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A Joint Effort

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LEXINGTON Repairing and replacing knees and hip joints is what Tharun Karthikeyan, MD does for a living. He’s well trained for it, having attended the University of Pittsburgh School of Medicine and completing an orthopedic surgery residency and trauma fellowship there. He also performed an adult reconstructive fellowship specializing in hip and knee replacement at the OrthoCarolina Hip and Knee Center.

All of that led him to join Lexington Clinic Orthopedics – Sports Medicine in 2012 as an adult reconstruction surgeon. What led him to also become the director of Total Joint Replacement at Saint Joseph Hospital is a slightly different path.

Saint Joseph Hospital voluntarily enrolled in the bundled payment care initiative with the Centers for Medicare & Medicaid Services (CMS) in July 2015. The bundled payment structure assigns a flat payment for a particular procedure, such as a total knee replacement. If the costs of that procedure exceed the flat amount paid by the insurance policy, then the hospital and providers are responsible for the difference.

What some might see as an unfair shift in the cost structure, Karthikeyan and his team viewed as a chance for improvement. “We saw an opportunity to potentially coordinate the care that could result in improvement in outcomes for our patients and significant cost savings for the hospital and CMS at the same time,” Karthikeyan says. “There’s incentive for us to bring down costs. At the same time, quality continues to be emphasized. Those things usually go hand in hand because complications and poor outcomes tend to cost more.”

Karthikeyan and hospital administrators developed the concept for the director of Total Joint Replacement as the leader of a cohesive team dedicated to positive patient outcomes as well as lowered costs. “Everybody started to realize that it needs to be more than isolated physicians doing procedures in completely different ways and not communicating with the rest of the people who help to take care of the patients,” Karthikeyan says. “It all has to do with a comprehensive, interdisciplinary team that works together to improve the quality of care of our patients, therefore improving outcomes.”

Now the team operates more cohesively, with physicians, nurses, physical therapists, case managers, registration clerks, and occupational therapists meeting on a regular basis to determine what can be done to improve the patient experience.

Among the solutions proposed was the formation of the Total Joint Academy. It is a mandatory program that every joint replacement patient must complete prior to surgery. The class covers what the patient can expect at the hospital, what steps they need to take to commit to physical therapy afterwards, and how to engage in risk modification ahead of time to improve their chances of success.

“The greatest improvement has been consistency of message,” Karthikeyan says. “The infrastructure that we’ve put in place for total joints means that everybody receives the same information from start to finish. The Joint Academy, led by Liz Lyons, has been critical. As patient expectations, surgeon expectations, and hospital expectations are aligned, then patients are more satisfied, have better outcomes, and costs come down.”

According to Karthikeyan, the data bears out the success of the program: the volume of total joint replacements at Saint Joseph Hospital has nearly quadrupled since July 2015, readmission rates have been reduced by nearly three quarters, patient satisfaction has improved substantially, and the hospital has experienced significant cost savings.

The progress seems to be coming at just the right time, as the length of approved hospital stays are being shortened by insurance providers. For instance, joint replacement is considered an inpatient procedure for most providers, but Karthikeyan notes that many insurers are starting to move toward approving it as an outpatient procedure.

“In my practice the average length of stay in the hospital for total joint replacement is 23 hours, but the average in the country is three days in the hospital,” he says. “What do you gain by keeping the patient in the hospital those extra two days? Most people are getting on board with the fact that the best place to recover is at home.”

Karthikeyan exclusively performs hip and knee replacements, as well as revisions, which account for approximately 25 percent of his procedures. The average age for knee replacement patients is about 63 years old, compared to 68 for hip replacements. Karthikeyan says those average ages are coming down as advancements allow for more effective outcomes for younger patients.

“The current generation of plastics has revolutionized our business,” Karthikeyan says. “The plastic was always the weak link in the system. The lifespan of an implant was usually contingent on that plastic. While we haven’t completely eradicated that problem, we see it at such a far lower rate that it has allowed us to expand these operations to fit a younger, more active population that we couldn’t have done 20 years ago. The paradigm has shifted such that we can provide this operation to people at a younger age.”

Karthikeyan also seems to be on the leading edge of a shift in hip replacement procedures. While the posterior approach continues to be the most common, Karthikeyan prefers the less invasive anterior approach and the supine positioning of the patient on the operating table. “It allows me to implant the components under X-ray, which lets me be extremely accurate in terms of component position, leg length, (and) restoration of the normal anatomy,” Karthikeyan says. “That confers a longterm benefit over the lifetime of the implant and the lifetime of the patient. The length of the hospital stay tends to be less, the amount of time in physical therapy tends to be less, and the time off of work tends to be less.”

He says that, while reliable, the posterior approach comes with downsides, including greater risk of dislocation, the trauma of muscle dissection, and muscle detachment.

Reducing those potential complications and longer hospital stays is a large part of the decision-making process in the new patient care model. “Once we really start paying attention to the global care of the patient rather than our one specific niche, when we start to see that episode of care as a whole, we see a lot of fat that can be cut,” Karthikeyan says. “If the hospitals and providers are able to take control over all of that, we can improve the quality of care while delivering it at a lower cost.”

I think we can improve the quality of care while delivering it at a lower cost. — Dr. Tharun Karthikeyan, Lexington Clinic

NFL Hall of Famer visits Lexington and Talks about Joint Replacement

LEXINGTON As part of patient outreach and education for total joint replacement, Saint Joseph Hospital Orthopedics hosted Hall of Famer and former Pittsburgh Steeler running back Jerome Bettis to talk about arthritis of the hip and knee and his personal experience with joint pain as a result of his professional football career.

Tharun Karthikeyan, MD, an orthopedic surgeon with Lexington Clinic and director of the total hip and knee replacement surgical program at Saint Joseph Hospital, visited patients with Bettis and later spoke at a seminar for patients regarding surgical and nonsurgical alternatives for knee and hip replacements.

Elizabeth Lyons, BSN, RN, CRRN, patient navigator for the total joint replacement program at Saint Joseph Hospital said, “We’ve had over 120 joint replacements since the seminar in April. Four of the 120 were attendees. We will be up to five within the next month.”