Ran Schwarzkopf

The perioperative surgical home as a future perioperative practice model.

HEALTH CARE IN THE UNITED STATES: WHAT’S THE UNDERLYING PROBLEM?Health care has been a subject of national debate in the United States for the past decade, as we are facing a crisis in both the quality and the cost of delivered care. Why are health care costs in the United States so high, yet key qu

Implementation of a Total Joint Replacement-Focused Perioperative Surgical Home: A Management Case Report

BACKGROUND:The perioperative setting in the United States is noted for variable and fragmented care that increases the chance for errors and adverse outcomes as well as the overall cost of perioperative care. Recently, the American Society of Anesthesiologists put forward the Perioperative Surgical Home (PSH) concept as a potential solution to this problem. Although the PSH concept has been described previously, “real-life” implementation of this new model has not been reported. METHODS:Members of the Departments of Anesthesiology and Perioperative Care and Orthopedic Surgery, in addition to perioperative hospital services, developed and implemented a series of clinical care pathways defining and standardizing preoperative, intraoperative, postoperative, and postdischarge management for patients undergoing elective primary hip (n = 51) and knee (n = 95) arthroplasty. We report on the impact of the Total Joint Replacement PSH on length of hospital stay (LOS), incidence of perioperative blood transfusions, postoperative complications, 30-day readmission rates, emergency department visits, mortality, and patient satisfaction. RESULTS:The incidence of major complication was 0.0 (0.0–7.0)% and of perioperative blood transfusion was 6.2 (2.9–11.4)%. In-hospital mortality was 0.0 (0.0–7.0)% and 30-day readmission was 0.7 (0.0–3.8)%. All Surgical Care Improvements Project measures were at 100.0 (93.0–100.0)%. The median LOS for total knee arthroplasty and total hip arthroplasty, respectively, was (median (95% confidence interval [interquartile range]) 3 (2–3) [2–3] and 3 (2–3) [2–3] days. Approximately half of the patients were discharged to a location other than their customary residence (70 to skilled nursing facility, 1 to rehabilitation, 39 to home with organization health services, and 36 to home). CONCLUSIONS:We believe that our experience with the Total Joint Replacement PSH program provides solid evidence of the feasibility of this practice model to improve patient outcomes and achieve high patient satisfaction. In the future, the impact of LOS on cost will have to be better quantified. Specifically, future studies comparing PSH to traditional care will have to include consideration of postdischarge care, which are drivers of the perioperative costs.

Effects of Perioperative Blood Product Use on Surgical Site Infection Following Thoracic and Lumbar Spinal Surgery

Study Design. Retrospective case-control review. Objective. This retrospective study explored the hypothesis that the perioperative administration of blood products is an identifiable risk factor of increased surgical site infections (SSIs) after thoracic and lumbar spine surgical procedures. Summary of Background Data. Surgical site infections are a significant cause of postoperative morbidity and mortality. According to the Center for Disease Controls National Nosocomial Infections Surveillance system, which monitors the rate of hospital-acquired infections in the United States, SSIs represent the third most commonly reported type of nosocomial infection, accounting for 14% to 16% of all nosocomial infections. The incidence of SSIs after spinal surgery is influenced by both preoperative and intraoperative risk factors. The relationship between blood products and SSIs has been a matter of debate for more than 2 decades. Several studies have supported the association between the use of blood products and the development of postoperative surgical site infections. Methods. A retrospective case-control study was performed. We reviewed the charts of all patients who had undergone thoracic and/or lumbar spinal surgery at the NYU Hospital for Joint Diseases between 2002 and 2007. All patients who had developed surgical site infections following spine surgery in this 5-year period were identified. Results. Data for 61 cases and 71 controls were included in this study. The analysis of the preoperative risk factors was performed for the entire population of patients. Body mass index and blood transfusions were found to be statistically significant risk factors for increased surgical site infections for this population. Conclusion. Our findings support current theories that blood transfusions may have modulatory effects on the immune system of the recipients. Our specific study in spine patients may contribute to the expanding literature on allogeneic blood transfusions and the risk of nosocomial infections and encourage surgeons to favor a more restrictive policy with regard to transfusions.

Total joint Perioperative Surgical Home: an observational financial review

BackgroundThe numbers of people requiring total arthroplasty is expected to increase substantially over the next two decades. However, increasing costs and new payment models in the USA have created a sustainability gap. Ad hoc interventions have reported marginal cost reduction, but it has become clear that sustainability lies only in complete restructuring of care delivery. The Perioperative Surgical Home (PSH) model, a patient-centered and physician-led multidisciplinary system of coordinated care, was implemented at UC Irvine Health in 2012 for patients undergoing primary elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). This observational study examines the costs associated with this initiative.MethodsThe direct cost of materials and services (excluding professional fees and implants) for a random index sample following the Total Joint-PSH pathway was used to calculate per diem cost. Cost of orthopedic implants was calculated based on audit-verified direct cost data. Operating room and post-anesthesia care unit time-based costs were calculated for each case and analyzed for variation. Benchmark cost data were obtained from literature search. Data are presented as mean ± SD (coefficient of variation) where possible.ResultsTotal per diem cost was

Prevalence of Staphylococcus aureus colonization in orthopaedic surgeons and their patients: a prospective cohort controlled study.

10,042 ± 1,305 (13%) for TKA and

Impact of metabolic syndrome on perioperative complication rates after total joint arthroplasty surgery.

9,952 ± 1,294 (13%) for THA. Literature-reported benchmark per diem cost was

Retrospective Analysis of Total Knee Arthroplasty Cases for Visual, Histological, and Clinical Eligibility of Unicompartmental Knee Arthroplasties

17,588 for TKA and

Effectiveness of telemedical applications in postoperative follow-up after total joint arthroplasty.

16,267 for THA. Implant cost was

Factors Determining Discharge Destination for Patients Undergoing Total Joint Arthroplasty

7,482 ± 4,050 (54%) for TKA and

The influence of sagittal spinal deformity on anteversion of the acetabular component in total hip arthroplasty

9869 ± 1,549 (16%) for THA. Total hospital cost was