Lessons From Abroad: Cases of Innovative, High-Value Musculoskeletal Care

Olivia Manickas-Hill, BA

Eugenia Lin, MD

Toby Colegate-Stone, MA (Oxon), MBBS, MRCS, MSc, FRCS (Tr and Orth)

Prakash Jayakumar, MD, PhD

None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Olivia Manickas-Hill, Dr. Lin, Dr. Colegate-Stone, and Dr. Jayakumar.

INTRODUCTION

The fundamental principles of value-based care and high-value care for the orthopaedic patient can be observed in various global settings. This chapter provides an overview of six national health care systems and the current initiatives and challenges around the provision of high-quality care.

CURRENT ISSUES WITH US HEALTH CARE

Health care spending in the United States is much higher than in other highincome countries.¹ As a share of the economy, the United States spends more than 17% of gross domestic product (GDP) on health care.² This is nearly twice as much as the average for members of the Organisation for Economic Co-operation and Development (OECD): the United States spent $10,207 per capita in 2017 and out-of-pocket costs were above average at $1,122 per capita. However, this higher spending does not result in better population health outcomes. The United States has the lowest life expectancy and highest suicide rate, chronic disease burden, and obesity rate of any other OECD country. In addition, rates of preventable hospitalizations and deaths are among the highest across high-income countries. In addition to higher costs and poorer outcomes, the US health care system is characterized by inequalities in access to care and insurance coverage. Poor health outcomes are exacerbated by societal inequalities that affect social determinants of health, such as access to healthy food, housing, or financial security.¹,²,³

CURRENT GLOBAL ISSUES WITH HEALTH CARE

Although the United States faces some tough challenges, health care costs in many nations across the globe are also rising rapidly, due in part to demographic changes such as aging populations and increasing rates of obesity.⁴,⁵,⁶ These demographic shifts have led to increased use of health care services⁷,⁸ and subsequent inefficiencies in treatment pathways. Many health systems now experience the systemic consequences of inappropriate use of tests and procedures, waste of resources, inequity, inequality, and variation in care.⁹,¹⁰ To treat a more health-burdened patient population, many nations are focusing on improving the quality of care delivered, based not only on objective clinical and process-level metrics but also on outcomes that are important to the patient.¹¹,¹²,¹³,¹⁴ Initiatives being implemented and lessons learned are described as the six countries discussed herein variably adopt the principles of value-based health care implementation in delivering high-value musculoskeletal care. These principles are (1) understand shared health needs of patients; (2) design solutions to improve health outcomes; (3) integrate learning teams; (4) measure health outcomes and costs; and (5) expand partnerships.

THE EFFECT OF MUSCULOSKELETAL HEALTH AND ORTHOPAEDIC CARE

As health care expenditures increase across the globe, it has been imperative to contain spending while simultaneously improving the quality of care.¹¹,¹²,¹³,¹⁴ Musculoskeletal conditions are common and providing health care for these conditions represents a significant portion of current and projected spending increases.¹² This is fueled by an increase in population age, obesity rates, and the use of costly surgical interventions.¹²,¹⁵,¹⁶,¹⁷ In the United States alone, the estimated cost of musculoskeletal expenditures was $237 billion.¹⁸ The high-cost, high-volume nature of musculoskeletal conditions and interventions, as well as inefficiencies in current management pathways provide substantial opportunity for improvement and a call for orthopaedic value-based health care initiatives.¹⁶,¹⁷

Several factors have led to experimentation in value-based orthopaedic care. Surgical interventions are common treatment options for many musculoskeletal conditions, are high in volume with discrete and easily definable pathways and workflows, and, for appropriate candidates, can yield excellent clinical and patient outcomes.¹²,¹⁵,¹⁶,¹⁷,¹⁹ Orthopaedic care that is volume-driven and procedure-focused, rather than based on value, condition, or outcomes, at times does not require a 360° whole-person approach. Many traditional care pathways remain focused on delivering high volumes rather than evidence-based best practices designed around the biopsychosocial needs of the patient, some of which can be highly effective, low-cost, nonsurgical strategies.¹²,²⁰,²¹,²²,²³,²⁴ The lack of attention to the holistic needs of patients, whether or not they proceed with surgical treatment, may result in suboptimal outcomes. This opportunity for improvement has launched a variety of value-oriented initiatives globally that are variably driven to improve patient outcomes¹⁷,²⁵ and costs.¹⁵,²⁶,²⁷ Some of these efforts also focus on utilization and limiting the use of inappropriate
interventions, promoting strategies to prevent unnecessary hospitalization, and methods to accelerate the development of standardized patient-centered care pathways over the full cycle of care.

The navigation of value-based health care reform is naturally receptive to the surrounding health care ecosystem and patient population. The following section includes a sample of international health care systems and initiatives that seek to implement value-based care in the treatment of musculoskeletal conditions. Lessons learned may help move US orthopaedic practices toward value-based health care.

THE UNITED KINGDOM: PATHWAY REDESIGN TOWARD HIGH-VALUE, INTEGRATED, MULTIDISCIPLINARY CARE

The United Kingdom National Health Service

Most United Kingdom (UK) residents access health care through the National Health Service (NHS), a publicly funded universal health care system.²⁸ Enrollment is automatic for UK residents who also have the option to enroll in private insurance plans for access to a private health care network. Health care accounts for a significant portion of government spending. In 2016, 9.8% of the UK’s GDP was spent on health care, with an average of $3,943 spent per capita in 2017. Average out-of-pocket health care spending was $629 in 2017 and the NHS recorded a deficit of $6.1 billion US (£4.3 billion) in 2020. In addition to increasing debt, the NHS also faces a growing shortage of primary and specialty care physicians. This financial pressure has been associated with a deterioration in some aspects of care quality, such as patient wait times. Recent cost-containing strategies include halting staff pay raises, promoting the use of generic drugs, and reducing payments to hospitals. In 2016, NHS Improvement launched a program to promote more efficient use of staff, equipment, and facilities that was projected to save up to $7.1 billion (£5.0 billion) over the subsequent 4 years.

Primary care is typically delivered by general practitioners (GPs) who are the first point of contact for patients seeking care. GPs are tasked with coordinating care as part of their NHS contract, and direct patients to community-based or hospital-based specialists when appropriate. Most specialists are salaried employees of NHS hospitals who are compensated based on nationally determined rates. Specialists may also have private practices alongside their NHS practice. Providers must register with the Care Quality Commission, the national body that monitors performance. A National Quality and Outcomes Framework provides practices with financial incentives to improve quality when the practices meet certain benchmarks for compliance with best-practice standards and maintenance of patient disease registries. A series of legislative measures have promoted improved integration of care between hospital-based and community-based health services. In 2016, the NHS formed voluntary integrated care systems modeled on Accountable Care Organizations in the United States. The Getting It Right First Time program was also introduced in 2016 as a national initiative designed to improve medical care within the NHS by reducing unwarranted variations.

Pathway Redesign in Primary Hip Osteoarthritis Care: King’s College Hospital, London, England

Local initiatives directed at improving outcomes relative to cost have been implemented outside broader government mandates focused on enhancing the quality of care. Physician-researchers operating within the King’s College Hospital NHS Trust pursued value-based health care solutions for patients with primary hip osteoarthritis (OA).²⁹ Primary hip OA is a common condition (affecting 10.9% of adults in the United Kingdom older than 45 years) with high rates of surgical utilization (the rate of hip replacements in adults older than 45 years in the United Kingdom is between 0.1% and 0.4%), presenting significant costs to the health system and demonstrating variable patient outcomes.³⁰

A retrospective assessment of 50 patients (20 men, 30 women) compared two surgical care models for total hip arthroplasty to identify elements that could advance the delivery of high-value care.²⁹ One model was a traditional hip OA pathway and the other an integrated multidisciplinary care pathway. In the traditional pathway model, patients were referred directly to an orthopaedic hip surgeon. These referrals were made at various points along the pathologic continuum in patients with hip OA care and came from multiple sources. In the second model, patients were treated within a multidisciplinary team integrated practice unit (Figure 1). This pathway began with patient triage involving extended-scope physiotherapists and consultations from orthopaedic surgeons before proceeding with multidisciplinary team care prior to surgery and postoperative physiotherapy. Patients were operated on by the same surgeons at the same orthopaedic elective surgical center with preoperative workups being conducted by the same teams. The primary differences between the two models were in the preoperative phase, specifically, the initial triage, prehabilitation, and overall care coordination by the multidisciplinary team in the preoperative and perioperative phases.

Value was assessed by a combination of patient-reported outcome measures (PROMs) and economic outcomes. PROMs included the Oxford Hip Score (OHS), European Quality of Life Index -5L (EQ-5D-5L), and European Quality of Life Index – Visual Analog Scale (EQ-VAS), all PROMs set by NHS England for the assessment of hip OA following total hip arthroplasty. Economic evaluation was conducted using Patient Level Information Costing System methodology and verified using the electronic patient record. Per-patient margin was calculated by subtracting the cost per individual patient from the reimbursement set by NHS England tariffs for the procedure. There was no difference in the preoperative to postoperative PROM changes between model 1 and model 2. Overall improvements in EQ-5D-5L, EQ-VAS, and Oxford Hip Score in both models exceeded the national expected average, and improvements were noted in pain, function, and psychological domains. Notably, there were disproportionate delays in postoperative physiotherapy for patients in model 1 through the lack of care coordination. Model 2 had lower costs than model 1. In combining the patient-reported outcomes and economic results, model 2 was deemed to provide the optimal approach through delivering improved patient outcomes relative to cost.

FIGURE 1 Integrated care pathway for hip osteoarthritis, Kings College London. GP = general practitioner, MSK = musculoskeletal, OT = occupational therapist. (Reproduced with permission from Tikkanen R, Abrams MK: U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes? The Commonwealth Fund, 2020. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019. Accessed May 8, 2023.)

Integrated Practice Unit-Driven Surgical Care for Rotator Cuff Tear: King’s College Hospital, London, England

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