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The Pipeline

AAOS 2011: Reducing Length of Stay While Maintaining Quality

A few common threads were interwoven throughout AAOS this year: a growing demand for orthopedic services with an aging population, an impending shortage of specialists to provide these services, increasing cost pressures that threaten the financial sustainability, and finally a growing emphasis on defining and demonstrating quality. Juggling each of these conflicting pressures will be an enormous challenge for providers in the years ahead, and a few papers presented this week were aimed at addressing these issues. Length of stay (LOS), was one area in particular that some emphasized as a way of counterbalancing each of these looming pressures, and a few papers presented some interesting findings on this commonly tracked metric.

Dr. Vivek Mohan presented on a Kaiser Permanente effort to integrate lean manufacturing principles to increase efficiencies in perioperative care for total joint replacement. A ten month effort--six for operating room efficiencies and four for patient carepaths--led by surgeons but involving many providers identified multiple improvement opportunities that led to a 40 percent reduction in average operating room turn-around times, a 29 percent reduction in average LOS, and a 50 percent reduction in skilled nursing facility (SNF) utilization. In his presentation, Dr. Mohan emphasized that these dramatic improvements happened "irrespective of age, gender, co-morbidities, and other risk factors," and that the care package they developed was intended to be effective for all patients. Dr. Mohan did not go into details on all of the specific improvements that they had identified through the process, though he identified several 'lean' concepts that were utilized. Among them, parallel processing, waste elimination, protocol creation, and standardization.

During the same session, Dr. Antonia Chen of University of Pittsburgh Medical Center presented data that demonstrated how physical therapy on the day of total joint arthroplasty was shown to reduce length of stay. Dr. Chen explained how her team had identified three areas of perioperative improvement could result in reductions of length of stay: pre-operative education, pain management, and physical therapy. For this study, they chose to isolate physical therapy (PT) in an attempt to identify the incremental benefit that more aggressive day-of surgery PT could bring. The prospective study of 128 patients receiving either a total hip or total knee replacement randomized those that received PT on the day of surgery against those that received PT starting the day after surgery. Patients with day-of PT were seen to reduce their LOS by almost a full day (average LOS of 2.8 days, +/- 0.8 versus 3.7 days +/- 1.8 days).

In both of the above studies, the reduced LOS was not shown to be associated with a negative impact on outcomes or readmission rates. The notion that overly aggressive attempts to reduce length of stay may be associated with poorer outcomes was brought up often, though a population-based study presented at a different sessions may start to undermine those claims. Dr. James Huddleston and team investigated the rates of readmissions among 1,802 Medicare beneficiaries that had received a total hip arthroplasty between 2002 and 2007. One of their initial hypotheses was that a relative reduction in LOS would be associated with an increased rate of readmission. In the end, however, the study actually showed an opposite association. From 2002-4 to 2005-7, the data set showed a significant decrease in LOS (an average of 4.4 days to an average of 3.8 days) alongside a slight decrease readmission rates (7.1 percent to 6.3 percent), which was counterintuitive to the popular wisdom.

Reducing LOS will only be one of many efforts needed to decrease cost and improve efficiency in a post-reform era, but each of these studies demonstrated an optimistic future, in that efforts to improve perioperative efficiencies can still maintain--and possibly improve--the quality of care delivered.