Algorithm 2: Case Study

Total Joint Replacement


The huge blue dot on the scatterplot cried out for attention. A high-level VDO report that graphs coefficient of variation on the y-axis and average cost per visit on the x-axis clearly indicated that major joint replacement was an opportunity to reduce variability. Within minutes, the decision support analyst had pulled up another report that indicated a variation of $10,000 per procedure among the 10 surgeons.

They brought that data to the attention of Bart Adams, M.B.A., executive director of the University of Utah Orthopaedic Center, who then gathered the surgeons to discuss. “Doctors want to see data. Valid data. VDO makes the data very transparent,” says Adams. “And when you get all of the surgeons and the chairman in a room together to talk about it, that has power.”

Data, no matter how accurate and real-time it is, will always need experts to interpret it. The group of orthopaedic surgeons looked at the data and immediately came up with a more nuanced story. Although the VDO costing data is granular, precise and real-time, it is limited by a blunt tool that lumps procedures together, namely DRGs. In this case, the very name (DRG 470 for Major Joint Replacements and Limb Reattachment) reveals its lack of specificity. Using a drop-down menu, the surgeons were quickly able to remove the trauma and cancer surgeons from the analysis. They were then ready to compare apples to apples and figure out what the cost variation was and what could be done about it.

Part of the strength of VDO is the visualization tool. Immediately, it was clear that the tall gold bar had the greatest variation. No surprise it was the implant, and they discovered the highest variability was from a surgeon who used an implant that wasn’t under a supply chain purchasing contract. Beyond the implant, they were then able to drill down and look at the cost of labs, pharmacy, radiology, supplies and literally 1,000 other charges at the provider and patient level.

It turned out that the variation between the two surgeons who do the vast majority of total hip and knee replacements, Christopher L. Peters, M.D., professor of orthopaedic surgery, and Christopher E. Pelt, M.D., assistant professor of orthopaedic surgery, was minimal. But the discussion on cost then segued into the discussion that Pelt and Peters really wanted to have on quality and outcomes.

VDO Opportunity Scatter Plot
VDO Average Cost chart

The entire team gathered with Chief Medical Quality Officer Robert Pendleton, M.D., to figure out a care pathway, a 90-day Lean rapid-improvement process that helps identify opportunities, design solutions and hardwire results. “Joint replacement is one of the most performed and one of the most quality-of-life-restoring surgeries,” says Pelt. “So much can be protocolized with this procedure to reduce the variability that leads to bad outcomes.”

By including everyone in the conversation (surgeons, anesthesiologists, nurses, physical therapists, physician assistants, case and clinic management staff), they were able to identify not only best practices but also the barriers to implementing them. Having patients walk on the same day as surgery, for example, was identified as critically important. When the team discovered that physical therapists ended their daily shifts at 3 p.m., they scheduled one therapist to work a swing shift to ensure consistency for afternoon cases. To reduce discharge delays, they created a new post-discharge order set that included the 17 most frequently missed orders, and improved educational materials so that patients were better informed about follow-up care before they were even admitted. In addition, five quality measures were added to the VDO tool so that providers can create reports that track compliance and overlay cost data with quality metrics and outcome.

Pathway Highlights

The team identified more than a dozen opportunities that they continue to work on to ensure perfect care 100 percent of the time. “There’s an inherent variability and complexity to patient care. And getting to the best and most standardized care is a delicate, consistent march,” says Adams. “VDO has given us a new way to organize and visualize the data. The tool’s not perfect, but the greatest advantage of VDO is that it has people engaged.”