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October 14, 2014
1:00 PM - 3:00 PM
Room Room 275-277
Comprehensive, Patient-Centered Total Care of Patients With Total Knee Arthroplasty: The Practice and Outcomes of the Perioperative Surgical Home (PSH)
Chunyuan Qiu, M.D., M.S., Vu T. Nguyen, M.D., Atef Morkos, M.D., Maria A. Morkos, Medical Student, Andrew T. Ko, Student, Jessica Y. Qiu, Student, Chandra D. Heyman, M.B.A., Jamie M. Cabrera, P.A., Narendra S. Trivedi, M.D., Diana LaPlace, M.D.
Kaiser Permanente, Baldwin Park, California, United States
Introduction: US healthcare is at a crossroads with the introduction and implementation of the Affordable Care Act. Moreover, the transition from a system of volume-based reimbursement to one that is value-based has created both uncertainty as well as new opportunities for the specialty of anesthesiology. As a result, reengineering perioperative processes is not only an imperative for the present, but also a necessity for the future of the anesthesiology. The Perioperative Surgical Home (PSH) is an aspirational concept that was proposed as one of many measures to meet this challenge, but it has yet to be fully defined and implemented. (1) At Kaiser Permanente, Baldwin Park Medical Center, we created an anesthesiologist-led team that serves the purpose of creating a PSH for the TKA patient. The aims of PSH include but are not limited to preoperative medical optimization, intraoperative anesthetic management and postoperative facilitation of functional recovery that extends not only into the hospital stay but also the post discharge period. We report here the methods in establishing this expanded anesthesia practice as well as its preliminary outcomes.

Method: Preoperative medical optimization begins with appointment with anesthesiologist 3-14 days prior to the scheduled TKA. Both the preparation for anesthesia as well as medical optimization are primarily managed by the anesthesiologist. For high-risk patients identified through our electronic medical record, a joint consultation is scheduled in which the patient is evaluated by both an anesthesiologist and an internist in a single appointment. The two specialists will then formulate a coordinated plan for the perioperative care of the patient. An example of TKA perioperative workflow is shown in Table 1. The following criteria were used to evaluate the effectiveness of the team: length of hospital stay (LHS), average pain score on discharge, completion of physical therapy on postoperative Day 0, skilled nursing facility (SNF) bypass rate and 30 day readmission rate. The data of the previous year was used for comparison. A total of 20 months data were collected, including 8 months of TKA data under the PSH protocol. The historical costs of hospital and SNF utilization were used to calculate the potential financial impact. The average cost was $1704 per inpatient day for TKA and average cost for SNF was estimated at $4111 per admission. Student’s t test was used, and p<0.05 was considered statistically significant.

Result: A total of 951 consecutive TKA patients were included in the study, of which the PSH group comprised 405 patients. The control group contained 546 patients: age 69±16.9 year old, F:M=1:1.7. The PSH group had an average age of age 66±10.1 year old, F:M=1.19. The comparison is shown in Table 2. Using current cost structure, $942,000 was saved in the form of reduced LHS ($610,000) and SNF bypass ($333,000).

Conclusion: The TKA is a costly surgical procedure with a total in hospital charge often exceeding $40,000 plus additional cost of $10, 000 or more in skilled nursing facilities (SNF) (2). We have established a PSH program for TKA to provide total perioperative care. The

anesthesiologist-led program has maintained excellent clinical outcomes with reduced LHS and increased SNF bypass rate. The practice of PSH for TKA in our facility has realized cost savings of $943,000 in 405 TKA patients over 8 month period. Moreover, this was accomplished without any additional resources or staff.

Reference: 1. Anesthesiology 2014; 119:1261-74; 2. Bone Jt. Surg. Am. 2007; 89:780-

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