key: cord-0769353-f0wywpe9
authors: Menendez, Mariano E.; Jawa, Andrew; Haas, Derek A.; Warner, Jon J.P.
title: Orthopedic Surgery Post COVID-19: An Opportunity for Innovation and Transformation
date: 2020-04-03
journal: J Shoulder Elbow Surg
DOI: 10.1016/j.jse.2020.03.024
sha: 297848f6922ed4a206bd99462ef143fe40a7c253
doc_id: 769353
cord_uid: f0wywpe9

nan

1 From The Codman Shoulder Society: 1

As the scale of the coronavirus pandemic continues to grow, so does the amount of 2 uncertainty. This virus has upended life as we know it. And we, as surgeons, are not particularly 3 good at dealing with uncertainty. 11 While uncertainty is the norm in areas such as business 4

forecasting and stock price valuations, we feel uneasy when grappling with tough questions, such 5 as whether to cancel elective surgeries that aren't immediately life-threatening, but could result 6 in more serious complications down the line. Take, for instance, cholecystectomy to remove 7 symptomatic gallstones: failure to provide timely definitive treatment may increase the risk of 8 potentially life-threatening pancreatitis. 12 How about delaying timely repair of an acute rotator 9 cuff tear in a young patient, which likely could impact the outcome? It can be hard to draw the 10 line for what is critical, urgent, or non-urgent surgical care. Many questions remain unanswered. 11

But this crisis also presents value-maximizing opportunities for innovation in the delivery 12 of healthcare, with orthopedic surgery as a particular segment presenting opportunity for value 13 creation. 14 The current period of turbulence and fear may be a learning experience for providers, 15 industry, and patients. It may promote collaboration and creative thinking that could spur 16 changes in behavior. Such changes would potentially create value for all stakeholders. 17

Here, we would like to share our thoughts of some changes that may permanently impact 18 orthopedic surgery going forward. We group these changes into three broad categories: (1) 19

technology-aided replacement of in-person services with virtual ones, (2) a greater shift in 20 surgeries from hospitals to surgery centers, and (3) increased pressure to be cost-conscious and 21

to follow evidence-based medicine guidelines. change associated with the coronavirus outbreak. Initial telehealth-related concerns regarding 25 insurance resistance, billing complexities, and privacy have evaporated as everyone is now 26 striving to keep providers and patients separate. We believe that long-lagging telehealth is here 27 to stay and will become the norm for orthopedic surgery. And there is early encouraging 28 evidence of its use for postoperative visits after rotator cuff repair. 4 Even before this outbreak, 29

our group was doing a study in collaboration with Harvard Business School looking at the safety 30 and effectiveness of virtual visits during the 90-day post-acute care period following shoulder 31 surgery. It was evident that most patients who underwent rotator cuff repair as well as shoulder 32 arthroplasty simply did not need to return to the office during this period. In fact, we could easily 33 see their surgical wound and instruct them how to self-examine themselves to alert us if there 34 was an issue. Moreover, it was evident to us that this would free up office capacity, ultimately 35 affecting the patient experience and cost-effectiveness of clinic utilization overall. 36 B) Decreased utilization of formal physical therapy. There is little evidence that the 37 amount of formal physical therapy after orthopedic surgery correlates with an improved ultimate 38 recovery. 8 We believe that home-based physical therapy surrogates through digital tools will 39 facilitate recovery for patients, increase compliance, and ultimately optimize costs and outcomes. 40

Virtual coaching with feedback and videos uploaded to media-sharing platforms such as 41

YouTube will reduce the need for as much hands-on physical therapy as we have come to 42 expect. Moreover, some companies are creating new technology inclusive of wearable devices 43 that interface with new computer monitoring programs to allow careful management of virtual 44 recovery with physical therapy. One such example is PT Genie (https://ptgenie.com; Beachwood, C) Online tools for postoperative recovery. We and others are creating interactive 47 modules either through third parties or through our own institutions that will concierge patients 48 through their recovery. This may include apps and websites with interactive input that identify 2) A greater shift in surgeries from hospitals to surgery centers: There is mounting evidence 77 that ambulatory surgery centers can maximize the value of most orthopedic surgery procedures, 78 including shoulder arthroplasty. 1, 2 Following the outbreak, there will be such a backlog of cases 79 in hospitals that many of them will get shifted to surgery centers. As surgeons get increasingly 80 comfortable performing more procedures such as shoulder (or knee and hip) arthroplasty in 81 surgery centers, they will want to keep doing them there. Patients are likely going to increasingly 82 prefer a surgery center--where there are no coronavirus patients--to a hospital as well. 83

Similarly, patients may be more motivated to go home after surgery, and avoid post-acute care 84 facilities to minimize the risk of contracting the virus. 85

A) Increased cost pressure within hospitals. There will be more pressure to tightly 87 manage costs within hospitals. This will initially be driven by the coronavirus. For instance, the 88 stock prices of the two largest hospital chains in the United States, HCA and Tenet, declined by 89 roughly twice as much as the S&P 500 from the end of 2019 through March 27, 2020. The 90 coronavirus pandemic continues for more than a few months, it is unlikely to be sufficient to 93 stem the financial losses experienced by hospitals. Even now in the midst of the crisis, some 94 hospitals are already cutting back on the compensation of their physicians and staff. Once we are 95 through the coronavirus crisis, hospitals will likely continue to face financial pressure due to the 96 migration of profitable orthopedic cases from hospitals to surgery centers. 97

In order to survive economically, hospitals will need to adopt more cost-conscious and 98 effective practices. Identifying these practices will require the use of sophisticated clinical and 99 operational analytics, and advanced cost measurement methodologies such as Time-Driven 100

Activity-Based Costing. 7 One of the first targets will be orthopedic implant costs, given the wide 101 variability and lack of transparency in their purchase prices across institutions. 3 102

surgery is based more on anecdotal than empirical evidence. The considerable accumulation of 104 cases after the outbreak may prompt stricter adherence to evidence-based practice guidelines as 105 to who to prioritize for surgery. This will create an opportunity to decrease unwarranted variation 106 of orthopedic procedures that provide questionable value to certain patients (e.g. arthroscopic 107 partial meniscectomy for degenerative meniscal tears, 10 subacromial decompression for shoulder 108 impingement) 5 . However, it is important to note that rigid approaches to care that don't allow for 109 any adaptation may pose barriers to innovation. Now actually may be a great time to innovate. 110

Either fail fast or allow the patients to reap the benefits. Creative thinking will be needed to 111 accelerate progress after this outbreak, and innovation is critical to creating future evidence. 9 112

For too long, healthcare has been a nidus for inefficient use of time and resources. The 113 future may not permit this in the United States any longer. No one knows exactly what will come of the coronavirus pandemic, but this was our best stab at some of the unexpected ways that 115 orthopedic surgery may change for the good. 116

Outpatient surgery as a means of cost 119 reduction in total hip arthroplasty: a case-control study

Neer Award 2016: Outpatient 122 total shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total 123 shoulder arthroplasty in a hospital: a matched cohort study

Variation in the Cost of Care for Different Types of Joint Arthroplasty

Disruptive innovation: can health care learn from other industries? A 129 conversation with Clayton M. Christensen. Interview by Mark D. Smith

Surgery for shoulder 132 impingement: a systematic review and meta-analysis of controlled clinical trials

Acquisition by Immersive Virtual Reality Training: A Randomized Controlled Trial

Activity-Based Costing to Identify Patients Incurring High Inpatient Cost for Total Shoulder 139

Is a formal 141 physical therapy program necessary after total shoulder arthroplasty for osteoarthritis

Balancing innovation and evidence. J Nurses Prof Dev

Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear

Acknowledge Uncertainty?

Timing of cholecystectomy after mild biliary pancreatitis: a systematic 153 review