Hello and welcome everyone. Thank you for joining us for Advancing Orthopedic Outpatient Safety and Outcomes with Actionable Insights. Our speaker today is Dr. Vicki Patterson. Welcome Dr. Patterson. Now I am going to be turning it over to you to get started. Thank you very much. So I'm going to talk today about ambulatory potentially preventable complications. And what I want to do is first tell you a little bit about myself. I am an orthopedic nurse practitioner, practiced for many, many years. I work for 3M in clinical and economic research. And I'm presenting today a little bit of methodology and some results that we've seen on a national level about a new component that we have developed. So first I want to ask a question. I'm going to do an audience poll. Have you or a family member experienced a complication after an outpatient procedure? And if you want, Jessica, I believe, is putting up a poll for you. All right. So it looks like a really high percent, 80%, have had experience with a complication. I think that's really important as we go through this. Oops, let me see if I can get rid of that. Knowing that outpatient complication rates that we have done on our national benchmarking were about 2% across all procedure groups. And I'll explain a lot more of that in detail. But when you look at that, what are other events that have had complications? Remember, J&J COVID blood clots were happening, and they stopped that whole process. And that was such a minute group of people that were having complications. So when you look at 2% of outpatient procedures having complications, that's 2 out of every 100 cases. And if you think about it, us as adults are going to have two to three or more outpatient procedures in our lifetime. And this data is actually from like 2008. So I know we've moved a lot more cases to outpatient. So this is the impact that these complications are having. They also have other impacts. So first, complications are really difficult to systematically analyze in the environments that we have at this time. And we know that complications add to patients' pain and suffering, give a negative patient experience. Healthcare people do not like that. It's against our edict to do no harm. There are litigation costs, your reputation, insurance premiums, or even inclusion in different care networks. And if you're in a value-based care center, those costs are actually going to be excessive of what your payment is because of the emergency room visit, the inpatient admission, the staff time, the ancillary services, even on consultants or your supply chain. And there may be a loss of reimbursement or penalties. So the reason 3M went looking for this is we wanted to look at all of these procedures that are moving to outpatient. We know that almost 70% of procedures are now done in the outpatient setting. And there's very few outcome-based projects or quality measurement systems for this. And the impact on patient safety, really, complications are the strongest indication of costs. So we're going to look a little bit about this. But in the orthopedic realm, this is just data from ASCs between 2019 and 2021. The rapid growth in orthopedic procedures moving to ASCs or hospital outpatient is dramatic. Hip replacements, who have now come off the inpatient-only list, are actually growing in the highest volume. And knee replacements have already taken over that high volume of outpatient procedures. And when you think about looking at these complications or outpatient safety, we've done potentially preventable complications in a hospital. And it's really easy. If you're in the hospital and you have a complication, it's already recorded. It's easy to look at. But if you're now in the hospital outpatient or ASC or even an MD doctor's clinic or GI clinics or office visits to have these procedures done, it's really difficult to start to fine-tune what that is because you have that procedure. And you might think it's not really a big deal because it's going to be done outpatient and you get to go home. But if you go home and you start to have a complication, first of all, you have to know what kind of complications to expect. And what are you going to do? You can go into your own hospital system, whether it's telemed or going to the hospital or an urgent care or an office. You might go to a different hospital system. You might even go to an independent hospital. But you might even call an ambulance to go for a complication to be taken care of. But there is no feedback loop to those original outpatient places because they close at 5. So the feedback loop is really, really choppy. You might go to have a patient come back to your clinic and say, oh, jeez, I had a complication. But that's an N of 1 to start to think, wow, what kind of complications are we having and what can we do about them? So what do we have now? Well, we have CMS with that OQR measure number 36. And what does it say? It says if you do an outpatient case that happens to be on this ambulatory or ASC procedure list and you show up in the ED or get admitted for any cause in seven days, we're going to look at that. Or ASCs. They have a lot of counts, and it's very manual. But there's not really a lot in complications. There's one for colonoscopies. There's one for cataracts. But they're not really thorough and complete. And if you think about this, I'm going to do kind of a patient scenario. This is Rose. She's 71 years old. She's got knee pain. So she goes in January to go see Dr. Bone and say, you know, I have this knee pain. They together look at it. They agree that she needs to have some surgery to replace that knee. Because he's booking out, she's now going to have her procedure done in March. They like to have people go to pre-admission testing to see how healthy they are to see if they can have an outpatient procedure. So she seems healthy enough. She has the procedure on the 24th, 10 a.m. She recovers. They send her home with some physical therapy at 5 o'clock. Several days later, Rose has some kind of chest pain and palpitations, short of breath. So she ends up going to an emergency room. They admit her transfuser. She gets better. Goes home. They tell her that they're going to send her note to a primary care doc and that she should go follow up for that anemia with that doc. A few days later, she goes to see Dr. Bones and says, he says, wow, your knee looks great. And she may tell him about this incident. But there's not a real good feedback loop. And this is not in anybody's quality standards. So now, because all of these procedures are moving to outpatient, when U.S. News & World Report starts to look at ranking hospitals, they actually licensed this component back in December. And they're starting to use it in their hospital ranking. And this year they used it with orthopedics and urology and expect to expand that over the next couple of years. So when we try to think about orthopedics or complications or procedures, is there any difference between hospital outpatient and ASCs? Well, you think that we want to do the healthcare where it's more efficient and a good use of resources. Maybe it's less expensive to be done there. Maybe it's more convenient for surgeons or proceduralists to do it there. But when we look at the Medicare data, and for ASCs specifically, for upper GI endoscopies, there were 500,000 done in an ASC. There were also 530,000 done in a hospital outpatient. So we are seeing similar procedures being done in various places. But we don't have any data on what are the outcomes of these. Are they safe? Are they efficient? So I want to put in here, what do we really need to know about ambulatory potentially preventable complications and these procedures? Well, let's look at it as public, as me. I want to know what procedures are going to have a risk. What is the actual risk of the procedure that I'm having? I don't want it on a big list. So having comparison of apples to apples, procedures to procedures across various facilities or geographic places is really important for me to know what the risk of my procedure is going to be. And then next I want to actually know what the complications could be. I want to know if there are standards. And if you look at the practice areas, is this a good place to have this procedure done? Should I have it in a hospital? Should I have it in ASC, outpatient doctor's office? And then which of these groups are the best to have that done with? Dr. Patterson, just really quick. It looks like you've got a Microsoft pop-up on your screen that we can all see, and it's covering your slides. I'm just going to not do – I hope it doesn't update me. We don't see it anymore, so you're on time. Sorry for the interruption. That's okay. Thank you very much. So what do we care about for a hospital system? What are our actual complications to the expected rate? And if we're going to focus on improvement, where do we focus? And how do we compare in the market? Or if one of our facilities is not performing well, are we using the same care pathways and the same education? And then should we use these metrics for practice agreements? If you're a provider, you kind of want to see what your procedures are like for outcomes compared to everybody else in the country or the region or your even health system. And it would be really truly informed consent because now you can see what kind of complications are falling out. And if I were the provider and I saw these complications, I could start to work on prevention in my own practice. And as the provider, do I want to take my cases there? Do I want to have my patients seen in this ASC or this hospital outpatient? So there's a lot of different reasons that you would care about ambulatory potentially preventable complications. If you're a payer, the same thing. How many of my members are going to go to the ED or inpatient? Do I pay better for better outcomes? And should we partner with this group? So let's get back to what is an ambulatory potentially preventable complication. It's a harmful event like an accidental laceration or a negative outcome, an infection, a bleed, any kind of problem that happens after the procedure is done. It has to be done after an elective procedure, so no emergency procedures. And it has to be performed in an ambulatory care setting. What we really tried to do was match those complications really plausibly and clinically with the procedure. So we're not really looking for natural progression of a disease like diabetes worsening. We're really looking for a complication that's potentially preventable. And we know they're not all preventable. So in our logic, we actually looked at some almost 3,000 different procedures that had a risk for a complication. And by that, I mean the procedure had a needle, a scalpel, a tube, chemicals, anesthesia into that patient that could potentially have a complication to it. And we started anatomically with this. And when we did anatomically looking at these procedures, we started looking at the risk in the complexity of that procedure. And I'll give you an example. A trigger finger is a very simple procedure. There's not a lot of blood loss. It's pretty low risk compared to a total shoulder replacement, which has bone and muscle and bleeding and a longer period of time. So that's a high risk grouping. We actually looked out for 30 days. And we had a clinical hierarchy. If you had two procedures on the same day, one of them would bubble to the top as the most risk occurring for that procedure. The next thing we looked at was complications. So we wanted to group some 1,500 different complications into complication groups that were like. So things like lung problems and bleeding problems, wound dehiscence, infections. And we wanted to make sure we had time limits that if you had this procedure and four weeks later or three weeks later you had this complication, we don't really think it was related to that procedure. And the next is the most important because we looked at where those complications showed up, if they showed up in the emergency department or as an inpatient admission. So this is an unplanned admission. And we actually can show if they showed up in an outpatient encounter. But we know when we looked at these for our benchmarks, our national benchmarks, we only wanted to look at the significant complications. So those that presented at the emergency room or as an inpatient admission. And that's kind of important to keep in mind for a couple of reasons. One, outpatient may be the best way to treat a complication. And two, we know that coding and the ability to present those complications may be a little bit different in outpatient documentation. When we looked at all of our data, we did see that there were some risk adjustments needed. So age over 75 or over 85 had higher risks. Disability status. So in the Medicare data, when you were under 65, you were dual eligible or had a disability. And we saw those patients had a higher risk for complications. And in very few of these, we noted that oncology diagnosis at the same time as the procedure actually had a higher risk for complications. So we have a cohort for oncology. And this is just a kind of sample of the complication groups. We have pneumonia and lung infections, aspiration, pulmonary emboli. We have bleeding, anemias, hemorrhage, and thrombosis. We have infections like septicemia, UTIs, and different kinds of infections. But one of the most specific things that I want to point out here is that if you had an infection or a complication of a device, implant, or graft, it has to be specifically related to that specialty. So if you had a cardiac procedure, only cardiac grafts, implants, or device mechanical complications would be associated with that. And this is what our data showed. So I like to show you what data we ran through this component and what it looked like. So this is the top 20 procedure groups. This is 2019 through 2021, Medicare, FIFA service, hospital outpatient data only. There's no ASCs, there's no outpatient clinics in this, but it's just to illustrate what this component will do. So the number one was upper GI endoscopy procedures. There are two and a quarter million of these performed in those three years in the hospital outpatient. 11,000 went to the ED with a complication directly related to that upper GI procedure. Some 34,000 were unplanned admissions for complications from that upper GI procedure. And some 44,000 showed as complications in the outpatient setting. But again, the data and the risk rate is only derived from ED and inpatient. So that risk of having that procedure is that you have a 2% chance of having a complication with that upper GI endoscopy procedure. So let's look at something else. Cataracts, that's a very low risk procedure. And as you can see, we have 808,000 of these done, but very few went to the ED and few went for inpatient admissions. And that complication rate is 0.21%. So you have a very, very low complication rate from that procedure. Let's get into orthopedics. Total knee arthroplasties, 305,000 were done in those three years in the hospital outpatient setting. And now we see how many are going to the ED, inpatient, and the risk of a complication for this group, and I'll get into some details about this, is 2.81. So almost three out of every hundred are gonna come back to the ED or inpatient from a complication from that procedure. So one of the things that is really good about this component is not only does it tell you what kind of procedures and what are the risks for those, it actually tells you what people came back into the ED or hospital for. So this upper GI, they came back for GI complications and significant bleeding, really good to know. Pulmonary and chest complications, septicemia infection. So now we're starting to look at what is it they're coming for and how can we work to prevent those? And we also did it by procedure groups. And I think orthopedic, I like this because if you think of a procedure, a spine procedure, neurosurgery can do this, orthopedics can do this, but because we divide it in procedure groups, everybody's getting apples to apples. Whether you do that cervical spine procedure or you do a lumbar sacral fusion procedure, you're going to be in the same category and the same risk. And you can look across to see that these risks are almost up to 3% for that lumbar spine. And now I wanna talk a little bit about actionable data. If you looked at the top 10 orthopedic procedures that were done in those three years in the hospital outpatient, we see that total knees is the top of this, followed by foot, mid and forefoot procedures, lumbar sacral spine, hand, and then hip, which is now climbing in our ranks as the years are going by, we've seen a dramatic increase. So when we look across that total knee, for example, and we see how many patients are seen and we see the risk of having a complication, you say, Mickey, so what? Well, let's look what they came in for. Number one, post-hemorrhagic anemia, UTIs, all of these next three are infections. So when you see this data come in for whatever service line or whatever hospital system or whatever region, whatever state you're in, you're now able to start to think, what do we do preoperatively for anemia? Did we check their H and H? Did they have anemia when they started? Did they stop their anticoagulants? If they're in the OR, did we use the tourniquet? Did we cauterize well? Did they need transfusion? Did we give them transaminic acid at the right dosing? And then what did we do for follow-up care? So this might be the place that we can start to action, get some action items on preventing or reducing those complications. Looking at the spine, lumbar and sacral spine, we saw that they had higher complication rates. So what did they come in for? They came in for septicemia and severe infections. So what do we go do? And do we look at how do we prep that skin? What do we teach them about their dressing? You know, hand-washing, all of the things, normal thermia while they're having the surgery, all the things that we can do to reduce those infections. Are we doing that? So how does this really work? If you wanna look at this, this is just, we've, you know, de-identified this data and kind of moved it around a little bit. But as we look at all of the hospital outpatient departments we can see how many procedures they had that were at risk. So you look at hospital A, they had 33, 79 procedures done that were in this at-risk category. And we can see how many actual complications they had and how many this data expected them to have with whatever procedures that they had. And you can tell that this hospital A has a rate expected rate of less than one. So they're doing better than expected. Now we don't expect no complications. We already have built into this how many expected complications we should see. And I believe as years go by and as we're able to unearth this data and give it back to hospitals and providers they're going to be able to act on it and start to prevent some of these complications. So I believe that this expected rate will decrease. If you were that hospital that had that 1.1, 1.01 you can look across your hospital network and look down at your main hospital. Was it your ASC? They did really great. They have a 0.8 complication rate but perhaps it's your regional hospital one or two that needs the focus of your attention. And this is really interesting because this is actually state data that we ran through. And in this state data, now 0% is at expected. We don't say it's no complications but it's the expected amount of complications. But on left-hand side of this graph you can see that there were actually, there was an orthopedic ASC that did 70% better than expected for complications. And on the far right of this, you can see an orthopedic ASC that did 70% worse than expected for complications. So as a state, you're going to know to focus your resources on this right-hand side of this graph. So how can we help? And one of the things that this now is a software that is downloadable, you can have it installed. We can help build and analyze reports for your data. You can choose some service line or procedure group that seems to be worse than expected or need some help to do a patient journey or an assessment of that service line or that procedure and do a clinical and process improvements, map out changes that could be necessarily to help improve those statistics. So I want to kind of stop here and see if there are any questions that you have about what this component does and what the data will show you. Thanks, Dr. Patterson. So just a reminder, please enter any questions into the Q&A box. And we do have a couple coming in. I know that we are about at time here but Dr. Patterson, do you have a couple of minutes to stay along if we- Absolutely, absolutely. So first question here, comment that this sounds super valuable to see, have visibility to the care gaps. What are the blind spots in the data? So that's a great question. So one of the things that we actually know from a hospital system is that you may not have complete data. So you may have, if somebody goes outside your hospital system or your geographic region for urgent care or emergency care, you may not have 100% of all of your data. But right now there's 0% of your data. And now we have national norms and now we are able to look at that. We also want to make sure that the data, this data that I'm showing you is really just Medicare data. It's really hospital outpatient. It's not all comers. But I think the blind spot in that is we don't even know what our own facilities are doing right now. Wonderful, thank you. And then just a comment or a question around kind of action plans coming out of the data that the software provides. So it highlights the visibility to opportunities. Do you have some examples of action plans that might be executed on after these insights are raised? Absolutely, so one of the really most common issue is infection. So when we look at procedures and we see infection, and I'll give you an example of this. Several years ago, and I don't know if everybody remembers this, but there was a new upper GI endoscopy scope that they were utilizing. And all these GI clinics bought it and they started using it and they could see everything and the vision was better and everything was better about using this scope. And they sent it to Central Sterile like they always do. Central Sterile cleaned it and sent it back like they always do. But several weeks later, after they started using this, patients were coming back with septicemia and we saw upper GI. They usually come back with bleeds. So septicemia would be unusual and it's a scope. So what happens in a root cause analysis is they start to look back and the manufacturer actually recommended a different method to clean these scopes. And when that was identified and Central Sterile started utilizing this new methodology to clean scopes, those infections went down. So it doesn't just show you if a provider is not doing well or a facility is not doing well, it can actually show you if a vendor's implant is not doing well or there's some break in your process. So that would be one of the things that you could utilize it for. Wonderful. That is all the questions that we have. Dr. Patterson, thanks so much for your time. Jessica, I might turn it back to you. So thank you so much for everybody for joining us. It was a great presentation and thank you so much to our hosts for hosting this webinar. As we shared at the beginning, the recording and slides will be made available after the webinar in the next few days. So if anyone has additional questions, feel free to reach out to us or Dr. Patterson's email is on the screen there. So if anyone has questions, feel free to send them along and thanks for joining us today and we'll see you next time.

ambulatory care

preventable complications

orthopedic outpatient settings

patient safety

national benchmarking data

clinical improvements