol, opioids, demen9a, blood sugar, nutri9on, circula9on

B.  Document pa9ent engagement through shared decision-‐making and designa9on of a Care Partner to assist pre-‐ and post-‐op

C.  Document op9mal prepara9on for surgery including nasal culture, cardiopulmonary fitness, delirium screen, aNen9on to life span

7

Cycle III: Standard for Surgery Defining Best Prac5ce Surgery

A.  General standards for a surgical team performing TKR and THR such as performing at least 50 cases per year and beginning surgery before 5 pm

B.  Elements of op9mal surgical process including: 1.  Mul9-‐modal anesthesia: adductor block 2.  Preven9on of infec9on: skin prep, an9bio9cs, laminar flow

environment, or surgical hoods 3.  Preven9on of bleeding and LBP: tranexamic acid 4.  Preven9on of thromboembolism: an9coagula9on 5.  Preven9on of elevated blood sugar: insulin

C.  Selec9on of the surgical implant: <5% failure rate at 10 years

8

Cycle IV: Standard for Care TransiNons WSHA Standard for Ensuring Rapid Return to Func5on

A.  Standard process for post-‐op care that provides accelerated recovery track with early PT, engaged care partner, and use of hospitalists/consultants

B.  Use standardized hospital discharge process aligned with WSHA toolkit

C.  Arrange home health services D.  Schedule follow up appointments

9

Quality Measures General Requirements

Providers measure and report quality

Year 1: providers install registries and standardized repor9ng methods

Year 2: providers begin to report to purchasers on a quarterly basis

10

Quality Measures 5 Domains

Quality Appropriateness

Evidence-‐based surgery

Rapid return to func9on

Pa9ent care experience

Affordability

11

Quality Measures Details

• Propor9on of TKR/THR pa9ents receiving formal SDM materials pre-‐opera9vely

• Propor9on of TKR/THR pa9ents for which there are documents pa9ent-‐reported measures of quality of life and musculoskeletal func9on prior to surgery

• Report of results from above measures

Appropriateness

12


• Propor9on of TKR/THR pa9ents receiving all of the following in peri-‐opera9ve period: • Measures to manage pain • Measures to reduce risk of venous thromboembolism & pulmonary embolism

• Measures to reduce blood loss • Measures to reduce infec9on • Measures to control blood glucose

Evidence-‐based surgery

13


• Propor9on of TKR/THR pa9ents with documented PT within 24 hours of surgery

• Propor9on of TKR/THR pa9ents for which there are documented pa9ent-‐reported measures of quality of life and musculo-‐skeletal func9on 6 months following surgery

• Results of measures from above

Rapid return to func9on

14


• Propor9on of TKR/THR pa9ents surveyed using HCAHPS

• Results of above measures

Pa9ent care experience

15


• 30-‐day all-‐cause readmission rate for TKR/THR pa9ents

• Number of TKR/THR pa9ents readmiNed for any of the 9 complica9ons included in the warranty

Affordability

16

Bundle ContracNng

•  Purchasers, health plans, and providers can nego9ate retrospec9ve or prospec9ve payment models – both approaches can work

•  Recommend aligning provider reimbursement with: 1.  Cost of measurement and repor9ng 2.  Delivery of quality

•  Reimbursement should be provided for evalua9on of pa9ents not appropriate for surgery

•  Contracts should include all four cycles because each one is important for pa9ent safety and affordability

17

Recommended Ac9on Plan

Proposal: The Bree Collabora9ve approve pos9ng the draq bundle for public comment, including both the clinical components and quality measures

Next Step: The APM subgroup will review feedback and present a final draq at the November Bree mee9ng

18

Quality is not what the supplier puts in. It is what the customer gets out. -Peter Drucker

19

Readmission Rates for TKR/THR Procedures in Washington State

Findings from 2011 CHARS Data

Accountable Payment Model Workgroup Robert Bree Collabora9ve

September 25, 2013

Overview of Methods •  CHARS dataset contains inpa9ent discharge informa9on from most of the hospitals in WA – All payers, all ages – Not risk-‐adjusted – More detail in summary handout

•  Analysis conducted by Charles Maynard PhD – Sta9s9cian from University of Washington – Complete methods available upon request (email requests to [email protected])

21

Important Note

Used a single ICD-‐9 procedure code to iden9fy TKR and THR without restric9ng by diagnosis so es9mated rates include some procedures that would not be included in the warranty (e.g. TKR/THR due to fractures)

22

Major Findings

None of the warranty complica9ons had a readmission rate higher than 1% •  Most at or close to 0

Highest readmission rate observed at a hospital that performed at least 40 procedures was 4.6% •  Periprosthe9c joint complica9on for TKR

Majority of TKR/THR readmissions are not caused by warranty complica9ons •  All-‐cause 30-‐day readmission rate for both = 4.8%

23

Proposed Next Step

•  Summary document contains blinded all-‐cause, 30-‐day readmission rates for TKR and THR pa9ents by hospital –  Includes sample sizes & 95% confidence intervals

•  Proposal: Share unblinded data about readmission rates for TKR/THR procedures with hospitals that request it for their own ins9tu9on – Will not share unblinded data for any other hospitals – Not publicly shared at this 9me

24

Total!Knee!and!Hip!Replacement!(TKR/THR)!Surgery! !Bundled ... · CycleIII:StandardforSurgery!...

Documents

Transcript of Total!Knee!and!Hip!Replacement!(TKR/THR)!Surgery! !Bundled ... · CycleIII:StandardforSurgery!...