To the Editor Jackson and colleagues1 described an opportunity for orthopedic surgeons to improve outcomes and reduce costs under Medicare’s new bundled payment plan for lower-extremity joint replacements. They identified transplant surgeons as role models because transplant surgeons “have learned to engage both traditional and nontraditional partners…in care redesign.”1 They mentioned skilled nursing facilities and home health agencies as such partners. They could have also mentioned behavioral health professionals, who have helped transplant surgeons identify and manage behavioral health conditions that frequently worsen outcomes.2 Ample research has found that hospitalized patients with behavioral issues, including those undergoing joint replacement, frequently have worse outcomes and generate higher costs.3 A meta-analysis of 6 studies of more than 8000 patients who underwent hip arthoplasty found that smokers manifested 2.58 to 3.71 times the incidence of prosthetic loosening, deep infection, and surgical revision compared with nonsmokers. In a study of 56 000 patients who underwent initial hip arthroplasty between 1998 and 2010, depression increased the chances of surgical revision over the next year by 64%—the highest of all 29 potential risk factors examined. Among 9000 Veterans Administration patients who underwent various surgical procedures, complication rates increased from 5.6% to 14% in a dose-response manner, with higher levels of preoperative alcohol consumption. These behavioral issues are also important risk factors for 30-day readmissions. Ample research has found that systematic, evidence-based screening and intervention for smoking, unhealthy drinking, and depression improve behavioral outcomes and reduce net health care costs.3 Well-trained health coaches can effectively deliver these services at a low cost.4 Such coaches could help orthopedic surgeons and their hospitals recognize and address important behavioral risks and disorders, improve joint replacement outcomes, reduce costs, and thrive under Medicare’s new bundled payment plan. Back to top Article Information Published Online: February 17, 2016. doi:10.1001/jamasurg.2015.5528. Conflict of Interest Disclosures: Dr Brown is owner and chief executive officer of Wellsys, LLC, which provides training and software to help health care professionals deliver behavioral screening and intervention. References 1. Jackson HA, Walsh B, Abecassis M. A surgeon’s guide to bundled payment models for episodes of care [published online October 21, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.2779.Google Scholar 2. DiMartini A, Crone C, Fireman M, Dew MA. Psychiatric aspects of organ transplantation in critical care. Crit Care Clin. 2008;24(4):949-981.PubMedGoogle ScholarCrossref 3. Brown RL. The business case for hospital-based behavioral screening and intervention. J Hosp Adm. 2015;4:95-103. doi:10.5430/jha.v4n6p95.Google Scholar 4. Brown RL, Moberg PD, Allen JB, et al. A team approach to systematic behavioral screening and intervention. Am J Manag Care. 2014;20(4):e113-e121.PubMedGoogle Scholar
JAMA Surgery – American Medical Association
Published: Jul 1, 2016
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