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High Value Healthcare Collaborative moves toward rapid adoption of orthopedic best practices
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Diffusion is the process by which an innovation – an idea, practice or object that is perceived to be new by the adopter – is communicated through certain channels over a given period among the members of a social system. The adoption of new ideas or practices usually occurs in an S-shaped curve. This curve reveals slow initial adoption, followed by marked increase in diffusion when the tipping point is met and followed by a leveling off of acceptance. The rate of adoption varies by innovation, so the slope of the S-shaped curve is variable.
In health care, literature suggests the rate of evidence-based medicine or best practices takes approximately 9 years to be fully implemented. Despite the proliferation of literature-based systematic reviews and evidence-based practice guidelines, the slope of the innovation acceptance curve still appears to remain relatively static. Until recently, training programs have worked under the “mentor-apprentice” model which encourages younger surgeons to adopt and rely on the experiences of their training mentors. Confirmation bias is common in professions such as the practice of medicine. Surgeons become more confident in their judgment as they acquire greater experience, requiring less positive evidence to support their views than they need negative evidence to drop them. Traditional medical conference formats have been called into question with regard to their value in furthering medical education and best care adoption.
From volume to value
The Patient Protection and Affordable Care Act of 2010, regardless of its implementation, has had a permanent effect on the practice of orthopedics in the United States. As presented at an American Academy of Orthopaedic Surgeons (AAOS) “From Volume to Value” CME event earlier this year in Washington, D.C., there is emphasis on the reduction of fixed costs of health care by reducing the amount of care provided. Incentives are being developed for the practice of quality health care and the improvement of the value of health care delivery. While much emphasis has been placed on the cost aspect of the value equation, practicing orthopedic surgeons have stressed the importance of maintaining quality.
The High Value Healthcare Collaborative (HVHC) is a consortium of health care systems founded in 2010 to address the crossroads of increasing quality and value and accelerating adoption of clinical best practices. The founding members of the HVHC are the Cleveland Clinic, Denver Health, Dartmouth-Hitchcock Medical Center, the Dartmouth Institute for Health Policy and Clinical Practice, Intermountain Healthcare and Mayo Clinic. This year, the HVHC added additional hospitals or health systems to the collaborative with plans to regularly continue its expansion. The aims of the HVHC are to identify best practices among leading health care providers and promote rapid diffusion to other health care institutions so all patients and providers can benefit.
Anthony M. DiGioia III, Editor
The HVHC identified nine conditions based on national prevalence and societal cost. Knee and hip replacement were among the nine conditions selected. The collaborative draws on the sharing and analysis of clinically enhanced administrative data to examine variation in health services delivery among the member systems; compare institutional processes of care delivery and identify opportunities to improve health care value; measure the effectiveness of alternative practices; and develop replicable and exportable innovations to spread best practices and thereby increase health care value.
The collaborative chose total knee replacement as its first condition to examine for several reasons. First, knee osteoarthritis is a common condition whose treatment is expensive. Second, total knee replacement is one of the most successful and studied surgical procedures and is highly effective at the restoration of function and the reduction of pain when nonsurgical options fail. Third, there are few population-level data on total knee replacement procedures and outcomes in the United States The collection and use of such data to derive best practices should improve joint replacement outcomes. Finally, data from the Dartmouth Atlas Project show a wide variation in knee arthroplasty rates among Medicare enrollees based on geographic location as well as gender and race. It is unknown whether total knee replacement is overused in some populations or underused in others.
Administrative data
The first step in this process was to collect data from all sites. The HVHC describes clinically enhanced administrative data as administrative data (largely from hospital coding and billing systems) with the addition of available clinical data collected routinely in the care of patients who have knee replacements. The administrative component included such data as the day of the week on which the procedure was performed, length of hospitalization and type of admission; patient demographics; source of admission; payer; diagnosis codes; procedure codes; charges; discharge disposition; and the operating surgeon.
Comorbidity data were also obtained for each admission. Complication data only could be reliably obtained for the admission because of varying rates of follow-up data reporting. Data included height; weight; patient’s American Society of Anesthesiologists score; and operating time, defined as the number of minutes between opening incision and closing suture for the total knee replacement. Limitations included the retrospective nature of this analysis and the lack of functional and clinical outcomes data for all patients. This limitation exists because of the different organizational missions of each system, but currently mimics the data available for sharing across a large swath of the United States.
David S. Jevsevar
Orthopedic surgeon representatives met at regular intervals to validate the data and examine the variability across systems. The degree of variability found was larger than anticipated, even across well respected health care organizations. There were differences in operating room time, length of stay, complication rates, and discharge disposition. The recommendations from our initial publication were in three areas: coordinated interdisciplinary care of patients; dedicated operating room personnel; and management of patient expectations. Each organization developed a plan to address areas of weakness and implemented these plans in a relatively short period of time.
Quality of care
For example, Mayo Clinic worked to have a dedicated operating room team for knee replacement. Intermountain Healthcare is piloting a preoperative interdisciplinary clinic based on the Mayo model to better assess patient preoperative health and risk status. These programs were implemented in a matter of months after the data review was complete. The HVHC process significantly shortened the diffusion curve for the best practices identified. Like the spokes of a wheel, the new members of the HVHC will be able to adopt these practices, significantly increasing the expedited spread of these innovative practices. Further longitudinal follow-up data after the institution of best practices will be examined to ensure that adoption by heterogeneous systems yield similar best practice results.
The High Value Healthcare Collaborative (HVHC) attempts to increase the rate of best practice adoption.
Image: Jevsevar DS
As the health care milieu continues to change rapidly in the United States, greater emphasis is placed on enhancing value in orthopedic surgery. Evidence-based guidelines, appropriate use criteria and best practices will continue to grow and spotlight the quality of orthopedic care we deliver. Rapid dissemination and adoption, different than traditional means, need to be developed to support the orthopedic value proposition. The HVHC model attempts to shift the slope of the S-shaped innovation diffusion curve to an expedited approach from traditional methods (see Figure). Other innovative approaches to improve or enhance the dissemination and clinical practice of best care will certainly follow.
Disclosure: Jevsevar is chair of the Evidence-Based Practice Committee for the American Academy of Orthopaedic Surgeons, stockholder for Omni Life Science, and is a consultant/presenter for Medacta USA, Omni Life Science and Maxx Orthopedics.