key: cord-0903014-x9e6r0h0 authors: Sambare, Tanmaya; Bozic, Kevin J. title: Preparing for an Era of Episode-Based Care in Total Joint Arthroplasty date: 2020-09-22 journal: J Arthroplasty DOI: 10.1016/j.arth.2020.09.028 sha: b3cb9ba1739126ef13bdecbcadc298d417b01d1c doc_id: 903014 cord_uid: x9e6r0h0 With a history of steadily rising healthcare costs, the United States faces an unprecedented set of health and financial challenges. The COVID-19 pandemic will only exacerbate these challenges, and it is of paramount importance to reform and refine health systems to maximize the value of care delivered to the patient. Recent developments related to value improvement in total joint arthroplasty suggest episode-based payment is likely to become standard practice given the current healthcare environment. Consequently, developing episode-based care models for total joint arthroplasty is in the best interests of surgeons, health systems, and patients. In this article, we review important developments related to value-based care in total joint arthroplasty and present an episode-based framework for delivering high value, patient-centric care. We examine each phase of a total joint arthroplasty episode – pre-operative, acute, post-acute, and follow up – and present several ideas with developing bodies of evidence that can improve the value of care delivered to the patient. In this section, we present an episode-based framework for TJA, highlighting several ideas with 96 developing bodies of evidence for each phase of a TJA episode. We believe each of these ideas 97 supports high value and patient-centric care in an episode-based model. Figure 1 of patient experience in surgical care [12] . PROMs also hold clinical importance, as we have 117 J o u r n a l P r e -p r o o f learned that patients with certain pre-operative PROM values are either more or less likely to 118 see meaningful clinical improvement from total hip or knee arthroplasty [13, 14] . Over the last 119 decade, PROMs have steadily transitioned from a topic of academic discussion into TJA patient 120 care and clinical decision making. However, PROM collection is still not routinely incorporated 121 into standard clinical practice, collection is not at peak efficiency, and non-responsiveness to 122 PROM collection instruments has been identified as a barrier to efficiently utilizing PROMs [15-123 17] . As implementation challenges -such as efficient workflow integration; patient, provider, 124 and staff attitudes; and barriers to patient completion of PROM surveys -are studied in more 125 depth, we should see a steady increase in PROM collection in TJA care. There remain important 126 questions around whether PROMs have sufficient reliability to be utilized in reimbursement 127 models and care improvement efforts; the answers to these questions should be clearer as we The first is an incentive for consolidation, as systems with sufficient patient volume seeking 295 greater control over resource allocation may establish their own post-acute care services. 296 Another implication, especially in leaner models of care comprising of primarily healthy 297 patients, is the added incentive to develop robust home-based rehabilitation programs that can 298 deliver comparable outcomes to more costly post-acute care settings. Finally, skilled nursing 299 facilities will likely observe decreased patient volumes and smaller profit margins as a result of 300 robust quality monitoring, post-acute care setting consolidation, and expanded home health 301 services. While this may be considered an unfortunate consequence of episode-based care, it 302 may also be seen as an opportunity to reward skilled nursing facilities that deliver better 303 outcomes for patients. 304 Austin and the Navy, in which a single clinic visit may allow the patient to have encounters with 350 an orthopaedic surgeon, physical therapist, mental health specialist, and nutritionist [36, 37] . 351 This streamlined model -theorized to reduce aggregate costs by limiting low value, fragmented 352 care -has the potential to improve patient experience, as care is delivered in a more cohesive 353 and convenient manner. As UT Health Austin and the Navy see greater volume with the IPU 354 model, we will have some data highlighting whether such a model is effective in delivering 355 greater value to patients with arthritis and therefore can be spread nationwide. We hope that our thoughts and discussion can help inform care redesign efforts. Between the 406 concepts discussed and those yet to be explored, the coming years present many exciting 407 opportunities to deliver high value, patient-centric care in total joint arthroplasty and to lead 408 redesign efforts in elective surgical care delivery . 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 J o u r n a l P r e -p r o o f Predictors of low patient-reported 491 outcomes response rates in the California Joint Replacement Registry Implementing electronic patient-reported outcomes measurements: challenges 495 and success factors Maximising the impact of patient 497 reported outcome assessment for patients and society Can machine learning 499 algorithms predict which patients will achieve minimally clinically important differences from 500 total joint arthroplasty? Machine learning and primary total knee arthroplasty: patient forecasting for a patient-specific 503 payment model The value of preoperative exercise and education for 505 patients undergoing total hip and knee arthroplasty: a systematic review and meta-analysis Long-acting opioid use independently 510 predicts perioperative complication in total joint arthroplasty Preoperative opiate use independently 513 predicts narcotic consumption and complications after total joint arthroplasty Chronic opioid use after surgery: implications 516 for perioperative management in the face of the opioid epidemic CDC guideline for prescribing opioids for chronic pain-519 United States How to solve the cost crisis in health care Time-driven activity-based costing more accurately reflects 523 costs in arthroplasty surgery Patient Outcomes Following Total Joint 525 Replacement Surgery: A Comparison of Hospitals and Ambulatory Surgery Centers Outpatient Total Hip Arthroplasty 528 Performed at an Ambulatory Surgery Center vs Hospital Outpatient Setting: Complications Medicare Program: Changes to Hospital Outpatient Prospective Payment 531 and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs. Final rule 532 with comment period Changes in discharge location and 534 readmission rates under Medicare bundled payment Spending in the post-acute care setting accounts for 539 a sizeable portion of spending associated with a hospitalization episode 544 Patient perspectives on post-discharge surgical site infections: towards a patient-centered 545 mobile health solution Bundled Payments Are Moving Upstream Navy medicine introduces 549 value-based health care The epidemiology of revision total knee and hip 551 arthroplasty in England and Wales: a comparative analysis with projections for the United 552 The bone & joint journal 90-day mortality after 409 096 total hip replacements for osteoarthritis, from the 556 National Joint Registry for England and Wales: a retrospective analysis Failure rates of stemmed metal-on-metal 559 hip replacements: analysis of data from the National Joint Registry of England and Wales Implementation of 565 patient-reported outcome measures in US Total joint replacement registries: rationale, status, 566 and plans Figure 1: An Episode-Based Framework for TJA Care Delivery (please display in color