Knee Replacement Surgery is a Complex Procedure
Posted on March 28th, 2013
by Gregory Hood MD, FACP
Knee replacement surgery is a complex procedure. Recovery from surgery requires thorough physical therapy and exercises. Options in providing such therapy have advanced in recent years. At the February 2013 Transitional Care Committee meeting a dialogue was held with three orthopedic surgeons, reviewing options and progress in effective therapy.
When appropriate, forward thinking orthopedic practices have embraced prompt outpatient therapy as a means to improve outcomes of surgery, reduce infection risks, enhance patient comfort and avoid wasteful expenditures of time and money in skilled nursing facilities.
Practices in both Lexington and Louisville estimate that over eighty percent of elective knee replacements are proven very capable of home therapy after a brief, 2-3 day, post-operative care. These practices have adjusted their practice accordingly. They work proactively with preoperative education classes with patients to reinforce the treatment plan and manage expectations. The aligning of physician goals with optimal patient outcomes through patient preoperative teachings has revolutionized post-operative care in these practices, and others.
The costs of post-operative care include the human costs of pain, absence from family, and risks of post-operative complications are given further weight by the additional costs of the expense of rehabilitation facility, rehabilitation services throughout the length of stay, and risks of readmission should complications arise.
This concentration to the surgeon’s style of care has overcome barriers to going home after surgery. The use of analgesic blocks instead of PCA pumps, of oral analgesia titration instead of protocoled intravenous drug regimens, and cost-conscious team based methods of intra-operative and post-operative care have each proven themselves as elements of care that facilitate medication selection and transition to home, either directly from the hospital, or from an appropriately shortened stay in a rehabilitation center.
Direct communication on the part of the primary care physician is an integral part of this model. When a patient is advised by their physician to consult an orthopedist for consideration of elective joint replacement it is essential that the patient be made to understand that it is with the implicit understanding that he or she has sufficient health to undergo both surgery as well as prompt initiation of home based rehabilitation. This message is then reiterated at the preoperative primary care visit, as well as the preoperative classes.
Through notification of admission to the Care Coordinators of QIP additional resources can be brought to bear to ease the patient’s care. This notification is also helpful to those who are admitted to rehabilitation facilities or nursing homes for rehabilitation. The QIP Care Coordinators follow and assist patients and their families while nursing home stays proceed as well. This service preserves the lines of communication with patient, family, and primary care physician. It prevents squandered days and errors or omissions of communication while receiving care within the facility.
Improvements in surgical procedure, preoperative and perioperative processes, the mindset of patient, surgeon and primary care physician as well as enhancements in communication all have proven themselves as methods by which patients of Quality Independent Physicians benefit.
Cardiovascular Disease; When is the right time to return to PCP?
Posted on December 20th, 2012
by Dr. Michael Harper
As we keep marching forward into this uncertain Obamacare world, we as practitioners and administrators are working to find a path to excellent, evidence-based medical care that is at the same time cost effective. Quality Independent Physicians are embarking on an 18-month pilot program to prove that our efforts can result in cost savings and positive health outcomes with our most challenging patients. I honestly believe that we are on the right track and are going to succeed.
It is clear that there will be no silver bullet that solves all the problems. Some of our practice adjustments will help, and some may prove fruitless. What is clear, however, is that we must do something to make changes in the way we use the medical dollar. It is going to take a change in approach and philosophy, starting with the role individual physicians can play in building toward a solution.
Primary Care Physician Role
Primary care physicians have the closest relationship with patients. In general, our patients trust our judgment and often will return to us to validate treatment recommendations from specialists. This is both a great responsibility and a prime opportunity to shape the expectations and the care of our patients. Let’s take the role of primary care physicians in the management of patients with complex disorders, such a cardiovascular disease. I think we all would agree that preventing, diagnosing and treating heart disease drives a large percentage of health care expenditures.
So recently, during one of our Patient/Provider Relations meetings, we invited three cardiologists to a round table discussion where we proposed a back-to-the-basics approach to caring for our patients with heart disease. We didn’t want to do it alone, though. By refining our understanding of different philosophies of current cardiology practices and the current literature, we could refine our practice model and maximize its impact on utilization.
What’s our theory?
Many of our patients have very stable cardiovascular problems: examples are definitively treated coronary artery disease, uncomplicated congestive heart failure and stable atrial fibrillation. We have created a culture where patients feel they need to see a specialist if they have ever been diagnosed with such a problem. Is this right? I think, no.
I challenge all primary care physicians to reclaim some of these patients. Our patients trust us, and we have a skill set that warrants that trust. If we have a patient that is stable two years out from a bypass or angioplasty, do they still need to see a cardiologist?
- We can prescribe the correct and cost effective medicines.
- We can see our patients regularly to ensure they are not developing symptoms.
- We can manage lipids.
- Very often, our re-vascularized patients receive routine follow up stress tests despite the lack of current symptoms. There is no scientific data to support such utilization.
- It is the PCP job to use the skill set we have developed to care for our patients in an evidence-based way and at the same time, saving cost to the system.
For many patients, it may be a leap of faith to ‘not see their cardiologist’ if that is what they have always done. Let’s take time to educate these patients. Let them know that if situations or symptoms arise we won’t stand in the way of going back to their cardiologist. We’ll treat them well and we’ll send them back if and when they need to go.
What the Cardiologist said
Across the board, our panel of cardiologists agreed with us. They did not feel threatened by primary care physicians managing routine cardiology problems. They stressed that they know which physicians are providing appropriate care, and are more than comfortable passing the baton to these physicians.
The time is right for primary care doctors to take accountability for caring for stable patients with complex illnesses. We can do it. And as a consequence, we’ll be known as an organization that knows our patients, provides the highest quality care and manages our costs second to none.