New Harvard Study Could Change Orthopedics Forever (Orthopedics This Week)
In what is likely the one of the first-ever attempt to map a cycle of care using an advanced economic model, researchers from Harvard have joined together with business gurus at the same institution. Jon J.P. Warner, M.D. is chief of the Shoulder Service at Massachusetts General Hospital and co-director of the Boston Shoulder Institute Fellowship worked in collaboration with Laurence D. Higgins, M.D. chief of the Sports Medicine and Shoulder Service at the Brigham and Women’s Hospital. A former president of the American Shoulder and Elbow Society (ASES), Dr. Warner told OTW, “Dr. Higgins and I have worked with Robert Kaplan and his colleagues at the Harvard Business School, and have just completed a study where we looked at the actual cost of an episode of care for rotator cuff surgery. By mapping the entire cycle of care and carefully analyzing each step, we were able to reduce the price of the entire one year episode of care by 15%.
“The tool we used—Time-Driven Activity Based Costing (TDABC)—allowed us to map the cycle of care. This accounting methodology analyzes use of resources including individual caregiver’s time for each step in the care cycle. A cost-capacity rate for an individual is their cost per minute for their time based on their salary and benefits and number of minutes worked per year. This is also combined with cost for using equipment and space. Such accounting is more accurate in representing true costs than allocation of historical costs. Moreover, this method allows us to analyze a care map looking for bottlenecks in the process and thus improve the efficiency of the entire care process. Applying this methodology allows us to bring healthcare delivery on par with other industries.”
“The single most important factor in the cost of rotator cuff repair was personnel (73%). So if you take a look at the evidence based medicine you see that the patient does not need physical therapy (PT) in the first four weeks after rotator cuff repair and voilà…you just saved a substantial amount of money.”
“We also found that in the entire year of care the day of surgery accounts for 53% of the total cost of care; PT is 22%. As a field we need to understand the value of taking apart what we are delivering. With this work we were able to improve 15 different elements of the cycle of care. We started the episode of care on the day that the patient signed up for surgery. This involved: measuring how many places he or she went, how many stops they have to make (and the indirect and direct costs of those stops), how many people they see on the day of surgery, how much time they spent in preanesthesia, what sort of bottlenecks there are from an equipment standpoint. Two institutions—Massachusetts General and Brigham and Women’s ambulatory center (Faulkner Hospital)—were studied. When all was said and done the cost difference between having rotator cuff surgery at one hospital versus another was inconsequential. These institutions used the same pathways of care and came up with the same cost of a cycle of care!”
“In addition to this study, we have established an outcomes registry for rotator cuff surgery; I believe that we are the first researchers to calculate the recovery curve for rotator cuff and shoulder replacement. The process is such that patients go online and input their feelings and information about pain levels. Then we calculate the mean recovery rate of patients’ pain and functional improvement. The most amazing finding was that two different surgeons at two institutions achieved the exact same outcome! People who have shoulder replacement recover faster than rotator cuff and do not experience much pain as compared to those undergoing rotator cuff surgery. But if you look at the standard deviation it decreases as the patient gets further from the point of surgery. So five weeks after surgery we’ll do risk modeling, but I think it’s high likely that these numbers represent a serious complication. Cardiothoracic surgeons have done some of this work in the past. We need to catch up with them…and with industry.”