
==== Front
Perm J
tpj
tpj
The Permanente Journal
1552-5767
1552-5775
The Permanente Press

38980759
10.7812/TPP/23.150
TPJ-23-150
Commentary
editors-choiceEditor’s choiceIncreasing Value for Patients With Total Joint Replacement: A Model for Hospital-Based Same-Day Discharge in an Integrated Care Setting
http://orcid.org/0000-0002-1079-6570
Hinman Adrian D MD 1
http://orcid.org/0000-0002-2200-6564
Prentice Heather A PhD 2
http://orcid.org/0000-0003-1941-8186
Paxton Elizabeth W PhD 2
http://orcid.org/0000-0003-1869-6440
Navarro Ronald A MD 3
http://orcid.org/0000-0001-6966-5068
Reddy Nithin C MD 4
1 Department of Orthopedics, The Permanente Medical Group, San Leandro, CA, USA
2 Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, CA, USA
3 Department of Orthopedics, Southern California Permanente Medical Group, Harbor City, CA, USA
4 Department of Orthopedics, Southern California Permanente Medical Group, San Diego, CA, USA
Adrian D Hinman, MD adrian.d.hinman@kp.org
Supplementary Materials: Supplemental material is available at: www.thepermanentejournal.org/files/2024/23.150supp.pdf.

2024
04 6 2024
28 3 163167
© 2024 The Authors.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Published by The Permanente Federation LLC under the terms of the CC BY-NC-ND 4.0 license https://creativecommons.org/licenses/by-nc-nd/4.0/.

Keywords:

Value
systems of care
surgery
quality of care
total joint arthroplasty
outpatient
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pmcTotal hip and knee replacements are proven effective for relieving pain and disability secondary to arthritis. Historically, these procedures involved up to a weeklong hospital stay, pain management strategies centered on opioid-based therapies, several days of prophylactic antibiotic treatment, preoperative donation of autologous blood and postoperative blood transfusions, and extended stays at postacute rehabilitation facilities. Contemporary total joint replacement (TJR), by contrast, involves use of blood-loss mitigation strategies substantially reducing the transfusion rate,1 single-dose preoperative prophylactic antibiotic dosing,2 multimodal pain management strategies reducing reliance on opioids,3 and same-day discharge for carefully selected patients.4,5

The volume of TJR surgical procedures in the United States has increased yearly as the population of elderly patients increased and the age of eligible patients decreased.6 With the increased annual volume, TJR is one of the largest drivers of spending for Medicare, Medicaid, and commercial insurance.7 In an effort to reduce spending and emphasize value associated with TJR, the Centers for Medicare & Medicaid Services introduced bundled payment initiatives, including the Comprehensive Care for Joint Replacement Initiative in 2013.8 These programs offer a fixed payment for the entire TJR episode of care, incentivizing hospitals and practitioners to focus on treatment options that ensure quality, reduce returns to care, and reduce overall cost.

The largest cost associated with surgery is room and board.9 In an effort to reduce costs, rapid recovery started being offered to select patients, discharging them home the same day as surgery, which is referred to throughout this commentary as “home recovery.” This process is the exception rather than the rule, being implemented by individual surgeons or hospitals, as most practitioners do not participate in the bundled payment initiative. As a result, wide variation in practice patterns and patient experience continues to persist across the country.10

In Kaiser Permanente, our large, national, integrated health care system, we implemented a patient-centered home recovery program for our patients with TJR in which patients are discharged home the same day as surgery. The program started with select hospitals in 2016 and was gradually expanded under a standardized, coordinated program across the system nationally (Supplementary Appendix 1), as described in Koplan et al.11 Through our home recovery program, we deliver patient-centered, evidence-supported care to nearly 30,000 patients with TJR annually. Studies evaluating the safety of the same-day program compared to the traditional inpatient stay also found outcomes and process quality metrics were maintained or improved, even for patients historically not considered eligible.11–13 Further, 93% of patients in home recovery were satisfied with their care.14 As of 2022, 80% of patients with primary TJR across our system were discharged home on the same day, with 90% of all patients with TJR discharged home the same day in some hospitals. This is higher than reported in other practices in the United States, with one study using National Surgical Quality Improvement Program data finding only 41.3% of knee replacements were outpatient in 2020.5 At the advent of our program, patients were individually selected for appropriateness for home recovery, whereas in 2024, patients are all assumed to be home recovery candidates unless specifically identified by the surgeon as “high risk” based on medical complexity. The success of our national TJR home recovery program results from standardizing care across all hospitals, coordination of care between services in the hospital and ambulatory settings, and adoption and widespread dissemination of technology to engage with our patients and their care teams.

In 2006, Porter and Teisberg introduced the “Value Agenda” in their book Redefining Health Care. They describe value in health care as the “health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.”15 Thus, to increase value for our patients we must either reduce the cost of delivering the same quality of care, improve outcomes without increasing cost, or both. The Value Agenda comprises 6 steps: 1) organize into integrated practice units; 2) measure outcomes and costs for every patient; 3) move to bundled payments for care cycles; 4) integrate care delivery across care facilities; 5) expand excellent services across geography; and 6) build an enabling information technology platform. We believe our home recovery program represents a model for delivering increased value to patients with TJR and represents a crucial step toward curbing increased costs.

Integrated Practice Units

At the hospital level, our home recovery team is multidisciplinary. The TJR pathway begins with preoperative care, which involves patient education with standardized in-person or online education about the TJR journey, preoperative medical optimization, family member or caregiver engagement, and identification of patient needs for safe home recovery. Every patient undergoing elective TJR goes through this process.16 We do not preselect patients to be “home recovery patients.” At each of these steps, potential barriers to safe home recovery, such as lack of a family member or caregiver, are identified and addressed by the team well in advance of the surgery date. In the case of a patient who has no available caregiver postoperatively for instance, a social worker from the team will help the patient navigate available resources to assist with the postoperative recovery. If necessary, surgery is scheduled for a date that permits removal of barriers to safe home recovery.

Immediately postoperative, patients are evaluated by a team, including orthopedic surgeons, anesthesia, nursing, physical therapy, and patient care coordinators. Together these team members make rounds, monitor the progress of patients through a defined path, and confirm the appropriateness of home recovery. Process improvement projects in some facilities have implemented time-based checklists for patients on the home recovery pathway. Using these checklists aids the team in identifying patients who have not met discrete goals by defined time points, possibly increasing their likelihood of admission. In this fashion, the team can intervene before admission to the hospital becomes inevitable.

Once home, directed physical therapy and close follow-up with multiple patient contact points helps to reduce adverse events and returns to care. Although some of these individual actions were occurring historically, our home recovery program is now centered around the coordination of care among all team members. Locally, these teams meet monthly to review home recovery data, and when identified, barriers to safe home recovery are addressed.

Measuring outcomes

In 2016, after we implemented our home recovery program, 7.2% of our patients nationally had a same-day discharge. These patients were identified ahead of time by their surgeons and deemed low risk. However, by the end of the fourth quarter of 2022, 81% of our patients were being discharged to home on the same day, with patients considered home recovery candidates preoperatively unless identified by their surgeon as having a substantial possibility for a complication or return to care, such as advanced age, poor physical function, or lack of home support.17 Our stepwise progress over this period was facilitated by evaluating various data related to outcomes and process compliance from the national to the surgeon level. Our program tracks outcomes and process measures and shares these data with the leaders from the orthopedic team in each hospital.11 These leaders in turn share these data with clinical quality leaders and orthopedic chiefs. Orthopedic chiefs then share these data with their local teams. Team members in each hospital have access to an online dashboard that tracks outcome measures, such as adverse events and returns to care, as well as length of stay in each hospital. Successful hospitals are highlighted, and often best practices are then identified and adopted by the other hospitals if not already in place. Process improvement plans are implemented at hospitals where gaps are identified. As a patient-centered home recovery program, we have emphasized patient satisfaction and safety throughout its expansion.12–14

Integrating across facilities/Geography

Our integrated health care network is made up of medical centers in 8 distinct geographic regions. More than 350 surgeons have performed TJR in these regions. Despite delivering care through a single health care system, as is the case nationally, variations in practice patterns and outcomes existed in our care for patients with TJR historically. Although surgeons in a few of our hospitals were selecting specific patients for home recovery in 2014, this practice was infrequent.

In 2016, we developed a National Total Joint Replacement Initiative. The initiative is composed of orthopedic and quality leaders and is supported by our health care system’s national quality team. Its mission is to identify best practices in TJR care and use these to standardize care for all our patients nationally.11 As a pillar of high-value care in TJR, the National Total Joint Replacement Initiative assisted in the codification and dissemination of best practices among all of our hospitals and practitioners nationally. Working with regional orthopedic leads, a home recovery playbook of best practices was developed and shared with all hospitals nationally. Examples of widespread adoption of practices that helped increase the safety and success of our home recovery program include the universal adoption of tranexamic acid to reduce perioperative blood loss. This step, combined with a review of the data surrounding blood transfusions and subsequent revising of transfusion protocols, has helped us reduce the transfusion rate following routine primary TJR to nearly zero. Additionally, the universal adoption of periarticular injections and, in some cases, nerve blocks with a concomitant utilization of multimodal pain medications has provided superior pain controls so our patients can recover at home while reducing the use of opioids.

Variation in practice among hospitals has been identified as one source of increased cost and variability in clinical outcomes.18 Establishing clinical care pathways for TJR, such as enhanced recovery after surgery, has been shown to both reduce cost and improve outcomes.19 By standardizing our approach to TJR episodes of care across all hospitals, we are able to mitigate variation in care delivery and improve quality while increasing the number of patients able to recover at home.

Technology

The foundation of our TJR home recovery program is patient-centered care. As we developed a system of home recovery for the majority of our patients with TJR, we leveraged our technology platform to ensure no loss in the ability to engage with patients in the perioperative period. Patients and home health practitioners use email, digital images, and video visits to communicate with the surgical team during a patient’s postoperative recovery. Proactive telephone calls and emails from the surgical team are made as early as postoperative day 1 to address common concerns such as pain, swelling, and nausea and mitigate returns for these issues. The ability to perform clinical assessments virtually through digital photos and videos reduces the need for patients (many of whom are mobility-impaired in the early postoperative period) to drive to offices for these assessments. Our technology platform also enables access to all clinical records for every member of the health care team in different care environments, helping coordinate delivery of care and reducing duplicative work.

Generalizability of home recovery program

Our patient population is demographically representative of the general populations in the communities served.20 For this reason, we believe the home recovery program is feasible for most hospitals in which TJR procedures are performed. However, our integrated health care system does possess some unique attributes that not only facilitated the adoption of this program but allowed for its spread to hospitals and TJR groups within the system. These included the alignment of incentives and partnerships among the 3 branches of the Kaiser Permanente health care system: the Health Plan (insurance), hospitals, and physician-led medical groups. Additionally, the coordination and communication between facilities and physicians allowed for dissemination of best practices and more rapid adoption and advancement of the program across the entire health care system.

Conclusion

Home recovery following TJR is preferable to an overnight stay for most patients and has a substantial impact on helping to curb costs associated with the episode of care. Increasing safe home recovery on a population basis will decrease chance of poor outcomes to our patients and increase available beds and hospital resources. We acknowledge that our model will not be applicable to every medical center. However, by designing a TJR home recovery program that is patient-centered, data-driven, and standardized across multiple hospitals and medical centers throughout Kaiser Permanente, we have found safe home recovery can be implemented to most patients with TJR on a population basis.

Supplementary Material

online supplementary file 1

Acknowledgments

We acknowledge all the Kaiser Permanente total joint surgeons and National Total Joint Replacement Initiative members who contribute to the success of the Total Joint Replacement Registry, as well as the Medical Device Surveillance and Assessment department, which coordinates registry operations.

Author Contributions: All authors participated in concept of the commentary. Adrian D Hinman, MD, initially drafted the manuscript. Heather A Prentice, PhD, and Elizabeth W Paxton, PhD, obtained the data and completed analysis of the data. All authors reviewed and edited manuscript draft and submitted final approval of the submitted manuscript.

Conflicts of Interest: None declared

Funding: None declared
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