There Is A Malaise Among Us

In my professional life, and on this blog, I have complained bitterly about the orthopedic surgery department in my community changing from physicians to technicians to “consultants” as they now prefer to be called.  These same physicians once aggressively sought out hip replacement patients to admit to their surgical service where they would provide admission, discharge oversight and care.  Now, these “consultants” see the patient before surgery, operate and then turn their patients’ post operative care over to their nurse practitioners, physician assistants and technicians as well as hospital based and employed internists or, the patient’s own medical doctor.

The “consultants” will no longer admit the patient to their surgical service, insisting that the patient be placed on the medical service and, they have taken steps to relinquish their skills in post operative and post surgical wound and general care. They see the patient before surgery, in the OR and several weeks later in the office to check on bone and appliance alignment and to remove the surgical sutures.   I am told the impetus for this change in the orthopedic role is cost and liability and based on specialty specific recommendations of consultants.

Over time, I have seen the post surgical stay reduced from 10 days down to less than four days. Patients no longer go directly home from the hospital.  In most cases, they are sent to skilled nursing homes for rehabilitation and strengthening. I have written about how these overregulated and inspected homes are spending so much money on personnel to keep them in compliance that they can’t afford to staff the facilities to provide skill, nursing and care.

With nighttime patient-to-nursing ratios of 40 residents to one nurse; how can anything get done each shift?   I have written about the conveyor belt / revolving door between recently discharged post hospital patients and the hospital Emergency Department using the 911 system and diverting emergency EMTs from true emergent issues to being a transportation corp.

An article in the Journal of the American Medical Association finally added some credence to my observations. Researchers looked at the subject of Medicare age patients receiving primary hip replacements and hip replacement revisions between 1991 and 2008.  They looked at over 1.4 million primary hip replacements and 348,000 hip replacement revisions. When looking at first time hip replacements they found that mean length of stay dropped from 9.1 days in 1991 and 1992 to 3.7 days in 2008.  This resulted in 20% fewer patients going directly home from the hospital and a 17% increase in patients going to skilled or intermediate care nursing facilities by 2007 and 2008.

The good news is that the overall death rate at 30 days declined from 0.7% in 1991 to 0.4% in 2008.  The bad news is that the rate of readmissions rate for complications of the surgery within the first 30 days rose to 8.5% in 2007 and 2008.

When we look at look at hip replacement revisions, the length of stay declined from an average of 12.3 days to 6 days. In hospital mortality declined from 1.8% to 1.2% but 30 day mortality increased from 2% to2.4% and 90 day mortality from 4% to 5.2%.  Fewer patients were discharged to home in 2008 than 1991 with a resulting increase in transfer to skilled and intermediate nursing facilities by about 17% at the end of the study dates.  When hospital readmission rate was looked at for revision of hips the readmission rate increased by 2007 and 2008 significantly

This data is about real human beings. It means we have not figured out the correct length of hospital stay for this procedure. It may mean that we have reduced the expense for the hospital stay while increasing the expense to the system, patients and family in other areas of health care accounting.

With regard to revisions of hips, more people are dying and more people are coming back to the hospital for readmission than in the past.  Maybe the orthopedic surgeons need to spend more post operative time attending to their patients directly for a longer hospital stay before transferring them to the care of others at a nursing home?

The topic is intensely personal to me especially as we approach Mothers’ Day. During the time of the study my Medicare age mother dislocated her hip repair repeatedly. Each time she was brought back to the operating room, given a whiff of anesthesia and the artificial ball joint was forcibly pushed back into the socket. She would awaken, be given a day or so of rehabilitation and oversight by the surgical assistants and mid level providers and then sent back to the skilled nursing facility for strengthening and rehabilitation before returning home. After each episode her orthopedist would tell me how much force and pressure and strength were required to push that hip back into the socket.

On one of those admissions the hospital physical therapist became alarmed by the fact that the involved leg appeared to be two inches shorter and externally rotated on the last day of therapy. She was having difficulty walking and bearing weight.  She called the surgeon who sent one of his staff to see her in her room prior to transfer. That staff member had never met her. He told her that our hospital physical therapy department was “notoriously inaccurate in measuring limbs.”  He didn’t examine the limb or order an x-ray but transferred her to the nursing facility immediately.

Upon arrival she could not stand up and bear weight. The receiving facility physical therapist requested a hip x-ray. The x-ray showed that she had been discharged from the hospital with the hip still dislocated. The ball could not stay in the socket because the pelvic bone had been fractured during one of the attempts to push the ball back in place.

My mom refused to go back to the same hospital or surgical group and was transferred to another center of excellence for extensive reconstructive surgery.  She has never ever walked independently again.

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