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Marylands leader in joint replacement 2015 Outcomes The Joint Center at Anne Arundel Medical Center Anne Arundel Medical Center is located in Annapolis the state capital of Maryland which is rich in history. Our beautiful facility includes all-private rooms free parking and easy access from major highways. Dear Colleague Welcome to the second annual Anne Arundel Medical Center AAMC Joint Outcomes Report. In the following pages is a summary of patient-reported outcomes clinical measures and operational and financial data we use to define the success of our joint replacement program at AAMC. New to this years report is a specific focus on the Multidisciplinary Rapid Recovery Protocol. Now in its second year of implementation this integrated patient-centered care model is driving continuous improvement across the full continuum of care for our patients. The Joint Center at AAMC is comprised of a multidisciplinary team of both operative and non-operative specialists who provide care for patients at every stage of their hip and knee pain. Consistently ranked the highest-volume joint replacement program in the state AAMC now performs more than 2000 surgeries each year the first program in Maryland to do so. Patients not only come to our program from all across Maryland but from all over the country to regain independence and improve their quality of life. Now in its second year of publication this report highlights the many notable achievements of our program. We believe publishing these healthcare outcomes enhances our culture of continuous improvement and increases value for patients. We are proud to present a robust data set that continues to grow in depth and breadth. At AAMC our joint replacement team is dedicated to continuously improving the care of our patients and our program is proud to be a leader in presenting transparent results. Respectfully Paul J. King MD Director The Joint Center at AAMC Table of Contents Executive Summary...............45 Case Volume.........................67 Experience................................8 Patient-Centered Care...............9 Multidisciplinary Protocol....1011 Quality Length of Stay.......1213 Quality Patient Outcomes...1415 Quality Clinical Outcomes.........16 Financial Performance...............17 Patient Satisfaction...................18 Patient Story.............................19 Research..............................2021 About Us............................2223 Contact Learn more about The Joint Center at AAMC online at askAAMC.orgJoint. AAMC Joint Nurse Navigators Tracie Ackermann Steffanie Dolle 410-268-8862 askAAMC Advice Line 443-481-4000 2015 Joint Outcomes 3 3910 5YEARSin a row as the busiest joint program in Maryland. average hours in the hospital for one-day length of stay patients.31 joint procedures performed in 2015 the most in Maryland.2006 procedures with patient-reported outcomes captured. IN SUMMARY Considered a national model for knee and hip replacement AAMCs program is the most sought-after in Maryland. The Joint Center at AAMC draws patients from around the country and remains committed to continually advancing our mission of delivering high-quality low-cost care. The 2015 outcomes report presents a wide variety of clinical operational and financial data points that present the depth and breadth of how we measure quality. Unless specified otherwise data is presented on a fiscal year basis JulyJune. Highlights of the report include VOLUME GROWTH of six percent annually has been realized for the past five years. In 2015 we performed 2006 joint replacements becoming the first program in the state to perform 2000 surgeries in a year and remaining the largest program in Maryland for five consecutive years. THE MULTIDISCIPLINARY RAPID RECOVERY PROTOCOL is the revolutionary patient-centered care process that is the foundation for providing the highest quality and most efficient care possible to our patients. In its second year of operation the protocol yields tangible benefits with 38 percent of joint replacement patients now leaving the hospital in one day along with declines in readmissions and complications of care. PATIENT-REPORTED OUTCOMES captured for 3910 procedures quantify the improvement in quality of life experienced by our patients. This data is used to study our care processes and implement best practices that benefit our patients. PATIENT SATISFACTION SCORES consistently in the top five percent of the nation over the past five years highlight our continued commitment to excellence. RESEARCH ACTIVITIES drive innovation as we continually search for opportunities to improve patient care including clinical trials the addition of dedicated research fellows and publication in national journals. As Marylands leader in joint replacement AAMC remains dedicated to advancing outcomes and building all care processes around our patients. 2015 Joint Outcomes 5 Case Volume AAMC JOINT VOLUME 5-YEAR TREND AAMCs hip and knee replacement volume grew six percent annually over the past five years. LEADING MARYLAND IN JOINT REPLACEMENT 1. Katz JN Barrett J Mahomed NN Baron JA Wrigirt RJ Losina E. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement. J Bone Joint Surg Am. 2004 09018691909 Patients managed at hospitals and by surgeons with greater volumes of total knee replacement have lower risks of perioperative adverse events following primary total knee replacement. 1 1568 1682 1693 1905 2006 MARYLAND JOINT VOLUME 5-YEAR CUMULATIVE COMPARISON TO TOP TEN MARYLAND HOSPITALS AAMC performed 27 percent more joint replacements than the second busiest program in the state over the past five years. FY15 JOINT VOLUME TOP 10 MARYLAND HOSPITALS AAMC performed more than 2000 joint replacements in 2015 over 10 percent more than the second busiest program in the state. joint replacement patients in Maryland choose Anne Arundel Medical Center.101out of MARYLAND POP. 5.9 MILLION 2006 1808 1632 1474 1419 1295 769 698 684 673 8854 6963 6684 6531 6342 6682 3883 3315 3282 3049 2015 Joint Outcomes 7 Expertise Through Experience MARYLAND JOINT VOLUME AAMC TOTAL JOINT FELLOWSHIP-TRAINED SURGEONS COMPARISON TO TOP 10 MARYLAND HOSPITALS At AAMC four fellowship-trained surgeons perform 75 percent of our joint replacement procedures. These four surgeons alone have performed the second-most joint replacements in the state over the past five years. Surgical mastery of joint replacement comes with experience. Our team at AAMC has the experience that drives optimal outcomes. -Marc Brassard MD Our use of dedicated joint replacement teams means that every patient in every phase of care from prehabilitation to post-discharge is handled by experts who understand the nuances of caring for joint replacement patients. -Justin Hoover MD PROVIDING A TEAM OF EXPERTS 6963 6688 6684 6682 6531 6342 3883 32823315 3049 Our care processes are designed around the patient to maintain the highest quality of care at each phase of the joint replacement experience. -Louis Ruland III MD Patient-Centered Care EVERY PATIENT EVERYTIME Patient and coach reunion luncheons allow patients to connect with our joint replacement community and provide feedback used to improve care. Dedicated joint nurse navigators guide patients through all phases of the care process. Patient preparation and education begins as soon as the decision for surgery is made. Prehabilitation physical therapy programs are tailored to patients needs to ensure they are optimally prepared for surgery and recovery. Operating room teams include specially trained RNs surgical techs PAs and NPs who participate in monthly surgeon-led education. Our Magnet -designated operating room and inpatient nurses are dedicated specifically to joint patients. Orthopedic rehabilitation teams collaborate with nurses and surgeons to provide the earliest safe opportunity for post-operative ambulation. Hackerman-Patz House our on-campus hospitality house allows patients and families to stay close by. Volunteers who are former patients from The Joint Center participate in the care of the patients during their stay. We partner with community physical therapists including AAMCs five physical therapy locations. 2015 Joint Outcomes 9 The Multidisciplinary Rapid Recovery Protocol provides the highest level of care for our patients in the most efficient manner. In place since 2013 it combines evidence-based medicine clinical outcomes measurement and lean methodologies. The Multidisciplinary Rapid Recovery Protocol The development and implementation of the Multidisciplinary Rapid Recovery Protocol serves as the foundation upon which we have built a program that accepts nothing less than continuous improvement in care because it is what our patients deserve. -Paul King MD PATIENT CENTERED. EFFICIENCY DRIVEN. OUTCOMES BASED. BEFORE SURGERY Determine surgery is the right decision. Maximize patient mobility and ambulation with twice-daily joint camp PT sessions. Offer fellowship and support through a discharge luncheon with other joint patients. INPATIENT STAY Ambulate most patients on the day of their surgery. Host joint patient reunions. Provide same-day PTOT evaluation where appropriate. Schedule candidate for a target one-day length of stay LOS and communicate to care team and patient. Establish contact between dedicated joint navigator and patient to discuss one-day LOS discharge to rehab and any other special circumstances. Transfer the patient efficiently from post-anesthesia care unit PACU to floor. Prevent readmissions and emergency room visits through follow-up calls from our nurse navigator. DAY OF SURGERY FOLLOWING DISCHARGE Offer patient education including joint classes. Refer patient to pre-op physical therapy. 2015 Joint Outcomes 11 GETTING PATIENTS HOME SOONER WITH THE MULTIDISCIPLINARY RAPID RECOVERY PROTOCOL 5-YEAR CUMULATIVE LENGTH OF STAY FOR JOINT REPLACEMENT SURGERIES Over the past five years AAMC joint replacement patients have a 13 percent shorter average LOS than the Maryland hospital average. AVERAGE LENGTH OF STAY 5-YEAR TREND AAMC reduced the average LOS for joint replacement patients by 18 percent over the past five years with primary total hip average LOS dropping 16 percent and primary total knee replacement average LOS declining 21 percent. Quality Length of Stay Our performance improvement initiatives optimize the length of stay for each patient. As of August 2015 nearly half 44.8 percent of our hip replacement patients and a third 33.3 percent of our knee replacement patients are discharged in one day. 2.79 3.22 2.50 2.69 2.87 2.89 The percent of joint patients with a one-day LOS increased by 35.6 percentage points since July 2013. As of August 2015 44.8 percent of total hip replacement patients had a one-day LOS. In July 2013 there were no patients with a one-day LOS for total knee replacement but by August 2015 the amount increased to a third of our patients. OF 1-DAY STAYS FOR JOINT REPLACEMENT PATIENTS OF 1-DAY STAYS FOR HIP REPLACEMENT PATIENTS OF 1-DAY STAYS FOR KNEE REPLACEMENT PATIENTS OF 2- AND 3-DAY STAYS FOR JOINT REPLACEMENT PATIENTS The percent of joint patients with two- and three- day LOS decreased by 16.5 and 18.4 percentage points respectively since July 2013. Hip and Knee Combined 2-Day Length of Stay Hip and Knee Combined 3-Day Length of Stay 2015 Joint Outcomes 13 MEASURING WHAT MATTERS TO OUR PATIENTS The Joint Center at AAMC measures patient-reported outcomes using leading industry methodologies. Over the past five years AAMC knee replacement patients experienced average improvements of 55 points and 44 points in total Knee Society Scores and the patient-reported Knee Function Scores respectively from pre-op to one year post-op. Over the past five years AAMC hip replacement patients experienced average improvements of 55 points and 50 points in Harris Hip Score HHS and Hip disability and Osteoarthritis Outcome Score HOOS respectively from pre-op to one year post-op. Quality Patient- Reported Outcomes Patient-reported outcomes measures used at AAMC include KNEE SOCIETY SCORE a measure of patient-reported function and objective measurements completed by physicians. KNEE FUNCTION SCORE a measure of patient- reported function. HHS an objective measure of hip function completed by physicians. HOOS a patient-administered questionnaire measuring five subscales of pain function and quality of life. The Knee Society Score looks at both patient-reported function and objective measurements of knee alignment stability and motion. A maximum score of 100 is possible for both the patient- reported function and surgeon-reported objective findings. AVERAGE KNEE SOCIETY SCORES 2011-2015 A subset of the total Knee Society Score the Function Score looks at only the patient-reported function portion of the survey. A maximum score of 100 is possible. AVERAGE KNEE FUNCTION SCORE KNEE REPLACEMENT PATIENTS 2011-2015 The HOOS is an instrument used to assess patients opinions about their hip and associated problems. HOOS consists of five subscales pain other symptoms function in daily living ADL function in sport and recreation SportRec and hip-related quality of life QOL. Each question is scored from 0 to 4. AVERAGE HOOS 2011-2015 The HHS evaluates hip function related to pain and mobility. It is widely used to evaluate both the rate of improvement and overall success of hip surgery. A maximum score of 100 is possible. AVERAGE HHS 2011-2015 36.8 88.3 92.0 46.7 87.3 90.8 42.2 87.5 92.2 40.1 93.8 95.0 2015 Joint Outcomes 15 30-DAY READMISSION RATE BY YEAR COMPLICATIONS OF CARE BY YEAR The Joint Center at AAMC maintains 30-day readmission rates below national averages. A 2013 study of 19919 patients from the American College of Surgeons National Surgical Quality Improvement Program ACS NSQIP reported an average 30-day readmission rate of 4.6 percent for total knee replacement and 4.2 percent for total hip replacement.1 AAMC reduced complications of care in parallel with average LOS since implementing the Multidisciplinary Rapid Recovery Protocol in 2013. 1. Pugely AJ Callaghan JJ Martin CT Cram P Gao Y. Incidence of and Risk Factors for 30-Day Readmission Following Elective Primary Total Joint Arthroplasty Analysis From the ACS-NSQIP. J Arthroplasty. 2013 10012891499. Quality Clinical Outcomes DELIVERING THE HIGHEST QUALITY CARE IS OUR FIRST PRIORITY FY15 AVERAGE CHARGE PER PROCEDURE BY PROCEDURE TYPE AAMC provides a full range of joint replacement procedures at a charge below the state average. 5-YEAR AVERAGE CHARGE PER CASE ALL JOINT PROCEDURES AAMC maintained an average charge per case below the state average for the past five years. In 2015 AAMCs charge per case was 13 percent below the Maryland hospital average. DELIVERING HIGH-QUALITY LOW-COST CARE TO PATIENTS AND VALUE TO THE MARYLAND HEALTHCARE SYSTEM Financial Performance 21701 19304 20867 23790 24542 23261 21796 26203 30857 31884 2015 Joint Outcomes 17 MAINTAINING A TRADITION OF EXCELLENCE Patient Satisfaction Patients likelihood to recommend AAMC consistently ranks in the top five percent of the nation for the past five years. The Joint Center at AAMC has been in the top 10 percent in the nation for overall patient experience four out of the last five years. Patient Testimonials I had knee replacement surgery at the Joint Center at AAMC. I would recommend it highly. I dont have any complaints. I thought everything was done very professionallyoverall they did an excellent job. All the caregivers and the people were very professional and the doctor was great. The stay was well organized. I was given the appropriate information. The service was excellent. The partnership they have in terms of physical therapy with the joint replacement is excellent. And the atmosphere and the attitude of everyone was extremely helpful. THE JOINT CENTER AT AAMC PATIENT SATISFACTION SCORES 20112015 As clinicians who have built our careers on empirical evidence we must never overlook the importance of the simplest measure of quality the voice of our patients. -Steve Faust MD The patient satisfaction measures of overall experience and the likelihood to recommend rank within the 90th percentile or higher for The Joint Center at AAMC. For these measures top box scores indicate how often patients selected the most positive response when asked about their experience. The higher AAMCs top box score the higher its percentile ranks among participating hospitals. The Joint Center at AAMC consistently ranks within the top 10 percent in the nation. The national percentile rank table on patient satisfaction can be found at As a missionary and electrical engineer Leonard Lieb spends most of his time helping others. So after 20 years of pain in his right knee he decided he couldnt let the pain hinder his work any longer. I had to stop to stretch my knee constantly says Leonard. Sometimes it locked up causing me to almost fall over and the pain woke me up at night. With limited time Leonard traveled with his wife from Haiti to the U.S. for a total knee replacement by Jim MacDonald MD an orthopedic surgeon at The Joint Center at AAMC. While the operation gave him back his mobility what Leonard values most is the care he received before and after his operation. The Joint Center team helped Leonard strengthen the muscles around his knee to speed recovery and explained each step of the process to him and his wife. They involved my wife so she could take care of me after I left the hospital says Leonard. After Leonard finished his final physical therapy session he says his doctors were just a phone call away. I really appreciated their availability says Leonard. They took an interest in my recovery so I could get back to Haiti. This operation greatly improves patients quality of life says Dr. MacDonald. Its inspiring to see a patient use his new knee not only to improve his life but help others as well. Leonard and his wife are still missionaries in Haiti and Hawaii where he serves as an electrical engineer without knee pain slowing him down. Hes also thankful for the smaller changes he notices daily like during his morning walk with his wife. Before my knee replacement I had to stop two to three times to stretch my knee says Leonard. Now I dont have to stop at all. The Joint Center gave me that mobility. Patient Story A CLINICAL PROFILE OF THE MULTIDISCIPLINARY RAPID RECOVERY PROTOCOL EXPERIENCE This operation greatly improves patients quality of life. Its inspiring to see a patient use his new knee not only to improve his life but help others as well. Jim MacDonald MD 2015 Joint Outcomes 19 REVOLUTIONIZING THE STANDARD OF CARE THROUGH RESEARCH WITH THE MULTIDISCIPLINARY RAPID RECOVERY PROTOCOL Research Do shorter LOS increase readmissions after total joint replacements Enhanced Recovery After Surgery ERAS pathways can be updated to shorten hospital LOS after total joint replacement surgery without adversely impacting postoperative complications or readmissions. What are the predictors of hospital length of stay in an ERAS program for primary total hip arthroplasty Several clinical factors and surgical variables were associated with a length of stay greater than one day. Knowing the predictors of a longer LOS helps optimize discharge protocols for patients in an ERAS program. What is the learning curve for the direct anterior approach total hip arthroplasty Surgeons considering the direct anterior approach can expect operative times to be equivalent to procedures done via a posterolateral approach but only after performing more than 400 procedures. 2015 RESEARCH HIGHLIGHTS REVIEW OF SELECTED RESEARCH ACTIVITY IN 2015 SCIENTIFIC FORUM PRESENTATIONS American College of Surgeons 2015 Clinical Congress Chicago IL on October 6 2015 Sibia US Zahiri HR Park AE King PJ MacDonald JH. Multidisciplinary ERAS for total joint replacements Readmission rates after updating ERAS to shorten length of hospital stay. Pennsylvania Orthopaedic Society Annual Spring Meeting in Boca Raton FL on April 9 2016 Sibia US MacDonald JH King PJ. The impact of surgical technique on operative and quality of life measures after primary total hip arthroplasty. POSTER PRESENTATIONS International Congress for Joint Reconstruction New York NY on October 2 2015 Sibia US Fowler MB Stone AH King PJ. Minimum five year follow-up of articular surface replacement ASR acetabular components used in total hip arthroplasty. Pennsylvania Orthopaedic Society Annual Spring Meeting in Boca Raton FL on April 9 2016 Sibia US Waite KA MacDonald JH King PJ. Predictors of hospital length of stay in an enhanced recovery after surgery program for primary total hip arthroplasty. American Society of Perianesthesia Nurses National Conference in Philadelphia PA on April 10-14 2016 King J Perzanowski M Polk J Ackermann T Seanger M Brouse J England K Grover J Lusby M. Improving throughput of joint and spine patients from phase I A rapid improvement event. PUBLISHED ABSTRACTS Sibia US Zahiri HR Park AE King PJ MacDonald JH. Multidisciplinary enhanced recovery after surgery ERAS in total joint replacement complication rates after improving ERAS to shorten patient length of stay. J Am Coll Surg. 2015 1002221S100. MANUSCRIPTS Published Rovaldi CJ King PJ. The effect of an interdisciplinary QI project to reduce OR foot traffic. AORN J. 20151016666-81. Sibia US Connors K Dyckman S Zahiri HR George I Park AE MacDonald JH. Potential fire hazard of bone cement in the operating room A case study. Am J Orthop. June 2016 Submitted Sibia US and King PJ. Minimum five year follow-up of articular surface replacement ASR acetabular components used in total hip arthroplasty. Sibia US Waite KA Callanan MA Park AE King PJ MacDonald JH. Do shorter lengths of stay increase readmissions after total joint replacements Sibia US Turcotte JJ MacDonald JH King PJ. What is the learning curve for the direct anterior approach total hip arthroplasty Sibia US MacDonald JH King PJ. The impact of surgical technique on operative and quality of life measures after primary total hip arthroplasty. Accepted Sibia US MacDonald JH King PJ. Predictors of hospital length of stay in an enhanced recovery after surgery program for primary total hip arthroplasty. J Arthroplasty. CLINICAL TRIALS Short- medium- and long-term survivorship of Attune primary total knee prostheses. A prospective randomized trial to examine the effectiveness of KneeMD on flexion contracture in total knee arthroplasty patients. A prospective non-randomized single cohort multicenter study to evaluate the clinical outcomes of total knee arthroplasty TKA using the JOURNEY II CR total knee system. A phase 2b randomized double-blind placebo controlled study to evaluate the safety and efficacy of staphylococcus aureus 4-antigen vaccine SA4Ag in adults undergoing elective posterior instrumented lumbar spinal fusion procedures. 2015 Joint Outcomes 21 About UsAAMC JOINT REPLACEMENT SURGEONS Anne Arundel Medical Group Orthopedic And Sports Medicine Specialists 410-268-8862 James York MD Belcher Pavilion 2000 Medical Parkway Suite 101 Annapolis Md. 21401 AAMC PavilionBowie 4175 N. Hanson Court Suite 301 Bowie Md. 20716 8638 Veterans Highway Millersville Md. 21108 AAMC PavilionOdenton 1106 Annapolis Road Odenton Md. 21113 AAMC PavilionPasadena 8109 Ritchie Highway Suite 200 Pasadena Md. 21122 Louis Ruland III MD Anne Arundel Orthopaedic Surgeons 410-573-2530 Wayson Pavilion 2003 Medical Parkway Suite 400 Annapolis Md. 21401 The OMNI Building 4000 Mitchellville Road Suite A214 Bowie Md. 20716 810 Landmark Drive Suite 110 Glen Burnie Md. 21061 Locations Locations Marc Brassard MD Stephen Faust MD Justin Hoover MD Paul King MD James MacDonald MD Magnet Recognition by the American Nurses Credentialing Center ANCC. Delmarva Foundation Excellence Award for Quality Improvement. Exemplar recognition for family presence awarded by the Institute for Patient- and Family-Centered Care IPFCC. Top 25 of the Nations Best Practices in Patient and Family Centered Care by the Caregiver Action Network. HealthStream Award for Highest Community Perception of Quality. Association of Community Cancer Centers Innovator Award. A not-for-profit regional health system headquartered in Annapolis Maryland Anne Arundel Medical Center serves an area of more than one million people. AAMC is recognized for orthopedic care emergency heart attack response and cancer care. A leader in womens services AAMC ranks second in Maryland for number of births annually and has a Level III neonatal intensive care unit. The states third busiest hospital measured by inpatient discharges. Outpatient locations in Bowie Kent Island Odenton Pasadena and Waugh Chapel. A multi-specialty medical group in 50 locations throughout the region. An accountable care organization ACO participating in the Medicare Shared Savings Program. A research institute with a simulation and innovation center. Total licensed beds................ 415 Inpatient admissions..........25391 Surgeries...........................22739 Joint replacements................2006 Births...................................5550 Emergency visits.................95916 Outpatient visits.............106000 Medical staff......................1000 Employees.........................4000 Operating revenue..... 630 million HONORS FACTS AND FIGURES FISCAL YEAR 2015 July 2014June 2015 Includes 40-bed facility Pathways dedicated to substance use and mental health treatment 2015 Joint Outcomes 23 2001 Medical Parkway Annapolis Md. 21401 askAAMC.orgJoint