This case study was produced by Health Innovation Forum with collaboration from Dr. Cy Frank, Executive Director, Alberta Bone and Joint Health Institute, Tracy Wasylak, Vice-President, South Health Campus, Calgary Health Region, Shawna Syverson, Director, Bone and Joint Health, Calgary Health Region, Joanna Pawlyshyn, Executive Lead, Bone and Joint Health, Capital Health, and Louisa Pothier, Regional Planner, Bone and Joint Health, Capital Health. — Produced as part of the 2008 program of the MUHC-ISAI

The problem

Hip and knee replacement surgery relieves pain and restores function and mobility, with a success rate as high as 95% after 10 years and 90% after 20 years. Demand for the procedures is high and growing.

The care patients receive can vary because practices and procedures are not standardized. Services are not integrated, and waiting times for access to an orthopedic surgeon and for surgery are long, exceeding the optimal time for most patients.

The program

In 2004, the Alberta Orthopedic Society, working with the Alberta Medical Association, the province’s health regions, the Department of Health and Wellness, and the Alberta Bone and Joint Health Institute, decided to partner in an effort to improve the quality of care for hip and knee replacement patients. They agreed to redesign the continuum of care for hip and knee replacements using a standardized approach extending from primary care through to surgery, recovery and rehabilitation. All aspects of the new approach would be based on informed decision-making using a combination of the best available evidence and sound medical judgment. Patient care would be fully integrated and delivered by a multidisciplinary team. In 2005, the partners launched the one-year Alberta Hip and Knee Replacement Pilot Project in the Capital, Calgary and David Thompson health regions to compare their new model with the conventional approach.

In the new model, assessment, diagnosis and non-surgical treatment are provided in multidisciplinary, community-based, single-purpose hip and knee replacement clinics. Patients are referred to the clinic by their family physician, who completes a simple two-page referral template that provides patient history, including past treatments, and indicates urgency. The template ensures that the required health information is provided and that the patient will see the appropriate care providers. At the clinic, a multidisciplinary team assesses patients for their need and/or fitness for surgery and, if surgery is required, helps them prepare. This step dramatically reduces delays and last-minute cancellations. Patients are then assigned a case manager who guides them along their care path and ensures they are at their optimal readiness for surgery. They also sign a contract, which can contain specific commitments to achieve optimal readiness, such as weight reduction, strengthening and smoking cessation.

Patients are assigned to the next available surgeon in the region, or to the surgeon of their choice recognizing that surgeon choice may mean a longer wait. Home care services for the postsurgical period can be arranged at the clinic prior to surgery and the clinic monitors postoperative rehabilitation.

Patient optimization is a critical component of the new continuum. Patients are known to experience better outcomes when they are at their optimal readiness for surgery. In the new approach, surgery may be delayed to allow sufficient time for patients to be optimized.

Grants of $18 million from Alberta Health and Wellness were provided to the three participating health regions to fund an additional 1,200 surgeries, set up the arthroplasty clinics and pay for equipment, renovations, staff training and project administration. The surgeries were performed in a controlled environment that was not subject to the day-to-day operational pressures of the system, such as competition for beds and operating room time.

Results at three-month patient follow-up were reported in June 2007. Patients who had a hip or knee replacement under the new model expressed greater satisfaction with the care they received, compared with patients whose surgery followed the conventional approach. Length of hospital stay fell from 6 days to 4.7 days. Wait times from first referral by a family doctor to first visit with an orthopedic surgeon dropped 85%, from 145 working days to 21 days. Wait times from first visit with an orthopedic surgeon to surgery dropped 87%, from 290 working days to 37. Hospital costs, including the operating room, prosthesis and patient stay, were reduced by 15% and total case costs by 2%.

Uptake

Standardizing surgical practice may be perceived as a challenge to physician independence. Despite this, the majority of physicians in the pilot project did change. Some surgeons also were reluctant to set up and run a second office in the hip and knee replacement clinics, as this can be a very inefficient use of their time.

Along with integration of the new care path, additional surgical capacity was required to bring wait times down. Dedicated funding for wait times from the federal government made the initial provincial investment easier. Capital Health and David Thompson were able to harness enough additional capacity from existing human resources. In Calgary, where there was no excess capacity available in the public sector to increase the number of surgeries (a number of hospital expansions in the city are underway), the health authority contracted with the private, for-profit Health Resources Centre to provide about 20% of all hip and knee procedures in Calgary. All procedures were centrally administered and paid for from the public purse.

Potential for expansion

The partners caution that results will be more difficult and take longer to achieve outside of a controlled pilot environment. But the effort has begun. The program’s surgical roster has more than tripled, from 13 to 45 participating surgeons.

The three pilot health regions — Capital, Calgary and David Thompson — began implementing the new continuum as their standard of care for hip and knee replacements in the fall of 2006 based on positive preliminary results. In the David Thompson Health Region, all orthopedic surgeons will be moving their primary arthroplasty practice to the new Central Alberta Hip and Knee Clinic, which will centralize patient intake. Alberta Health and Wellness is encouraging the province’s six remaining health regions to adopt the new approach, making it available province-wide.