A Model of Efficiency
Alberta’s optimal care experiment

Dennis Jeanes
Special to the Canadian Orthopaedic Association
Toronto, ON

During the recent federal election, as the Conservatives strategically dominated the headlines throughout December with their daily policy-platform releases, one non-partisan news item managed to break through the campaign promises, briefly capturing the national spotlight. And it’s easy to see why.

An interim report from the Alberta Hip and Knee Replacement Project, released on December 19, indicated stunning reductions in average wait times: from 35 weeks to six weeks for a first orthopaedic consult, and from 47 weeks to 4.7 weeks between consult and surgery. Average hospital stays were reduced by two days. Surveyed surgeons and patients both expressed high satisfaction. And while media coverage tended to concentrate on the Project’s laudable results (attributed vaguely to new “central assessment clinics”), the real story about the process was largely overlooked.

“This whole thing was set up to pilot test a new way of delivering care and was therefore established as a randomized controlled trial,” says Dr. Cy Frank, co-chair of the Alberta Bone and Joint Health Institute and one of the model’s architects. With critically important dedicated new funding from the province’s Ministry of Health and Wellness, the Institute - which comprises an unprecedented integration of Alberta’s academic and clinical resources in the musculoskeletal field - began implementing its year-long Hip and Knee Replacement Project in April 2005. “We didn’t just focus on the surgery aspect, which many have thought of as the main bottleneck,” says Frank. “We believe the problem is much bigger than OR time and bed shortages, so we tried to link each patient with a case-managed continuum of care.”

To avoid the all-too-frequent “hip pain, please see” approach to referrals and recruit the right patients for the trial, the Institute’s project team developed a comprehensive referral form that family physicians in the participating health regions (Edmonton, Calgary, Red Deer) were asked to use. Not only did the referral forms serve as the patient’s ticket to enter the surgical stream, they also provided doctors with valuable tools and information for gauging the severity of a presenting patient’s hip and knee symptoms. Recognizing that filling out the forms imposed extra work on the doctors, the Institute partners even negotiated with the Ministry a special fee as an incentive to comply.

The first stop for potential surgery patients was one of the trial’s new central assessment clinics, where multidisciplinary teams usually GPs, nurses, PTs and OTs - received incoming patients for triage. Each patient was assigned a case manager who reviewed the form and, with the team, decided whether surgery was indicated or not. (For those patients who resisted straightforward classification by this method, the case manager defaulted toward a surgical consultation, while those patients who clearly didn’t qualify for surgery were directed to appropriate nonoperative care.) After giving their informed consent, 2400 hip and knee patients were then divided randomly between experimental and control groups. The same surgeons operated on both groups, but the pathways by which the patients arrived at the OR were distinctly different.

The controls simply went down the typical care path of any joint-replacement patient in Alberta’s public-health system. By contrast, the experimental patients embarked on a different kind of journey through an ideal parallel system. “The entire care path was managed according to the world’s best practices,” explains Frank. “We did a literature search for what is the best care at every step of the treatment for people in different risk categories. What’s an appropriate wait time? What’s appropriate regarding transfusion, drugs, anesthesia, pain control, etcetera? Everybody on the clinical team agreed to manage according to best practices.” Even the patients signed an agreement to try to comply with such therapeutic advice as smoking cessation or weight reduction or pre-surgical physiotherapy. “Obviously, it’s non-binding, but it puts some responsibility on patients, which could turn out to be quite important in the long run.”

As might be expected, virtually everything in the optimal care path is being measured and compared to the usual old way, including direct and indirect costs, subjective and objective patient outcomes, compliance to best practices and, of course, access times. Also prior to the trial, so they could compare with professional consult fees in the control group, Institute partners negotiated a shared case rate with the surgeons and their teams (including internal medicine) for managing a patient on the optimal care path. Worth noting, as well, was the use of a private clinic in Calgary so the optimal care path could instantly generate new surgical capacity for the trial. An added benefit of the private clinic was unprecedented transparency in accounting, so that expenses could be tracked down to the last sponge and suture. Indeed, the three participating health regions agreed to adopt similar accounting procedures to capture costs.

The ultimate goal of such financial detail is to calculate how much it will cost in Alberta to manage the burden of illness in joint-replacement surgery to the standards set out by the Wait Time Alliance. “We know the population demographics,” says Frank, “We will know the cost of care. We will know how many people are going to need joint-replacement surgery. We will also know what resources are going to be required using this optimized efficient system. So we’re going to take all the mystery out of the debate and make it transparent for people.” One thing is already starkly clear, the patients in the experimental group are moving so quickly along the optimal care path that “they’re way ahead of the control patients who are still waiting months to years to see the same surgeons.”

However, anyone who tries to emulate this model under real-world conditions, says Frank, should prepare for a bumpy start-up phase: “In our experience, it took several months for the case managers and all the team members to learn their roles and what’s appropriate. They had to make the connections with the internal-medicine specialists and the anesthesiologists, tune up patients’ medications, and get everything lined up preoperatively in a timely fashion.”

Preliminary analysis suggests that case-costs (that is: the costs of care for each patient across the continuum of care) appear to be very similar between the control and experimental approaches. According to Frank, in the optimal care path, much of the costs are “front-loaded” because of the case managers and clinic personnel, but it “saves money at the back end because patients’ hospital stays are shorter.” And that’s a function, he says, of properly preparing patients and managing to standards.

Among the expected legacies from the Alberta Hip and Knee replacement Project, once it produces its final report, will be the referral templates (which could continue to be used by GPs) and a database that can feed back information to individual surgeons, health regions and the provincial health ministry. Given the dire shortage of orthopaedic surgeons for the foreseeable future, says Frank, “we’re trying to optimize the efficiency of existing people and resources and show the benefits of managing transparently to appropriate standards of care. We hope that this pilot, despite its clear establishment under “best-case circumstances” with new funding and incremental resources in Alberta, will demonstrate that significant efficiencies can be found and that we can actually deliver bone andS joint care more effectively with different models of care in this country.”