Transforming total joint arthroplasty at UF Health
A University of Florida Health arthroplasty program that launched with the tripartite mission of lowering costs while improving outcomes and the patient experience has proved highly successful and become a transformative catalyst for the health system’s department of orthopaedic surgery.
The adult arthroplasty service’s patient- and family-centered care, or PFCC, program for hip and knee replacement surgeries, started in 2015, enhanced a collaborative, data- and quality-driven clinical, research and educational culture in a highly recognized program. Indeed, UF Health orthopaedics earned a Top 50 ranking nationally in the 2020-21 U.S. News & World Report survey of hospitals nationally. U.S. News also ranked UF Health hip and knee replacement procedures each as “high performing,” its highest rating.
“There is a longstanding tradition of arthroplasty excellence in our department,” said Hari K. Parvataneni, MD, a professor and division chief of the adult arthroplasty and joint reconstruction program at UF Health. “William Enneking, our founding chair, performed the first hip replacement in the Southeast about 50 years ago. And William Petty, our second chair, founded Exactech Inc., which is still based in Gainesville. We are extremely gratified to see the long-term benefits our efforts have brought for patients. Arthroplasty care, first and foremost, is about patients. And so for us, our central priority is to provide the highest level of patient care that we can.”
Achieving the triple aims, he said, took a redesign of a total joint arthroplasty program that integrated and operationalized quality improvements involving faculty, trainees and every member of the treatment team.
“A large aspect was to engage providers, making quality improvement and value-based care part of our daily lives,” Parvataneni added. “This cultural shift enhanced the experience of providing care, achieving the so-called quadruple aim that includes patient satisfaction, engagement and the efficiency of the health care team.”
He noted that UF Health’s fully comprehensive total joint program is highly recognized, and one of the busiest and most robust in the southeastern United States. The program boasts an outpatient arthroplasty rate of nearly 60%, one of the highest in the country. This has been achieved while maintaining high quality. The joint replacement program, part of the UF Health Orthopaedic and Sports Medicine Institute, has been ranked “excellent” by the Centers for Medicare & Medicaid Services, or CMS, its highest quality category.
In addition to reducing hospital stays, PFCC also has reduced complications and readmissions while increasing mobility and transforming opioid use in arthroplasty. UF Health arthroplasty has seen a more than 50% reduction in opioid prescriptions for primary and revision arthroplasty, while improving pain control and patient satisfaction, Parvataneni said. The UF Health arthroplasty opioid management program has received CMS’ best practices designation and has been presented at the Institute for Healthcare Improvement.
This reduction is particularly noteworthy for the fact that this metric and others include those patients who are referred to UF Health for failed knee or hip replacements at other facilities and need revision surgery. Revisions are considered by many to be recalcitrant to other quality improvement and opioid reduction strategies.
About a third of UF Health arthroplasty volume consists of revision arthroplasty procedures referred from other centers all over the Southeast, making it one of the busiest in the region.
“We have a high-volume revision practice,” Parvataneni said. “We’ve shown that by using the same PFCC principles that we applied to primary patients, we can actually make quite dramatic improvements in revisions.”
In fact, the division has been able to dramatically reduce hospital length of stay by 20%, while the home discharge rate increased 25% for revision surgery patients. Also, readmissions are down 34%. These statistics are a reflection of the cultural shift that resulted from the improved primary patient experience, program physicians said.
These changes were also “high value” in that they saved the health system and payers considerable cost, Parvataneni noted, “and ours is the first center to report this effect in this challenging segment of arthroplasty patients.”
Quality improvement across the board has been closely integrated into all clinical aspects of the total joint program, but has also closely merged into research and the trainee curriculum.
“Normally, there’s a disconnect,” Parvataneni said. “Quality improvement is usually a project you are obligated to do before you graduate residency. But QI is basically what we do every day. It’s part of the patient care we deliver.”
“We seek out our own frustrations, where we see care as less than ideal, and these automatically become quality improvement projects,” said Chancellor F. Gray, MD, co-chair of the PFCC program and the associate physician director of quality in the department of orthopaedics. “We try to model the culture of quality as part of our hidden curriculum as we engage with our medical students, residents and fellows.”
Quality improvement is embedded into education, clinical care and research. “Everyone embraces it,” he said.
And eventually, Gray noted, team members integrate this culture into their own practices after leaving UF Health.
UF Health Arthroplasty’s seven fellowship-trained surgeons, in addition to Parvataneni and Gray, are Justin Deen, MD, Scott Myers, MD, Hernan Prieto, MD, Luis Pulido, MD and Richard Vlasak, MD
Other achievements of UF Health’s arthroplasty program:
- One of the few fully comprehensive total joint arthroplasty programs offering the full spectrum of care, including two hip preservation experts.
- Two faculty members who are current or former health policy fellows with the American Association of Hip and Knee Surgeons.
- Two faculty members serving on the Musculoskeletal Infection Society and the International Consensus on Orthopedic Infections.
- Several faculty in the top percentile nationally of Press-Ganey patient surveys.
- More than a dozen articles on quality improvement or health policy published in peer-reviewed journals in the last four years by residents or fellows.
- A 2019 American Joint Replacement Registry/American Academy of Orthopaedic Surgeons Analytics Institute grant for predictive analytics related to patient outcomes after hip and knee arthroplasty.
- Best poster (featuring opioid reduction work) at the 2019 American Academy of Pain Medicine.
- Game Changer Award for a predictive tool at the 2019 International Congress for Joint Reconstruction.
- One of the most competitive fellowship programs in the Southeast.