Published 7/1/2018
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Karen Metropulos, MBA
AJRR subscriber captures the intersection of data, evidence-based medicine, and integrated clinical pathways
The American Joint Replacement Registry (AJRR) is the largest hip and knee arthroplasty registry in the United States, exceeding the 1 million procedures milestone in 2017, and is a part of the Academy’s growing family of orthopaedic registries. TriHealth Good Samaritan Hospital (GSH), located in Cincinnati, has been an AJRR subscriber since January 2015. Other healthcare institutions can learn from GSH’s registry-supported integrated clinical pathway (ICP) and adverse event (AE) reduction programs focused on blood transfusion, venous thromboembolism (VTE), ineffective pain management, and more.
Mark A. Snyder, MD
Prior to participating in the AJRR, GSH had created one of the earliest, most comprehensive, and utilized Level III proprietary registries in the country. The registry is still used in combination with the organization’s AJRR-enabled capabilities to collect Level I, Level II, and Level III data. Figure 1 (see the online version of the article) provides a comprehensive list of all AJRR data elements.
A six-month transition period enabled GSH to move from its legacy registry to AJRR. The transition required an initial investment, support from surgeon leadership, and an additional full-time employee to manage registry operations.
AJRR’s patient-reported outcomes (PRO) functionality (Level III) includes data required for the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement initiative. As a CMS-designated Qualified Clinical Data Registry, AJRR collects 38 measures that are highly relevant to the majority of orthopaedic surgeons, their practices, and their CMS reporting needs.
GSH launches AE-reducing
Zero In On Zero program
Mark A. Snyder, MD, former medical director of the Orthopaedic Center of Excellence and physician executive director of the TriHealth Orthopaedic and Spine Institute, said, “GSH has deployed a novel, AE-reducing Zero In On Zero (ZIOZ) program for total knee and hip arthroplasty patients, which is coupled with Level III registry and facilitates problem solving with evidence-based information.”
All 10 ZIOZ AE initiatives mentioned in this article led to decreased complications, including the following three examples:
- GSH created and integrated an anemia clinic to measure and address complete blood count. The clinic provides treatment of anemia and reduced blood transfusions and related complications to zero over a 12-month period (Figs. 2 [online] and 3).
- GSH purchased mobile compression devices for all total joint replacement (TJR) cases within the system to prevent deep vein thrombosis and VTE, eliminating VTE re-admissions and deaths (Fig. 4).
- GSH purchased liposomal bupivacaine for multimodal problem-solving method (MMPM) care to support an opioid-sparing program, thereby reducing complications from opioid use and preventing poor pain management (Fig. 5, online).
Level III registry data formed the background proof of concept for all three efforts.
Photo credit: American Joint Replacement Registry
Photo credit: Courtesy of TriHealth GSH and Mark A. Snyder, MD
Courtesy of TriHealth Good Samaritan Hospital and Mark A. Snyder, MD
Courtesy of TriHealth Good Samaritan Hospital and Mark A. Snyder, MD
Fig. 1 The American Joint Replacement Registry data elements are highly relevant to orthopaedic surgeons, their practices, and the Centers for Medicare & Medicaid Services’ reporting requirements.
Fig. 2 Within the ZIOZ program for transfusion reduction, the best practice model is structured around three phases of care: before, during, and after the procedure. The best practices in each phase are rated for their effect on transfusion reduction: (S) strong influence, (M) moderate influence, and (I) inconclusive influence.
Fig. 3 After experiencing a record high transfusion rate (9.5 percent of hip and knee procedures) in 2016, TriHealth Good Samaritan Hospital reduced and maintained a 0 percent transfusion rate in 2017.
Fig. 4 The Zero In On Zero program for venous thromboembolism (VTE) re-admission/death elimination achieved zero level adverse event outcomes. The best practice model is structured around three phases of care: before, during, and after the procedure. The best practices in each phase are rated for their effect on VTE re-admission/death elimination: (S) strong influence, (M) moderate influence, and (I) inconclusive influence.
Fig. 5 The ZIOZ program for preventing poor pain management” achieved near-zero level adverse event outcomes. The best practices in each of its three phases are rated for their effect on positive pain management outcomes: (S) strong influence, (M) moderate influence, and (I) inconclusive influence.
Photo credit: Courtesy of TriHealth GSH and Mark A. Snyder, MD
Defining ZIOZ practice concepts
The ZIOZ program combines registry data and supporting practice concepts that empower the analysis of preventable problems and yield meaningful results related to TJR. Components include the following:
evidence-based medicine (EBM): an approach to medical practice intended to optimize decision making by emphasizing the use of evidence from well-designed, related research
ICP: multidisciplinary care plans that detail essential steps in the care of patients with a specific clinical problem
MMPMs: relating to, having, or utilizing more than one problem-solving approach
Sharing meaningful results
GSH has enjoyed broad Level III registry adoption, which is combined with extensive multimodal problem-solving ICPs. Together, the Orthopaedic Center of Excellence’s TJR efforts have reduced complications, eliminated 30- and 90-day readmissions by 90 percent, and lowered total episode 120-day costs by nearly 25 percent. Full utilization of the Institutional Review Board-approved Level III registry validated extensive multimodal problem-solving methods for 10 AEs and the rate of 90-day all-cause readmissions in more than 2,000 primary total hip and knee arthroplasty patients over six years (less than 1.5 percent). The observed AEs, including the three already detailed, are transfusions, infected total hip and knee arthroplasties, prolonged lengths of stay, postoperative urinary retention/postoperative nausea and vomiting, delayed physical therapy, poor discharge handoffs, dissatisfaction, dislocations, patient falls, 30-day readmissions, VTE-related readmissions, and ineffective pain management.
Not only does the intersection of Level III registry, EBM, and ICP compliance enable clinical analysis, it also drives collegial consultation between compliant and noncompliant multidisciplinary physicians and surgeons.
“When greater numbers of the medical staff closely adhere to the safety and quality recommendations that come out of this multimodal ICP program, they are more likely to provide optimized PROs and the safest, most cost-effective care,” Dr. Snyder said.
Conclusion
Dr. Snyder stated, “The ZIOZ program is delivering measurable and targeted results at GSH every day. Registry participation tells patients, payers, providers, and points of service that we are serious about eradicating preventable complications, readmissions, and excessive costs. Our Joint Commission Advanced Orthopaedic Certification is, in part, dependent on registry participation. Without AJRR, we would not have the proof we need for the ICP initiatives, nor the health system push to support initiatives like mobile compression devices purchased for every TJR case. We view [this] program and registry participation as cornerstones of our current and future quality care delivery efforts.”
Karen Metropulos, MBA, is a content writer and blog editor at the AJRR, part of AAOS’ Registry Program.
Editor’s note: This article is the second of a three-part series illustrating practical aspects of AJRR participation through shared success stories from subscribing institutions. The next installment will feature MountainView Regional Medical Center and appear in the August issue of AAOS Now.