Hip replacement data lead to efficiency
Hip replacement data lead to efficiency
Bryn Mawr Hospital tops in group
Medicare Provider Analysis & Review (MEDPAR) data indicate a decline in hip fracture admissions for all but the oldest patients. But there were still some 280,000 cases in 1998. (For more on the data, see list, p. 81.) That equates to some brisk business in hip replacement surgery for hospitals. And knowing how you compare to others is more important than ever.
Judy Dahle, RN, MS, director of OR Bench-marks in Santa Fe, NM, says the endeavor started five years ago by looking mostly at cost issues. "There are plenty of people looking at outcomes," she notes. "We felt looking at cost efficiencies was more important."
Nineteen hospitals were involved in the most recent hip replacement study. They looked at 80 cases over a six-week period in 1999 and included some of the premier hospitals and health systems in the country, such as Seton Medical Center in Austin, TX, Providence St. Peter’s Hospital in Olympia, WA, and Bryn Mawr (PA) Hospital.
The study looks at the equipment and supplies used, their cost, time spent on a replacement, and staffing issues. (For more on the data collected and the performance of the best hospitals, see lists, pp. 79-81.)
"We look at turnaround time, which is important for surgery," says Dahle. "We look at the staff mix."
Over the five years, Dahle says there have been few changes in the kinds of data collected. "Not much has changed in the procedures," she says. "What supplies are used is pretty static. But we do make some changes. We never used to include the cost of anesthesia supplies, and now we are doing that." The group will also start including salary ranges for procedures, although these data are largely regionally driven. "We can break the information out in different ways to make it valuable to users," she says.
The hospital groups are instrumental in determining what data are collected, says Dahle. "We want to know where the administration is looking for cost and time efficiencies."
What makes the OR Benchmarks programs, which include 16 high-volume, high-cost procedures, unique is that the data are collected real time by the personnel doing the procedures. They fill out simple worksheets that the company uses to collate the data. "You can be held accountable to any data, but it’s a lot easier to get buy-in if the data are real time and you know exactly where they come from."
There is also an agreement of definitions that makes the information valuable to participants, says Dahle. "If you say start time or induction time, we know among ourselves exactly what we mean."
The comparisons are done among like groups of hospitals, too, so that medium-sized teaching hospitals like Bryn Mawr are compared to other teaching facilities of similar size, and small rural hospitals look at data from other small rural hospitals.
Along with the single procedure reports, OR Benchmarks produces a book that includes all major hospital processes, from scheduling to discharge, from salaries to computer systems.
Bryn Mawr came out on top in the hip replacement survey. According to Claire Baldwin, assistant vice president for patient services at Bryn Mawr’s health system, Main Line Health, one of the key performance indicators where the hospital excelled was in how long the surgeries take. "The longer an operation takes, the more time the patient is under anesthesia, and the longer the patient is open to possible infection," she says.
The results also showed Bryn Mawr hospital as being cost-effective and time-efficient in its procedures, Baldwin adds.
Robert Good, MD, says that the outcomes from the OR Benchmarks survey is not the only proof the hospital has that it does well. The facility also excels according to the Hip & Knee Registry, maintained by the University of Massachusetts. "As a result of this study, which evaluates hip and knee replacement patient satisfaction at five and 18 months post-op, we know that our orthopedic program is one patients can depend on," he says.
What the data show
The OR Benchmarks study shows that 86% of supply costs come from the artificial hips. The study notes that although noncemented prostheses cost about $1,000 more, they seem to be a better option for younger patients who have better bone density. Bryn Mawr rarely cements implants, compared to an average of 68% among the 80 cases.
The costs of the implants, ranging from $2,200 to $5,160, haven’t changed a lot over time. Total supply costs ranged from $2,653 to $5,869, and the number of items used ranged from 82 to 173. Towel use is down significantly, as is autotransfusion equipment use.
The latter seems to be a result of more facilities encouraging patients to donate their blood before the procedures, the study says.
Staff ratios ranged from using all RNs to using between two and four non-RN tech staff. A quarter of the hospitals had staff on hand who were not paid by the facility — including physicians, private scrub staff, or physician’s assistants.
Just over three-fifths of the cases started on time in 1999, compared to 49% the year before. Turnover time — the time from setup to cleanup for a single procedure — was down one minute to 44. Dahle says that because this time has moved little since 1997, it may be the "gold standard" for times and might not be able to move without significantly increasing staffing costs.
And what do you do if your facility doesn’t match up with some of the better performers? According to the study, best performers have this advice:
• If the supply costs for your facility are greater than the first quartile cut off, there is room for improvement.
• If your facility has an issue with pricing or consumption and if the total supply cost is high, it may be due either to using too many items or paying too much for them. Compare the total number of items used by the best performing facility. "If your number of items is greater," the report says, "your focus should be toward trimming consumption as opposed to pricing. If you use a similar profile of supply items when compared to the best performing facility, then you might discuss pricing with your materials manager."
• Some facilities prepare a supply profile by surgeon. The best mark supply item list could be given to surgeons for comparison.
• Don’t compare providing the best care possible — which all surgeons want to do — with providing the best affordable care possible. Nurses, surgeons, and support staff are more likely to embrace change if an atmosphere of teamwork and constructive flow of ideas is encouraged.
| Hip Fracture Data |
| Number of Hip Fractures |
| 1995: 290,980 |
| 1996: 295,980 |
| 1997: 291,191 |
| 1998: 279,519 |
| By Age Group |
| > 90 |
| 1996: 41,305 |
| 1998: 45,756 |
| 65 to 69 |
| 1996: 12,326 |
| 1998: 9,372 |
| Source: Medical Provider Analysis & Review, Dept. of Health and Human Services, Washington, DC. |
[For more information, contact:
• Judy Dahle, RN, MS, Director, OR Benchmarks, Santa Fe, NM. Telephone: (877) 877-4031.
• Robert Good, MD, Chief of Orthopedic Surgery, Bryn Mawr (PA) Hospital. Telephone: (610) 527-2727.
• Claire Baldwin, Assistant Vice President, Patient Services, Main Line Health, Bryn Mawr, PA. Telephone: (610) 526-3752.]
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