Better care for hip osteoarthritis patients by Santeon

BETTER CARE FOR

HIP OSTEOARTHRITIS PATIENTS CARE FOR IMPROVEMENT

2018

EDITION

CONTENTS

FOREWORD

CHAPTER 1 BETTER CARE THROUGH COLLABORATION

CHAPTER 2 8 FASTER IMPROVEMENT IN A STRUCTURED IMPROVEMENT CYCLE 8 METHOD IMPROVEMENT CYCLE WITH IMPROVEMENT TEAM 9 DETERMINE SCORECARD 14 COLLECTING AND DISCUSSING DATA 14 INCLUSION OF PATIENTS’ EXPERIENCES

‘ COMPARING THE OUTCOMES THAT REALLY MATTER TO OUR PATIENTS IS A SIMPLE AND VERY POWERFUL IDEA’.

18 18 20 20 22 23 23 23 24 24 25 26 30

CHAPTER 3 IMPROVEMENTS IN HIP OSTEOARTHRITIS CARE SO FAR FEW COMPLICATIONS DURING THE HOSPITAL ADMISSION SHORTER STAY AROUND OPERATION (K3) IMPROVEMENT INITIATIVES FOR STAY DURATION REDUCTION IN X-RAY PHOTOS PER PATIENT (K5.1.1) GREATER AWARENESS FEWER LIFESTYLE RULES FOR ACTIVE HIP PATIENTS FASTER RETURN HOME WITH MEDICATION, POST-DISCHARGE NEW LEARNING MODULE FOR MEDICATION USAGE BETTER INFORMATION ABOUT THE OPERATION DATE GREATER TRANSPARENCY ABOUT REVISIONS GREATER FOCUS ON PROMS WHAT’S NEXT?

ATTACHMENTS 32 ATTACHMENT 1 INVOLVED IMPROVEMENT TEAMS 34 ATTACHMENT 2 EXPERTS 34 COLOPHON

PIETER DE BEY, SANTEON DIRECTOR 2

FOREWORD

‘ I believe that you improve by taking the time to reflect, rather than by hurtling through the treadmill.’ Under the name of ‘Santeon’, seven top clinical hospitals collaborate closely in order to improve care. This collaboration is unique because the professionals get to take a look ‘behind the scenes’ at each other’s hospitals. They compare treatment outcomes and learn from one another. To better exploit the improvement potential in the outcomes between the hospitals, we began setting up Improvement Cycles in 2016. The initial results for breast cancer care were publicly shared in December 2017, and now we are doing the same process for hip osteoarthritis care. Value-Based Health Care (VBHC) is an excellent extension of Evidence-Based Medicine (EBM). ‘Evidence-Based medicine’ (EBM) is the explicit, judicious and conscientious use of the best evidence available when making a decision, together with the patient, about his or her treatment. EBM begins and ends with the patient; therefore, it is comparable to VBHC, but it primarily focuses on controlled studies and guidelines. Usually, a significant amount of time passes before the research findings are put into practice. At Santeon, what we do in this regard is more akin to a ‘pressure-cooker system’. We make the process more manageable by breaking it down into smaller pieces. These subjects, in terms of size, may appear less relevant, but they are essential for the patient. They make all the difference because the results are directly implemented. We believe that it’s better to take small, meaningful steps to see results than it is to wait for that big step that may turn out to be overly ambitious. It’s about focusing on what is important for the patient. And that goes faster, naturally, when we also discuss this with the patient. Because of these short lines of communication, we achieve rapid results. Specialists like to continue learning and to be ever more knowledgeable. This takes care of a step not only in the patient’s treatment, but also in their own learning process. I believe that you improve by taking the time to reflect, rather than by hurtling through the treadmill. That sometimes leads to conflicting feelings. Such as that time could also have been spent on an operation or on a consultation hour at the clinic. We often think that way, unfortunately, because production benchmarks require it. 4

After the first outcomes of the results, for each hospital we prioritised issues for analysis to test in practice. For me, this is one of the most wonderful things because this is when the first improvements appear. Such as unnecessary elements that we could save time on, like an X-ray that can be removed from the process. Not only is this one treatment less for the patient, it also saves time for the various departments and it saves on costs. By retrieving feedback (from patients) and evaluating the available literature, we’ve abolished the restrictive lifestyle rules that applied during the rehabilitation after a total hip prosthesis, such as having to sleep on one’s back. This is a good example of how EBM can be put into practice more quickly with VBHC. By centring VBHC improvement processes around patients’ questions and implementing them with patients, EBM is put into practice more quickly, and it makes improving the quality of care better and more fun. In this issue, we share the outcomes and results of the improvements achieved with regard to hip osteoarthritis care. I’m proud that I’ve been able to collaborate intensively on this. Rudolf Poolman, OLVG orthopaedic surgeon

CHAPTER 1

Better care through collaboration Value-Based Health Care (VBHC) focuses on optimising patient outcomes at advantageous rates. At Santeon, we have developed a VBHC model in which doctors and treatment teams from seven hospitals structurally learn, improve and implement points for improvement at their own hospitals. The Santeon hospitals openly work together to achieve faster and better patient outcomes. The Improvement Cycles were initiated in 2016. At every hospital, a multidisciplinary team discusses a disease and/or a patient group whose care could be improved upon. The improvement teams from the seven hospitals periodically (every six months) discuss results and potential improvement actions. This improvement process takes place on an ongoing basis. Improvement Cycles have now been initiated for breast cancer, hip osteoarthritis, strokes, prostate cancer, colon cancer, lung cancer, kidney damage, birth care and rheumatism. Coronary artery disease and IBD are slated to follow in 2018. After proceeding through three cycles, each lasting six months, we make the results publicly available in the interest of transparency. The first report, which appeared in December 2017, described our approach to, and the results of, the quality improvement process for breast cancer treatment. We can now also publicly

share the outcomes of the first three improvement cycles for hip osteoarthritis. In this publication, we describe the approach taken and the results achieved thus far. And Santeon’s VBHC working method appears to result in improved hip osteoarthritis care. Canisius Wilhelmina Hospital (CWZ) has not been included in this publication as its data was not sufficient. Canisius Wilhelmina Hospital, however, has since initiated Cycle 4 of the quality improvement process. Maasstad Hospital has been a Santeon hospital since June 2017. Given that the quality improvement process was launched in 2016, the only data available on hip osteoarthritis from this hospital originate from the third cycle. Santeon works with an international advisory board made up of methodological experts in the fields of VBHC, validation and data analysis. From a clinical management, public health and decision sciences perspective, board members share their expertise on outcome indicators and the selection process. The international advisory board critically discusses and evaluates the Santeon working method, data and analyses, and it dispenses advice on the basis of this discussion.

SAMYRA KEUS, PROJECT LEADER BART AMENT, PROJECT LEADER/DATA ANALYST MARJAN GORT, PROJECT LEADER

CHAPTER 2

Faster improvement in a structured improvement cycle METHOD IMPROVEMENT CYCLE WITH IMPROVEMENT TEAM Every six months, in addition to collecting Santeon-wide outcomes, cost and process data are also gathered from hip osteoarthritis patients. A multidisciplinary improvement team has been compiled for this at every hospital. The improvement team consists of one or two patients, as well as the professionals who play a role in the patient’s care. For hip osteoarthritis, these professionals include an orthopaedic surgeon, a geriatrician, an anaesthesiologist, a nursing specialist, a physiotherapist and care management. The improvement team is supervised by both a project leader and a data analyst. As full members of the improvement team, the patients and experience experts participate in selecting indicators,

FIGURE 1

prioritising improvements and developing and implementing improvement plans. They use their personal experiences to help others think about ways to improve care, making them a very valuable addition to the improvement teams! Each hospital’s improvement team meets on a bi-monthly basis. The team members select points for improvement, discuss the hip osteoarthritis data that has been collected and analysed and research the expected causes for the differences. An improvement plan is subsequently drafted and implemented based on the content of their discussion. Every six months, data is collected once more, and the seven improvement teams from the various hospitals meet to exchange their experiences and working methods. The next cycle

subsequently begins with looking for variations, researching causes and implementing improvements (see Improvement Cycle, FIGURE 1). DETERMINE SCORECARD At the start of the hip osteoarthritis improvement cycle (see FIGURE 2) the improvement teams jointly determine the patient group, treatment options and scorecard in three steps.

gender, socio-economic status (based on postal code via CBS) and Body Mass Index (BMI). In total, 9,082 newly diagnosed hip osteoarthritis patients fulfilled the inclusion and exclusion criteria of the Santeon hospitals (TABLE 1). Of these patients, 3,201 underwent a primary total hip replacement within one year. Maasstad Hospital patients are slightly younger on average than the patient groups at other hospitals. In addition, one can see that Catharina Hospital patients are relatively older. (FIGURE 3).

1. Definition of patient group In step 1, a uniform patient group is defined in order to collect data and conduct analyses on the same group of people at each hospital. For example, the decision was made to look only at those patients who were diagnosed at their own hospitals. This has the advantage of bringing the entire care process into view, which is typically more difficult for patients who have been referred. An overview of all the inclusion and exclusion criteria is available in TABLE 1.

TABLE 1

for Santeon’s VBHC programme INCLUSION CRITERION • Hip osteoarthritis diagnosis EXCLUSION CRITERIA

• P atients with prior DBC hip osteoarthritis within the last three years. • Patients younger than 18 years • Patients with Total Hip Prosthesis (THP), left and right • Operated patients in the LROI database who have a diagnosis other than osteoarthritis. • Patients with non-primary hip replacement (revision)

For the hip osteoarthritis patients, relevant patient characteristics were collected during the January 2015-December 2017 period (Cycles 1 - 3). These characteristics include aspects such as age,

Santeon VBHC improvement Cycle

IMPROVEMENT CYCLE Starting the team and the process

Determine scorecared and improvement plan

Collecting data & looking for differences

Continuously giving feedback & learning Implementing improvements

DBC (Dutch abbreviation) = diagnosis treatment combination LROI (Dutch abbreviation) = National Register of Orthopaedic Implants FIGURE 2

Three steps for creating a scorecard

1. DEFINITION OF PATIENT GROUP Analysing differences & identifying improvements

Hip-osteoarthritis patient selection

2. TREATMENT OPTIONS

3. INDICATORS

• Outcomes • Costs • Process

This could influence the outcomes. The hospitals have nearly the same ratio of men to women as regards hip osteoarthritis and primary total hip replacement (FIGURE 4). The hospitals, however, differ significantly in their distribution of socio-economic status. Patients who visit Medical Spectrum Twente have a relatively low socio-economic status compared to the patients who visit St. Antonius Hospital (see FIGURE 5). FIGURE 6 illustrates that, for the Santeon hospitals, Maasstad Hospital and Medical Spectrum Twente patients have a higher than average BMI.

FIGURE 3

FIGURE 4

Distribution of age

Santeon 12

Catharina 10

Maasstad 14

Martini 13

MST 13

OLVG 14

St. Antonius 11

25% <60 years

50%

<60-70 years

75%

100%

Catharina

CWZ Maasstad

Martini

MST

OLVG

St. Antonius

25%therapie Geen woman

FIGURE 6

Distribution of socio-economic status (SES)

FIGURE 7

Santeon

> 70 years

After an orthopaedic surgeon has diagnosed a patient with hip osteoarthritis, there are different treatment options available. These entail a conservative policy (with physiotherapy, pain medication and/or lifestyle advice) or a surgical procedure. When installing the prosthesis, the orthopaedic surgeon can choose from three different approaches to the hip joint, namely from the

Distribution of men and women

Radiotherapie man

FIGURE 5

entirety — from first reporting to a GP to receiving aftercare — It was necessary and desirable to expand the scorecard throughout the chain in the future.

2. Treatment options For the established patient group, the most common treatment options were identified from the moment the orthopaedic surgeon diagnosed hip osteoarthritis (FIGURE 7). This model was chosen because there was insufficient data available from outside the hospital, such as data on physiotherapy administered outside of the hospital. This means that the data from both pre-operative and postoperative physiotherapy has not been included, as is the case for pre-operative and post-operative geriatric care. In order to chart the care process in its

100

50% Resectie

100

Distribution of pre-operative BMI 100 50 100 25 50

Orthopaedic surgeon consult

CWZ

Uncemented

Direct lateral

Posterolateral

100%

Overig

Overview of treatment options for hip osteoarthritis patients.

Non-surgical policy

75% Chemotherapie

Chemoradiatie therapie

front (front or anterior approach), the side (lateral approach) or the rear (posterior or posterolateral approach). The hospitals differ substantially in their chosen approach (FIGURE 8). The surgeon’s preference and patient characteristics play an important role in this. Compared to other hospitals, Martini Hospital employs the anterior approach more often for its patients’ operations. Patients sometimes prefer the anterior approach, due to the positive stories they hear about it from other patients.

Surgical policy (Total Hip Prosthesis, THP) Geen therapie

Resectie

Radiotherapie

Chemoradiatie therapie

Chemotherapie

Return home Cemented Other destination

Anterolateral

Overig

100

Hybrid Santeon 32

Catharina 34

Maasstad 36

Martini 37

MST 67

OLVG 25

St. Antonius 9

25% SES < average

Santeon 1

Catharina 1

Maasstad

SES = average

75% SES > average

MST

OLVG

St. Antonius 1 0%

26 28 39

45 25%therapie Geen

BMI < 18.5 Radiotherapie BMI 18.5-25

Martini 1

100%

54 50%

50% Resectie

75% Chemotherapie

100%

Chemoradiatie BMI 26-30therapie BMI >Overig 30

Geen therapie

Resectie

Radiotherapie

Chemoradiatie therapie

Chemotherapie Overig

Source: LROI 10

100

They believe that they will recover more quickly and that the post-operative lifestyle rules, such as movement limitation, will be less strict. Martini Hospital examines the effect of this approach on the outcome of a hip replacement. This hospital also examines any resultant tissue damage (Polada 1, 2014 - 2016). The results of this will soon be published. In addition, we are currently researching whether the costs and the effects of the anterior approach are proportionate to the costs and effects of the posterolateral approach (Polada 2, 2015 - present). Major differences between the hospitals are visible in the type of fixation selected for the total hip prosthesis (FIGURE 9). St. Antonius Hospital and Medical Spectrum Twente primarily opt for cemented fixation, while Maasstad Hospital primarily opts for uncemented. One of the reasons for this is that the population attending Maasstad Hospital, on average, consists of younger patients.

3. Scorecard During the third step, the improvement teams determine a joint scorecard that lists the patient’s most important outcome, process and cost indicators (FIGURE 10). The following are the guiding principles for collecting data: relevant, practical and feasible. For example, no new data is collected; however, existing data sets are used that can automatically be extracted from the varoius source systems (e.g. the Electronic Patient Dossier). The outcome indicators are based as much as possible on existing indicators, such as those of the International Consortium for Outcome Measurement (ICHOM) and the National Register of Orthopaedic Implants (Dutch abbreviation: LROI), but also on patient-reported outcome measures (PROMs). To determine cost indicators, we analysed where the majority of the costs are incurred for the hospitals’ hip osteoarthritis treatments (e.g. OR, clinic or diagnostics).

In addition, several orthopaedics at Maasstad Hospital have a strong preference for installing uncemented prostheses because they have had good experiences with them for many years.

SACHA DEETMAN, a patient and a member of the hip osteoarthritis improvement team at OLVG.

FIGURE 8

‘ Actually, you shouldn’t tackle points for improvement in care without involving the patient.’

Santeon

Approaches

FIGURE 9

Catharina

Martini

MST

OLVG

25% anterior

anterolateral

50%

posterolateral

58 2

MST 2

100% direct lateral

OLVG 49

St. Antonius 13 75%

Martini

100

Maasstad 82

40 33

St. Antonius

Santeon 19 Catharina 37

100

Maasstad

Type of fixation

86 25%therapie Geen

50% Resectie

75% Chemotherapie

uncementedRadiotherapiehybrid Chemoradiatie cementedtherapie

100%

Overig

Source: LROI 50

100

The most important cost generators were determined for the largest cost categories, (e.g. operation duration, operation frequency, etc.). These were then added to the scorecard as a cost indicator. The waiting time for total hip replacement has been included as a process indicator.

for accountability purposes. The data are suitable for formulating hypotheses about improvement purposes, but not for drawing conclusions about the performance of a hospital. Whenever variation is detected, the improvement teams discuss whether it is interesting enough for further research.

COLLECTING AND DISCUSSING DATA Data have now been collected three times throughout the course of the improvement cycles. This was uniformly carried out at all of the hospitals and was coordinated by the programme manager, data managers and data analysts from the Santeon Programme Office. The data were validated together with the relevant professionals for each hospital and were also discussed with the various improvement teams of the seven Santeon hospitals.

Internally — that is, within and among the Santeon hospitals — the data from the scorecard are shared and discussed confidentially. To safeguard each other’s trust, we only share outcome indicators whose data are deemed sufficiently stable (not all outcome indicators are simple and unambiguous to collect and, therefore, are difficult to compare and interpret).

As part of the Improvement Cycle, we examined the effects of the improvement measures at each hospital. The results of the outcome, cost and process indicators have not been case-mix corrected. All possible patient characteristics that could explain variations (e.g. age, gender, BMI, etc.) were collected for possible further analysis. The data compared are not the result of scientific research nor can they serve as scientific evidence, and as such cannot be used

FIGURE 10

INCLUSION OF PATIENTS’ EXPERIENCES Not all of the care outcomes important for patients can be summarised in figures. That is why patients who participate in the improvement teams are also asked to share their experiences: What went well? What could be improved upon? We use so-called ‘mirror conversations’ to control whether these experiences and potential points for improvement also apply to patients at the other hospitals.

Hip osteoarthritis scorecard (Cycle 3) 1 2

PROMs (quality of life, pain and functional status)

OUTCOMES

From left to right: Jelmer Jager (physiotherapist), Sacha Deetman (experience expert) and Berber Selten (nurse/team leader)

IRINA MEIJERS ‘The special thing OLVG NURSING about VBHC, SPECIALIST compared to other

improvement projects, is that you sit down at the table with the patient.’

4 Complications during hospital admission for primary hip operation (blood transfusion, urinary tract infection, thrombosis or pneumonia) 5 Complications after the primary hip operation (during and within 30/90 days after hospital admission)

COSTS PROCESS

Repeat operation on the same hip within two years of post-OR (repeat operation at own hospital)*

Net OR time, per patient

Average purchase price per hip

Stay duration for patients with total hip operation: incl. repeat hospital admissions, per patient.

Hospital admission on the day of the operation (only applicable to primary hip operations, not to revisions)

Diagnostic activities, per patient

Waiting time to total hip operation, per patient

*A different patient selection process applied for this outcome measure due to the specific focus on revisions

CARINA ‘ Every care provider wants the “best care” for his or her GERRITSMA patients. But what is the best care? Quality and outcome ORTHOPAEDIC figures reveal only so much. The primary concern is the SURGEON, patients themselves, and they are all different. We compare MARTINI HOSPITAL our processes and outcomes with each other, but we also

know the patients under our treatment. This means that we can learn from each other and adapt our processes, wherever necessary, to provide each patient with the optimal treatment.’

(hip diagnosis & primary hip replacement in 2013, 2014 and 2015 for Cycles 1, 2 and 3, respectively).

ANITA TEN HAGE, ANASTHESIOLOGIST ATÂ MARTINI HOSPITAL

REMMELT VEEN ORTHOPAEDIC SURGEON AT ST. ANTONIUS HOSPITAL 16

RUDOLF POOLMAN ORTHOPEDIC SURGEON AT OLVG

ELGUN ZEEGERS ORTHOPEDIC SURGEON AT MEDICAL SPECTRUM TWENTE

CARINA GERRITSMA ORTHOPEDIC SURGEON AT MARTINI HOSPITAL

NIEK SCHEPEL CATHARINA ORTHOPEDIC SURGEON AT CATHARINA HOSPITAL

CHAPTER 3

Improvements in hip osteoarthritis care so far Since the launch in 2016, the teams have completed three Improvement Cycles for hip osteoarthritis. During these Improvement Cycles, multidisciplinary teams selected the topics for which they believed they could achieve improvements. Below, for several indicators, we describe which variations were observed during the first data collection, which follow-up actions were taken and what was measured during the third Improvement Cycle. FEW COMPLICATIONS DURING THE HOSPITAL ADMISSION All Santeon hospitals exhibit low complication percentages during hospital admissions for a total hip replacement (FIGURE 13). These data were collected from the complications registry. We investigated whether under-reporting might explain the low percentages at the Santeon hospitals. To test this, a team at OLVG (including the medical micorbiologist) assessed patients via a chest X-ray and a urinary sediment examination. At OLVG and Catharina Hospital, the patient dossiers were also controlled to determine whether they had a lung or a urinary tract infection. This confirmed, at least for OLVG and Catharina Hospital, the low percentages we

FIGURE 13

found. When discussing the low complication percentages, there did appear to be a difference in the infection prophylaxis for the hip replacement performed at the different hospitals. An inventory of the participating hospitals demonstrated that the peri-operative antibiotic prophylaxis varied in amount and frequency. In addition, there was a variation in the advice given to the patient to prevent wounds from becoming infected with staphylococcus aureus. For example, there was variation in the use of prophylactic nasal ointment and scrubbing the body with disinfectant soap. Discussing these outcomes within the improvement team (including the nursing specialist, the patient and the medical microbiologist, among others) allows for better coordination of medical advice.

Patients without complications during their hospital admission

Santeon

96 97

Catharina

94 96

Maasstad

RUUD STOKVIS OLVG patient and rowing enthusiast.

Martini

97 98

MST

98 96 96 96

OLVG

St. Antonius* 20%

0% Cycle 1

40%

60%

80%

99 100%

Cycle 3

Geen therapie

Resectie

Radiotherapie

Chemoradiatie therapie

Chemotherapie Overig

*A portion of the admission data was not available due to the transition to the new EPD.

100

‘ Comparing all of the data on hip operations between the hospitals is interesting. It’s a lot of work to collect the statistics, but given the results, it’s worth it. 19

only 34%. In Cycle 1, the median hospital stay at Santeon hospitals due to primary hip replacement was four days (Q25% - Q75%: 3-5). In Cycle 3, this was reduced to a median stay of three days (Q25% -Q75%: 3-4). In FIGURE 16, we see a trend of a declining hospital admission duration; this decrease is due to improvement initiatives implemented by five hospitals. FIGURE 17 depicts the percentage of patients with a relatively long stay of four or more days around their operation. The only dates available from Maasstad Hospital were from Cycle 3. All other Santeon hospitals exhibit an improvement (a reduction), ranging from 4% to 66% between Cycle 1 and Cycle 3.

Cumulative decreasing stay within Santeon

FIGURE 16

FIGURE 14

Patients without complications within

100%

75%

50%

25%

IMPROVEMENT INITIATIVES STAY DURATION More hospital admissions on the day of the operation (K4) For a hip replacement, patients can be admitted on the day of the operation itself. For the patient, this offers the advantage of a greater likelihood of a better night’s sleep; and for the hospital, this contributes to optimal deployment of their beds. However, in Cycle 1, it appeared that a large proportion of patients were being admitted a day earlier at several hospitals (FIGURE 18). The percentages of patients admitted on the

FIGURE 15

90 days of a primary total hip operation

4 5 6 number of admission days

98 97

Santeon

95 96

Catharina

97 94

Catharina

96 94

98 98

Martini

99 100

MST

97 96

OLVG St. Antonius* 20%

0% Cycle 1

40%

60%

80%

98 100 100%

Cycle 3

*A p ortion of the admission data was not available due to the transition to the new EPD.

Patients without complications within 30 days of

Maasstad

Martini

95 94

MST

St. Antonius* 0%

20% 40% 60% 80% Geen therapie Resectie Chemotherapie Cycle 1 Radiotherapie Cycle 3

Chemoradiatie therapie

Catharina

Maasstad

Martini

MST

OLVG

53 87

St. Antonius *

14 20%

0% Cycle 1

Cycle 3

100

97 97

OLVG

day of the operation ranged from 26% to 100%. Martini Hospital compared their organisation of the care process on the morning of an operation to this care process at the Medical Spectrum Twente and Catharina Hospital. At Medical Spectrum Twente, for example, all patients are admitted to the holding of the OR on the day of operation, if possible. At Martini Hospital, a similar change in the care process has caused an increase in the percentage of patients admitted on the day of the operation from 26% (in 2016) to 46% (in 2017). OLVG has achieved that all of its orthopaedic team members are now operating according to the same care path. It also became apparent that the figures from the former West location were the primary cause for the higher number of hospital admissions on the day before the operation. Due to the merger and relocation of the entire orthopaedics department to the West location, the working method of the East location had been employed. A hospital admission clinic has been set up so that patients are better prepared for the ward on the day of the operation.

a total hip operation (unplanned re-admission)

Santeon

40%

60%

80%

100%

Cycle 3

*A p ortion of the admission data was not available due to the transition to the new EPD.

Santeon

Maasstad

or longer around a primary total hip operation

around a primary total hip operation

Cycle 1

SHORTER STAY AROUND THE OPERATION (K3) From the perspective of costs and for the patient, it is better to keep the hospital admission as short as possible. A longer than necessary hospital stay can lead to avoidable complications such as delirium and a general loss of function. However, self-sufficiency is paramount upon being discharged. The rapid decline and relatively lower position of the curve associated with Cycle 3 in FIGURE 16 shows that patients were discharged sooner after total hip replacement in comparison to Cycle 1. Whereas, in Cycle 1, 57% of all operated patients had a stay of four days or longer, this declined in Cycle 3 to

Percentage of patients with a stay of four days

FIGURE 17

cumulative percentage of patients

Few complications 30 and 90 days after the first total hip replacement (FIGURES 14 AND 15) The percentages for complications within 30 and 90 days after the total hip prosthesis were also low in Cycle 1. Hip luxation emerged as an important complication in the patients’ prioritisation of the outcome indicators. As one patient put it, ‘Everything stops, of course, when you dislocate your hip.’ This is why, in part, the percentage of hip luxations has been further researched at all of the hospitals. Upon further researching patients who reported to the accident and emergency department (A&E) after being discharged for their hip replacement, the percentage of hip luxations appeared to be accurately low.

98 100%

Overig

*A p ortion of the admission data was not available due to the transition to the new EPD.

Accelerated recovery Medical Spectrum Twente has started implementing ‘Rapid Recovery’, learning about this from Martini Geen therapie Resectie Chemotherapie Hospital, which has been workingOverig on the programme Radiotherapie Chemoradiatie therapie since 2012. For ‘Rapid Recovery’, patients follow an intensive exercise programme whereby they are

100

FIGURE 18

Hospital admission on the day of the operation 57

Santeon

Catharina

100 97

Maasstad

98 26

Martini

46 98 99

MST 56

OLVG

97 88

St. Antonius * 20%

0% Cycle 1

40%

60%

80%

98 100%

Cycle 3

*A p ortion of the admission data was not available due to the transition to the new EPD.

already out of bed on the day of the operation, with the help of a physiotherapist and nurses. The patient is informed about this via an information brochure that he or she receives at the outpatient clinic. This brochure describes the entire step-by-step process for before, during and after the operation. The advantage of the ‘short stay treatment plan’, which basically lasts for three days, is that it prevents the muscles around the hip from weakening. In addition, there is a lower risk of complications. 21

complications and a long hospital stay are guided by trained first-line physiotherapists so they can be more fit for their operation. This is expected to result in a faster recovery and a shorter stay for this group of high-risk patients. The effect of a shorter stay on outcomes As with all cost indicators, the indicator ‘stay duration around the operation’ must always be considered in relation to the outcomes. The available outcomes exhibited no difference between hospitals with shorter or longer hospital stays. Given the evidence for a greater risk of complications and a decline in overall functioning due to an (extended) stay, the reduction in the stay duration is a success. The orthopaedic consultants play a major role at Martini Hospital. They check the wound leakage so that the patients are able to go home sooner. The improvement teams are seeking greater insight into the value of care via the PROMs (an ongoing improvement initiative) and insight into the use of physiotherapy after discharge (an ongoing improvement initiative). REDUCTION IN NUMBER OF X-RAY PHOTOS PER PATIENT (K5.1.1) The faster decline and the lower position of the curve for Cycle 3 in FIGURE 19 indicates that fewer X-rays were taken at the Santeon hospitals for patients who underwent a total hip operation, in comparison with Cycle 1. Whereas in Cycle 1, 70% of all of the operated patients had three or more X-rays taken, this declined to 52% in Cycle 3. FIGURE 20 shows the percentage of patients who had three or more X-rays taken for a total hip operation. The only data available from Maasstad Hospital were from Cycle 3. Medical Spectrum Twente exhibits a clear decrease in X-ray diagnostics. Whereas in Cycle 1, 95% of the patients had three or more X-rays taken, in Cycle 3 this declined to 43% of the patients. During the Cycle 1, Santeon-wide discussion about data, it became evident that patients at Medical Spectrum Twente received an average of one additional X-ray compared to the other hospitals. To further reduce radio-diagnostic activities, we examined which diagnostics were performed and why. It turned out that an X-ray was also taken upon the referral of the GP with questions about hip osteoarthritis.

When this diagnosis was indeed made, and the hip had to be replaced by a prosthesis, another X-ray was taken with a balancing ball to determine the size of the prosthesis. The calibration bullet is now immediately photographed upon suspicion of hip osteoarthritis, and this has resulted in the cancellation of the second X-ray. GREATER AWARENESS Compared to the other Santeon hospitals, a higher percentage of arthrographies were performed on patients at Catharina Hospital. We have conducted in-depth analyses and promoted greater awareness in the orthopaedics department. Currently, the percentage of arthrographies has already significantly decreased in this patient group, while the outcome indicators remained the same FEWER LIFESTYLE RULES FOR ACTIVE HIP PATIENTS ‘If I have to comply to everything, I’ll sit still on a chair all day’, explained a patient to OLVG’s improvement team. An inventory revealed approximately 70 verbal and written lifestyle rules that patients were supposed to follow after undergoing a total hip replacement. These lifestyle rules have since been removed when there is no evidence or expectation that they will benefit the patients or increase their comfort (expertise of care professionals and the patients). The focus is now on the activity of the patient. The improvement team at Catharina Hospital also indicated that the information about physiotherapy and the limitations of anti-luxation advice was no longer up-to-date. We have put together an implementation team and performed a literature review to implement the most recent recommendations. The brochure material has been adapted, and staff have been informed about the change in the lifestyle rules.

FIGURE 19

Cumulative decreasing number of X-rays within Santeon for a primary total hip operation

100%

75%

50%

cumulative percentage of patients

Pain relief is adjusted accordingly, to prevent nausea. Approximately one third of the patients at Medical Spectrum Twente recover in Bad Boekelo (Energ-IQ), with good scores for physical outcomes and patient satisfaction. This concerns a nine-day recovery programme at a resort hotel with an intensive training programme. The patient arrives at the resort hotel on the second day after their operation. During the Santeon-wide meeting, there appeared to be a difference of opinion about whether or not to discharge patients with wound leakage. Patients whose wound is still moist typically remain in a hospital until it is completely dry. Medical Spectrum Twente and St. Antonius Hospital have initiated a process that allows patients still experiencing wound leakage to go home. Patients are monitored daily by the home care nurse, and they remain under the responsibility of the medical specialist. At Medical Spectrum Twente, patients who have been discharged with wound leakage are checked more intensively, shortly after their discharge, by a nurse at the special wound treatment outpatient clinic/ follow-up treatment. At Catharina Hospital, due to the improvement initiative, the hospital stay has been reduced to three days. The improvement initiative was initiated by a patient and physiotherapist participating in the team. The staff has been informed, brochures have been adapted and the anaesthesiologist has adjusted the pain management so that the patient is not too nauseated to recover. If possible, the patients are mobilised on the day of the operation. Furthermore, Catharina Hospital is consulting with Martini Hospital to learn from its experiences with the Rapid Recovery Programme. An improvement initiative on long-term admissions has also been launched at OLVG (Rapid Recovery). In this context, every aspect of the care for the hip replacement was examined to ascertain why the patients were still in the hospital. For the Rapid Recovery project, delegates from all of the disciplines were involved in the care path. The major achievement at OLVG’s West location was the establishment of a nursing home department for geriatric rehabilitation care (GRZ) at the hospital. This has resulted in improved throughput in the orthopaedic nursing department. A ‘Better in Better out’ (BiBo) pilot was launched at the end of 2017. For this pilot, patients who are at a high risk of

25%

Cycle 1

4 5 number of X-ray photos

Cycle 3

FIGURE 20

Percentage of patients with three or more X-rays for a primary total hip operation

Santeon

Catharina

81 84

Maasstad

Martini

MST

62 95

43 60 60

OLVG 20%

0% Cycle 1

40%

60%

80%

100%

Cycle 3

St. Antonius Hospital is missing due to insufficient data (in connection with the transition to a new EPD (Electronic Patient Dossier).

FASTER RETURN HOME WITH MEDICATION, POST-DISCHARGE The main point of improvement for a patient from the OLVG improvement team was the management of the medication transfer after discharge. Patients pick up their medication at the pharmacy upon being discharged (obtaining their prescription on the department). 23

This patient indicated that the waiting time at the pharmacy was long and uncomfortable. ‘You already feel lousy and you just want to go home’. Other patients noted this same experience during a mirror conversation. It turns out that patients are usually discharged at the end of the morning, and they arrive at the pharmacy at the busiest moment of the day. Because the medication requires a lot of customisation, the necessary ‘clipping time’ to obtain the right amount is approximately twenty minutes per patient. This has been since been tackled as an improvement initiative, and the prescription for the patient is now written with numbers that correspond to those on the packaging. The prescription is sent to the pharmacy one day prior to the discharge, and it is ready for the patient once he or she arrives at the pharmacy. At this moment, we are researching whether the medication can also be handed over to the department itself. The latter has already been realised at Martini Hospital with ‘Medication safety at discharge’. A new uniform procedure has been introduced for transferring medication upon the discharge of the patient. The Electronic Patient Dossier has been adapted for this method, so medication verification is now an automated part of the work process. NEW LEARNING MODULE FOR MEDICATION USAGE A special (compulsory) learning module has been developed at Martini Hospital to provide

clear instructions to all concerned about the new approach to the usage of medication. This minimises the errors committed with medication. Every subsequent link in the chain (GP, geriatric medicine specialist, pharmacist and thrombosis service) receives timely and correct information about the patient’s medication usage. With this method, the patient receives information about safe medication use, so that he or she can also be alert about this. The pharmacist’s assistant provides this information on the day of the discharge. In addition, patients can take advantage of a service that delivers the medication they will take at home directly to their department before they are discharged. All patients also receive a regimen for tapering their pain medication. Patients are telephoned by the orthopaedic consultant approximately five days after their discharge. Initially, patients had multiple questions about the pain medication because they could not remember the oral information. Patients now clearly understand how to deal with their pain medication.

place rather than the date. The exact date is set two weeks before the operation to minimise the chances of a cancellation. Staff members have been informed of this change and they are communicating this to their patients. GREATER TRANSPARENCY ABOUT REVISIONS The previous statement by a patient that, ‘Everything stops, of course, when you dislocate your hip’ is certainly also the case for revision surgeries (repeat operations). FIGURE 21 illustrates the percentage of patients who have not undergone a revision surgery within two years. Of all the patients in the Santeon hospitals, 97.9% have not undergone a revision surgery within two years. For a comparison between the Santeon hospitals

FIGURE 22

and other Dutch hospitals, we used the LROI dashboard (see also: http://www.lroi-rapportage. nl, the National Registry of Orthopaedic Implants). This depicts the proportion of revision surgeries performed within a year of a primary total hip operation in 2015, per hospital in the Netherlands. This has been corrected for age, gender, ASA score, diagnosis (osteoarthritis versus other diagnoses), BMI, the Charnley score and smoking. The Santeon hospitals have identified themselves in this data (see FIGURE 22). All Santeon hospitals scored approximately the average, with the exception of Martini Hospital. On average, this hospital had a lower percentage of revisions after primary total hip replacement; it also had the lowest revision percentages.

Percentage of revision surgeries within one year. LROI national comparison.

BETTER INFORMATION ABOUT THE OPERATION DATE Catharina Hospital had a higher number of cancellations for the operation date than the other Santeon hospitals. This was very annoying for the patients. Therefore, the decision was made not to record the date for an operation in advance. Patients are told the period in which their operation will take

4 FIGURE 21

Patients without a revision two years after undergoing a primary total hip operation 98 98

Santeon Catharina Maasstad

98 98 97

Martini

100 98

MST

98 98

OLVG St. Antonius 20%

0% Cycle 1

97 97

40% Cycle 3

60%

80%

99 98 100%

200

400

600

800

Number of primary total hip prostheses per care provider in 2015 Geen therapie

Resectie

Radiotherapie

Chemoradiatie therapie

100

Chemotherapie

Overig

Catharina

Maasstad

Martini

MST

OLVG

St. Antonius

©LROI, June 2017

Subsequently, Medical Spectrum Twente and Maasstad Hospital also had a low number of total hip replacement revisions. In order to learn from all of the Dutch hospitals, the other hospitals in the funnel plot would preferably also be identified. Therefore, even greater transparency in the next LROI publication would be welcomed. GREATER FOCUS ON PROMS One of the most important outcomes — certainly for the patient — is quality of life. Within the Santeon hospitals, this is measured with the EQ-5D (an index score and thermometer). The symptoms experienced due to osteoarthritis are measured with the HOOS-PS (a shorter questionnaire) and a numerical pain scale (at rest and with activity). Patient Reported Outcome Measures (PROMs) are administered to all patients who have been diagnosed with hip osteoarthritis. PROMs offer patients and orthopaedists the opportunity to gain insight into the outcome of the treatment and any patient-oriented aftercare. Currently, only those patients who undergo an operation (total hip replacement) receive PROMs; this takes place prior to the operation and at three and twelve months after the operation (see FIGURES 11 AND 12). The PROMs, however, do not provide any insight into the functioning, pain and quality of life of the

FIGURE 11

hip-osteoarthritis patient group that has not had an operation. The patient group receives only the questionnaire at the start of the treatment. This information could be helpful in the decision-making about whether or not to operate. Compared to Cycle 1, the PROMs response percentage has increased for all of the hospitals. An analysis team has been set up at Medical Spectrum Twente, consisting of a team head and a secretary, who are responsible for the PROMs request. The response is checked, and patients receive a small reminder or a phone call if they fail to complete it. As a result, the response percentage has increased. At Martini Hospital, patients receive a digital questionnaire as an intake to inventory their personal history and the relevant circumstances of their complaints (Digital Auto Medical History Dutch abbreviation: DAA); PROMs are part of this questionnaire. Patients receive the questionnaire prior to their first consultation. This gives the orthopaedic surgeon a good idea of the patient’s complaint(s) and the reason for him or her to visit the Orthopaedic Outpatient Clinic. In addition, by completing the questionnaire in advance, patients are better prepared for their consultation. DAA and PROMs enable both the orthopaedic surgeon and the patient to ask specific questions during the consultation.

FIGURE 12

PROMs response, pre-operative

PROMs response, three months post-operative

Santeon Catharina

OLVG

20% Cycle 1

40% Cycle 3

60% no data available

80%

100%

St. Antonius

34 0%

MST

St. Antonius

OLVG

Martini

MST

Maasstad

66 44

Martini

Catharina

Maasstad

Santeon

61 14 20% 40% Geen therapie

0% Cycle 1

Radiotherapie Cycle 3

60% Resectie

80% Chemotherapie

Chemoradiatie therapie no data available

100%

Overig

From left to right: Heleen Hoogeveen; Martini Hospital data analyst, Susanne Tielemans; Catharina Hospital data analyst, Yvette van der Zande-van Gestel; Catharina Hospital data analyst, Daisy Pieterse; Santeon data analyst and Harmke Groot; OLVG data analyst

The relatively low response percentage at Martini Hospital in 2017, three months after the patients’ hip replacement, was an underestimation. Some of the patients operated on in 2017, because of an orthopaedic research (Polada 2), completed a different questionnaire in this period than the regular PROMs. It appears that, due to a multitude of tasks and activities, it is difficult for orthopaedic consultants to consistently telephone patients who have not completed their questionnaire. With the appointment of a research assistant, Martini Hospital is attempting to achieve a higher response rate in the short term, as well as the feedback of the Geen therapie Resectie Chemotherapie PROMs information the orthopaedists. Radiotherapie Chemoradiatieto therapie Overig OLVG has also begun implementing DAA. In addition to the current disease-specific PROMs, the added

100

value and the feasibility of implementing a generic PROM is being researched. An evaluation has shown that we require a working method that specifically focuses on the expansion of the lists and the subsequent telephone calls to the patients. In order to achieve this, an employee or nurse will be appointed to increase the response rate for the digital intake and the PROMs. With better analyses and feedback, the results of the treatment can be clearer and more transparent. We will also examine to what extent the insights gained from PROMs can be better utilised to benefit the individual patient in his or her post-operative care. The response percentage is essential for this.

ROALD VAN LEEUWEN PROGRAMME LEADER AT SANTEON

ANNEMIEKE GROENESTIJN PROJECT LEADER AT MAASSTAD HOSPITAL 28

BART AMENT PROJECT LEADER / DATA ANALYST AT CANISIUS WILHELMINA HOSPITAL

SAMYRA KEUS PROJECT LEADER AT OLVG

MARJAN GORT PROJECT LEADER AT MARTINI HOSPITAL

Attachment 1 The improvement teams

What’s next? ‘Comparing the outcomes that really matter to our patients is a simple and very powerful idea. Every time I have the chance to attend one of our improvement team meetings, I’m struck by how driven the medical professionals are to continuously improve health care. The comparison regularly offers surprising insights, and it is only possible thanks to the openness and professionalism of our doctors, nurses and VBHC specialists. The fact that patients participate in these meetings ensures that the conversations are about the topics that are important for them. By also comparing costs, we contribute to our ambition to provide the best possible care, and to keep it affordable. We’ve asked ourselves whether we should publish our VBHC method and the figures in a report like this.

We decided to publish them because we believe that it is vital to have transparency in health care. By being open, we can learn from each other and from others. And, hopefully, others can learn from us. And we hope, therefore, that others will follow this example. This report also shows that there are still steps to be taken. For example, we have not yet shared our data on Patient Reported Outcome Measures (PROMs). We expect to be able to do this the next time, if we have a larger group of patients who have completed our questionnaires. Far more important, of course, is that we still see opportunities to make improvements that also matter to our patients: We will continue to focus on this at Santeon.’ Pieter de Bey, Santeon Director

ATTACHMENT 1 INVOLVED IMPROVEMENT TEAMS CANISIUS WILHELMINA HOSPITAL

MEDICAL SPECTRUM TWENTE

This hospital did not participate in the first three cycles for which we are sharing the results here.

Elgun Zeegers

Orthopaedic surgeon

Claar Bijleveld

Anaesthesiologist

CATHARINA HOSPITAL

Anita Mulder

Nursing specialist

Niek Schepel

Orthopaedic surgeon

Inge van Keulen

Nurse

Rob Lanfermeijer

Experience expert

Michelle Bisschop

Secretary of orthopaedics outpatient clinic

Judith Wilmer

Clinical geriatrician

Melanie Mecking

Physiotherapist

Kim Bijleveld

Anaesthesiologist

Sandra Oude Wesselink

Data analyst

Marieke van der Steen

Scientific researcher

Elly Huiskes

Project leader

Gerard Kiebert

Physiotherapist

Sylvia de Mey

Mariette Stellenboom

Nursing specialist

Ilse-Marita Smeulders

Senior nurse

OLVG

Kim Hommeles

Senior nurse

Rudolf Poolman

Orthopaedic surgeon

JosĂŠ Meulepas

Project leader

Sacha Deetman

Experience expert

Yvette van der Zande-van Gestel

Data analyst

Ruud Stokvis

Experience expert

Susanne Tielemans

Data analyst

Irina Meyers

Nursing specialist

Annabeth Groeneveld

Nursing specialist

Experience expert

Berber Selten

Nurse/team leader

Pieter Bakx

Orthopaedic surgeon

Helma Meijer

Geriatrics nursing specialist

Christiaan Verhelst

Nurse supervisor

Jelmer Jager

Physiotherapist

Seppe Koopman

Anaesthesiologist

Vanessa Scholtes

Orthopaedics policy adviser

Robbert Boer

Physiotherapist

Rogier Jansen

Medical microbiologist

Elise Hussaarts

Physiotherapist

Carolien Vinkesteijn

Operational manager

Maxime Frank

Orthopaedic physician-assistant

Amanda Klaassen

Orthopaedics staff member

Karin Kraaijeveld

Orthopaedic physician-assistant

Rik Nienhuis

ANIOS

Ina Molegraaf

Transfer nurse

Doeke Bijlmakers

Data analyst

Hetty ten Oever

Nursing department team leader

Samyra Keus

Project leader

MAASSTAD HOSPITAL

Renee Vis

Outpatient clinic team leader

Rob de Vogel

Orthopaedics manager

Martijn Kuijper

Data analyst

Remmelt Veen

Orthopaedic surgeon

Gerdine Pols

Data analyst

Christel Braaksma

ANIOS orthopaedics

Ellen Parent

Project leader

Gijs Jansen

Physiotherapist

Annemieke Groenestijn

Project leader

Saskia Visser

Senior nurse

Sara Bolle

Physiotherapist

Sjors van de Maat

Department head

MARTINI HOSPITAL

ST. ANTONIUS HOSPITAL

Carina Gerritsma

Orthopaedic surgeon

Trudy Hermans

Bas ten Have

Orthopaedic surgeon

Wencke Ameling

Outpatient clinic assistant

Hieke van der Veen

Unit head

Wouter van Maarseveen

Sonja Niemeijer

Care coordinator

Karin de Gooijer

Data analyst

Steven Bijlholt

APS recovery

Jos Kroon

Project leader

Anita ten Hage

Anaesthesiologist

Tjerk Munsterman

Physiotherapist

SANTEON

Lidy van Lente

Physiotherapist

Roald van Leeuwen

Programme leader

Marjan Gort

Project leader

Coco Levendag

Adviser

Heleen Hoogeveen

Data analyst

Jos Hendrikx

Data analyst

Hetty Prinsen

Data manager

Daisy Pieterse

Data analyst

Lea Dijksman

Adviser

Annemarie Haverhals

Programme leader until December 2017

Team head

Manager

ATTACHMENT 2 EXPERTS

WE THANK THE INTERNATIONAL ACADEMIC ADVISORY BOARD FOR INSIGHTS INTO THE METHODOLOGY USED: Prof. Fred van Eenennaam, Programme Coordinator of the Decision Group Prof. Grant T. Savage, Professor of Management, Co-Director, Series Editor at George Washington University Prof. Søren M. Bentzen, Director of the Biostatistics Shared Service at the University of Maryland Prof. Valery Lemmens, Head of EMC/IKNL research

COLOPHON

Text and editing Lea Dijksman Coco Levendag

‘ WHAT WE DO IS TO IMPROVE CARE TOGETHER WITH THE PATIENT BY SHARING KNOWLEDGE AND INSIGHTS FROM DAILY PRACTICE’

Samyra Keus Maartje Wielders Marloes de Wit

Design Telvorm graphic design Photography Joris Lugtigheid Hans Moinat

More information Santeon Herculesplein 38 3584 AA Utrecht info@santeon.nl +31 30 25 24 180 www.santeon.nl

ROALD VAN LEEUWEN SANTEON PROGRAMME LEADER

Manja Herreburgh 34

Santeon Herculesplein 38, 3584 AA Utrecht, info@santeon.nl, www.santeon.nl Canisius Wilhelmina Hospital Weg door Jonkerbos 100, 6532 SZ Nijmegen Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven Maasstad Hospital Maasstadweg 21, 3079 DZ Rotterdam Martini Hospital Van Swietenplein 1, 9728 NT Groningen Medical Spectrum Twente Koningsplein 1, 7512 KZ Enschede OLVG Oosterpark 9, 1091 AC Amsterdam â&#x20AC;˘ Jan Tooropstraat 164, 1061 AE Amsterdam St. Antonius Hospital Soestwetering 1, 3543 AZ Utrecht â&#x20AC;˘ Koekoekslaan 1, 3425 CM Nieuwegein