Outpatient joint replacement: Patient selection vs. pathway selection


Leading experts in joint replacement came together at a SwiftPath RoundTable held in conjunction with Becker's ASC Conference last fall in Chicago.

In this meeting, as in others that SwiftPath has held across the country, high-volume joint replacement experts gathered to discuss the critically important elements of outpatient joint replacement. Each topic is addressed using the Delphi method. The Delphi method is a structured format where joint replacement specialists gather with the goal of achieving consensus. These surgeons are asked specific questions and respond anonymously. Answers are collated and reviewed in the light of relevant literature and further discussion. Multiple rounds of questioning are done, and questions reformatted until consensus is achieved.


“This is a very effective way of developing clinical pathway guidelines, as has been shown by Bini and Mahajan a recent lead article in the Journal of Arthroplasty. It is a very inclusionary approach where the participants become invested in and committed to those clinical pathway guidelines. That is how you increase adoption rates,” says Craig McAllister, MD, president and CMO of SwiftPath.


SwiftPath’s RoundTable meetings typically involve 12 to 16 high volume joint replacement surgeons — each averaging over 250 joint replacements annually. This means that each meeting represents a collective volume of over 4,000 joint replacements per year. These meetings have addressed over 75 issues pertaining to outpatient joint replacement including modern pain management, surgical approaches, discharge criteria, home care monitoring and patient reported outcomes.


“All experts agree that patient selection issues are key to any approach to outpatient joint replacement, but most attempts to develop patient selection criteria are flawed because they look at failure modes rather than predictive analytics,” Dr. McAllister says.


Dr. McAllister goes on to point out that the traditional notions of patient selection focus on which patients should or should not have surgery and rely on data that is mined from large hospital databases. These studies juxtapose co-morbidities and other negative predictors against negative events such as complications, hospital acquired conditions and readmissions.


“Why would we use a list of negative factors and hospital related events to predict a positive outcome from outpatient joint replacement protocols?” Seasoned joint replacement experts that have pioneered outpatient joint replacement have their own ways of deciding which patients are appropriate — in their hands. While these pearls of wisdom are helpful, they don't really provide objective decision-making aids for other surgeons.


“The SwiftPath Pathway Selection App takes a completely different approach. We are not talking about a standard patient selection formula like most surgeons are used to,” says Dr. McAllister. Results from the RoundTables were used to create a series of weighted questions and answers. Ira Kirschenbaum, MD, is the Chief Medical Information Officer of SwiftPath. He and the SwiftPath team of programmers used input from the RoundTables to write a program that derives a calculation based purely on patient input. The "Pathway Selection App" yields a score that is used by their surgeon to help decide which pathway — inpatient or outpatient — is most ideal for them.


“We have utilized this approach in well over 500 joint replacements. In a study presented at AAHKS in 2015 and at AAOS in 2016, the Pathway Selection App was over 99 percent accurate in predicting which patients can be successfully discharged on the day of their joint replacement,” says Dr. McAllister.


Thomas Meade, MD, is a fellowship trained knee replacement specialist working at Coordinated Healthcare in Pennsylvania. He is among the early adopters of the SwiftPath Program and one of the presenters in Chicago. He has personally performed over 220 successful outpatient total knees using the SwiftPath Program — the most in Pennsylvania.


“I have to give the SwiftPath team credit. The Pathway selection tool includes a variety of relevant predictors. A score comes up, and this score is actually validated. The cool thing about this program is every patient gets on these protocols. Let's say you're a little older, and you have some medical co-morbidities. You've had heart bypass surgery, and you're on a blood thinner. Well, maybe you need to be in a hospital for a day or two; but you are on the same rapid recovery program and this tool is part of the patient engagement platform. I think that was one of the biggest benefits of me getting involved with the SwiftPath program," says Dr. Meade.

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