Category: JULY – AUGUST MD News 2022

Innovation in Health Care

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by Kathryn Ruscitto

Monday, June 29, 2020

We clearly have a long way to go to get past this virus. So many challenges, and so many thanks for all front line clinicians and staff who have gotten us this far.

There are some bright spots of innovation emerging from the chaos. As with any period of complexity, we are also presented with great opportunities for change.

The key will be improving the disaster we have seen in supply chain. For any of us who tried to buy masks, gloves or other protective materials for organizations, the fluctuating quality, costs and global fraud involved in obtaining that equipment suggests we need to remold our manufacturing and supply chain. Innovators, please jump in!

We need to examine access to care and the disparities that emerged across urban and rural communities. This means determining how we use data and best practices to better assess and understand these disparities and create a response system for the next pandemic. This also means better systems for addressing vaccine and treatment protocols.

Kathryn Ruscitto

The isolation and fear that has emerged for at-risk elders living at home or in long-term care facilities needs attention. How do we provide better protection and support? Great opportunity exists to apply emergency management algorithms to protecting important community members.

While these trends suggest new opportunities, innovation in health care is already happening on many fronts.

In talking to graduates and startups, I keep stressing this time as an chance to advance bold new ideas and new products. Some examples of promising new startups from the Blackstone LaunchPad powered by Techstars at Syracuse University include:

MedUX: medux-llc.com is an award-winning medical product company based on user-centered design. Its first product is a wearable/portable IV system for people in hospital, infusion center and home infusion settings. This product is also used in emergency first response and military situations, offering patients infusion treatment without being tethered to an IV pole.

PAANI: paanisolutions.com, a venture developed by two female founders, addresses a public health crisis in India, where 163 million people lack access to clean water. Using a traditional sari cloth, they engineered a culturally appropriate filtration system to capture pathogens and particulates.

Visos: visosvr.com is a VR platform specifically for medical applications, working in conjunction with a team of advisors that include leaders in the health industry.

Promptous: promptous.com is led by a team building a digital health innovation venture in the insurtech space. It is a blockchain-powered platform to make access to dental benefits simple, seamless and transparent. Their goal is to help make dental benefits affordable and accessible to the 74 millions who go without dental insurance.

In-Spire: news.syr.edu/blog/2018/04/24/engineering-and-computer-science-students-win-panasci-business-plan-competition-with-wearable-inhaler, is a sleek wristband asthma inhaler developed by two female founders who won the CNY Biotech Accelerator Medical Device Innovation.

SugEx: dailyorange.com/2019/10/su-senior-invents-watch-monitor-glucose-levels-diabetes-diagnosis , a wearable technology to make glucose monitoring easier, was developed by an engineering student and industrial design student (one of whom was unexpectedly diagnosed with juvenile diabetes while in college).

If you have any interest in being a mentor for a promising student startup, head to launchpad.syr.edu. Mentors play a key role in accelerating learning about application in a clinical setting. I’ve served as a mentor for MedUX and have enjoyed watching many a great product be launched.

It’s a challenging time, and if you encounter a student concerned about the future, share the exciting startup ideas that are emerging for health care and the opportunities that they can help to explore.

Kathryn Ruscitto, Advisor, can be reached on LinkedIn at Kathrynruscitto or at krusct@gmail.com.

For further ideas on innovation in health care:

covidinnovations.com

rockhealth.com/portfolio

startupdigest.com/digests/health

builtin.com/healthcare-technology

Accelerated Recovery Without Opioid Risks: How New York Surgeon Andrew Wickline Reinvented the Joint Replacement Experience

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By Elesa Swirgsdin

Friday, June 17, 2022

Andrew Wickline, MD, is raising the bar on total knee and hip replacements with game-changing protocols that minimize the need for pain medications while maximizing results.

Andrew Wickline, MD, Nicole Urbanke, RN, Jodi Pearsall, RN, Kristin Thayer, ST, Stevana Hanna, ST, Dana Siriano, RN, Paul Crescenzi, CRNA
 

Total knee and total hip replacements typically lead to painful recovery periods filled with difficult physical therapy sessions. Not only does this deter some patients from getting a procedure that can vastly improve their quality of life, but it also raises the risk of patients developing an opioid dependency after surgery.

Andrew Wickline, MD, an orthopedic joint replacement specialist at Genesee Orthopedics & Plastic Surgery in New Hartford, located about 50 miles east of Syracuse, has proven this troubling trend doesn’t have to continue. After developing Therapy-Free Total Knee Replacement, a program that virtually eliminates the need for traditional physical therapy following a joint replacement, Dr. Wickline published the lowest opioid use rates in the country for this type of procedure, with high patient satisfaction and positive long-term outcomes.

His groundbreaking protocols have also led to the lowest patient costs and the lowest complication rate in the state of New York, even among patients with a high number of comorbidities.

Responding to Patient Needs

“At the end of the day, a huge part of a doctor’s job is customer service,” Dr. Wickline says. “I asked my patients, what can I do better? The answers made me think about why we do such aggressive physical therapy after joint replacements, and if there could be a better way. That was the inspiration for developing my therapy-free program.”

Many patients told Dr. Wickline that the joint replacement surgery itself wasn’t a bad experience, but the physical therapy prescribed during recovery was nearly unbearable, especially for total knee replacements.

“I heard things like, ‘I hate therapy. It was absolutely terrible.’ Or ‘My mom won’t go back to do the other knee because she doesn’t want to go through therapy again,’” Dr. Wickline says. “I started looking at what we could do differently.”

Some patients also had to travel long distances for physical therapy, which presented a significant obstacle to a successful recovery. After developing an at-home therapy plan for these patients, Dr. Wickline found that they experienced less pain, better range of motion, and a faster overall recovery than those who followed a traditional, intensive inpatient physical therapy program. This success has been seen with patients from Pakistan, southeast Asia, Canada, the Caribbean, Texas, North Carolina, New Jersey, Maine and Pennsylvania.

 Andrew Wickline, MD

Siobhan Fitzgerald, RN, BSN, Nurse Administrator

Apex Surgical Center

Exceeding Expectations

Dr. Wickline began using a home-therapy method for all of his patients combined with a comprehensive education and optimization plan. The results showed not only an easier recovery, but patients needed drastically fewer narcotics for pain relief following surgery. In 2020, he published the results of his new study, in the Journal of Orthopaedic Experience & Innovation. It involved 386 patients who had total knee replacement. During a 12-week period, 86.3% of patients needed 10 or fewer opioid pills, while 18.9% used zero opioids.

Dr. Wickline’s results are 16 times less than the national average and five times less than the next best published opioid reduction paper from Mayo Clinic.

“I saw a new study that said the average across the country is 1,200 morphine milligram equivalents for the three-month period after total joint replacement,” Dr. Wickline says. “That’s around 160 oxycodone 5mg pills for 90 days — compared to 10 pills or less with my protocol. There is still a disconnect, and we need better opioid stewardship in New York and across the country.”

In 2021, more than 107,000 people in the United States died from opioid-related overdoses. According to some studies, between 8% and 12% of people who are prescribed opioids for pain after joint replacement may develop an addiction.

Dr. Wickline’s approach replaces the typical 90-minute physical therapy sessions three times a week with four simple 8-minute exercises once an hour. Using elevation and ice after the exercises also keeps swelling down, which further decreases pain.

“If you sprain your ankle badly, you’re not going to do a 90-minute workout three times a week,” he says. “It turns out that you don’t need to do aggressive, tortuous therapy if you control swelling. Formal therapy is best used to fine tune recovery at five to six weeks after surgery.”

More than 85% of patients in Dr. Wickline’s study did not need formal physical therapy, leading to an average personal savings of $720 in therapy copays and more than $3,000 savings to insurers. In addition, 64% of patients in the study went home the day of surgery and 91% were discharged within 23 hours. Currently, 95% of patients go home the same day their joint was replaced.

Patients who follow the program also experience significantly fewer complications.

“Our readmission rate is 1.2%. That is markedly lower than results published by some big institutions,” Dr. Wickline says. “That’s also where cost is kept down. If you get readmitted for a fracture, suddenly the cost for that patient has gone up dramatically. According to Medicare cost data, I have the lowest 90-day cost in the state, even though my patients have a higher number of medical issues.”

Contributing Success Factors

Dr. Wickline is among a small percentage of surgeons in the country performing tourniquet-free knee replacements. This practice lowers the risk of blood clots by 19%. It also reduces pain and infection risk and improves incision healing.

In addition, Dr. Wickline is the only site in New York offering personalized kinematic alignment and medial pivot knee replacement. It restores each patient’s normal anatomy of the knee and provides knee motion that most closely resembles that of the native join — without painful ligament releases that increase swelling.

Improving nutrition with branched-chain amino acid protein supplementation and specific anti-inflammatory diet changes also plays a significant role in an accelerated recovery program.

Lastly, Iovera cryoablation, a temporary freezing treatment around the knee, provides patients with three months of post-op pain reduction.

Total Hip Replacement Results

Dr. Wickline delivers similarly impressive results for patients undergoing total hip replacement. In 2020, he published another study in the Journal of Orthopaedic Experience & Innovation reporting the results of a six-week long study following 207 patients after their hip replacement. About 97% of these patients required 10 opioid pills or less, with the average being 3.5 pills per patient in the six weeks following surgery. Patients followed a home-therapy protocol and 95% were able to skip formal physical therapy at six weeks. He has used the muscle sparing anterior hip approach since 2007.

Preparing Patients for Success

Comprehensive patient education is a critical component of Dr. Wickline’s program.

“No one prepares for the Super Bowl the day before the game. They prepare for weeks ahead of time,” he says. “It’s the same with joint replacement.”

Dr. Wickline has written two separate patient books for knee and hip replacements, each about 65 pages long. The goal of the books — now in their 13th edition — is to help patients succeed with proper preparation prior to surgery. The books cover topics like nutrition, getting the living space ready, and what to expect every step of the way before and after surgery, as well as during recovery.

“They answer pretty much every question that a patient has asked over the last 20,000 plus surgeries,” Dr. Wickline says. “They are extremely comprehensive.”

The books are designed to be read at certain intervals prior to surgery, so that patients can, for example, change their diet four weeks before the procedure to set themselves up for a successful recovery. An app is currently in development for patients who prefer watching videos more than reading.

Ongoing Research

Dr. Wickline continues to study opportunities to optimize recovery protocols. His research focuses on the correlation between swelling and pain and is a main focus of his current research.

“The more you control swelling, the better the joint feels,” he says. “We’re doing 3D optical scanning where we’re looking at several different infection control protocols to see if they reduce swelling. We’re also performing bioimpedance testing to look at how much fluid is in the leg before and after surgery. It’s about creating a normative baseline so we can start adding or subtracting different things from the protocol to see what improves or worsens swelling.”

Dr. Wickline also participates in the geko Cross Therapy Registry for Edema, a clinical trial that collects data on how geko neuromuscular electrostimulation technology affects swelling.

Another research focus area centers on the effectiveness of various non-opioid pain management methods, such as pre-op cryoablation, which Dr. Wickline offers to help reduce post-op pain for up to three months without narcotics. He is involved in a study focusing on how long various pain relief methods last and what is most effective for patients with osteoarthritis.

Prominent Surgeons Adopt New Joint Replacement Protocol

After Andrew Wickline, MD, published his studies on therapy-free joint replacement, orthopedic surgeons around the country, as well as in other parts of the world, began to take a keen interest in his method.

Andrew Wickline, MD

“I was having great success with my total hip and total shoulder patients, but my total knee patients seemed to suffer,” says Chris Mellano, MD, orthopedic surgeon in Manhattan Beach, California. “I commonly heard patients say, ‘I hope I never have to do that again.’ I was searching for a way to make the experience easier and less painful.”

Dr. Mellano came across Dr. Wickline’s study on therapy-free knee replacement — and couldn’t believe what he was reading.

“A large percentage of patients used no narcotics after surgery, which is unheard of in my experience,” he says. “Most also did not require formal outpatient therapy, another astounding accomplishment.”

Dr. Mellano was further shocked to find that the patients in the study were not hand-picked to be ideal patients and instead included people of all ages, including those with multiple comorbidities.

Dr. Mellano decided to visit Dr. Wickline’s practice to observe his protocols firsthand. What he saw validated the published results and inspired him to adapt these new techniques into his own practice.

“The most important factor I learned was exceptional dedication to patient education,” Dr. Mellano says. “Patients went into surgery with a clear understanding of the procedure and how to optimize their outcome. On a surgery day, Dr. Wickline and his team efficiently performed multiple total joint replacements without sacrificing patient care in any way. I left feeling empowered by his example.”

After returning to his practice, Dr. Mellano began implementing many of Dr. Wickline’s protocols, including providing patients with educational guides.

“My results have been transformative,” he says. “The first five patients each took zero narcotics and told me that their outpatient total joint procedure was a wonderful experience.”

Far-Reaching Benefits

Dr. Mellano is not alone in his experience. Michael Engl, MPH, a board member of the elite European Knee Associates, who operates in northern Italy, recently traveled to New York to observe Dr. Wickline’s protocols in action.

“Here in Europe, total joint replacements that allow patients to leave the hospital after a few hours is very uncommon,” he says. “It was almost unbelievable. By visiting Dr. Wickline, I am convinced that the knowledge I gained is as high as that of attending international meetings. It was very inspiring to discuss the differences in our pathways.”

Stephen Howell, MD, knee arthroplasty surgeon at Adventist Health Lodi Memorial in Lodi, California, known for his role in helping develop the kinematic alignment method, was looking for a way to perform outpatient total knee replacements when COVID-19 stopped elective inpatient procedures.

“Since adopting Dr. Wickline’s protocols in July 2020, nearly all of our TKA procedures have been outpatient,” Dr. Howell says. “His pain program works synergistically with the kinematic alignment approach. These techniques complement and potentiate each other.”

Looking to the Future

Dr. Wickline hopes that more surgeons across the country will adopt his unique protocols into their practices to reduce the need for narcotics and improve patient outcomes. Several prominent surgeons have already incorporated his techniques into their own protocols, an encouraging sign (see sidebar on page 8).

“It can be hard to get people convinced because these methods are so different, and change can be scary,” Dr. Wickline says. “But the bottom line is if patients follow the program, they’re going to have great outcomes. The key is getting patients engaged. You just have to give them the winning game plan.”

Dr. Wickline earned the 2020 Excellence in Surgery award at the 9th Annual Excellence in Healthcare Awards presented by the Central New York Business Journal. Visit andrewwicklinemd.com to schedule an appointment. You can also call his personal assistant, Mrs. Lorilynn Szkotak, at 315-738-5069.

The Right Way to Curb Opioid Abuse by Americans

Did you know that your grandma could become addicted to opioids because of a knee replacement? It’s more likely than you might think. Knee replacements — with more than 1 million performed every year — nearly always require opioids for pain control. It’s no surprise that the proportion of older adults seeking treatment for opioid abuse nearly doubled in recent years, particularly as the number of joint replacements increased drastically.

Every pill surgeons order can cause substance abuse. A 10-day opioid supply carries up to a 20% risk of addiction. A 24-hour supply runs a 6% chance of addiction. By getting their wisdom teeth pulled, your teenager — consuming opioids for one day — could develop an addiction. Approximately 80% of heroin addicts first misused prescription narcotics.

I propose a radical solution …

Excerpted from an op-ed in the New York Daily News by orthopedic joint replacement specialist Dr. Andrew Wickline on how to immediately begin reducing opioid addiction. To read the full article, visit nydailynews.com and search for Wickline. Siobhan Fitzgerald, RN, BSN, Nurse Administrator

New York Medical Malpractice Market Trends

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By Jenn Negley

Friday, June 17, 2022

Frequency and severity of claims, social inflation, and tort reform are the key drivers pushing malpractice carriers to seek increases during a hard market or reductions in a soft market.

While New York was slower to transition to the soft market of the past 20 years, the good news is that the same might be true of the significant increases we are now seeing in other states. As reported by the American Medical Association, “Rates that jumped 10% or more between 2020 and 2021 were reported in 12 states.”

See below for those states, listed with the share of comparisons reflecting increases of that size:

  • Illinois: 58.9%
  • West Virginia: 41.7%
  • Missouri: 29.6%
  • Oregon: 20%
  • South Carolina: 16.7%
  • Idaho: 11.1%
  • Kentucky: 7.4%
  • Delaware: 6.7%
  • Washington: 6.7%
  • Michigan: 5.4%
  • Texas: 4.9%
  • Georgia: 3.7%


Jenn Negley

Recent unprecedented trends have upended the predictability carriers rely on to maintain their financial strength. Prior to COVID-19, the number of shock losses rose at an alarming pace due to so-called social inflation in jury awards not seen in previous years. While carriers continued to lower pricing concurrent with the drop in frequency of claims, they had not factored in the drastic increase in payout amounts.

There is now a concern, post-COVID, that there will be a significant increase in the frequency of claims, making reduced rates unsustainable. There is also a belief that because many patients delayed routine tests and treatments during the pandemic, health complications will increase as conditions progress further than what we normally see.

Most states, even in the most competitive markets, are seeing a third straight year of overall rate hikes. New York lags behind due to less competitiveness and its Department of Financial Services, which exerts more stringent control on rate filings.

Admitted carriers like The Doctors Company, a newer entrant to the marketplace that’s still aggressively pursuing market share, reduced their rates at the end of last year in the central region. While the carrier MLMIC has held steady on rates, with some selective increases per specialty, it also filed discounts through risk purchasing groups to maintain a hold on their market share. On the non-admitted risk retention group side, expect to see some increases, but overall, these carriers will look to keep “good” accounts and maintain rate flexibility, unlike admitted carriers.

All of these factors are driving rate increases in other states. In New York, while some downstate regions are the most litigious in the country, Central New York is not immune either, making it a difficult market to navigate.

It Is Never Tenable to Leave Savings on the Table

As a buyer, it’s important to keep an eye on a carrier’s financials due to the stressors this market creates. It’s also important to engage the market and take advantage of potential savings while it is available. Working with an experienced professional who specializes in malpractice insurance allows you to test the market and avoid costly mistakes. Working with an insurance broker who has a deep understanding and insight into each carrier’s appetite and rate history is key.

While New York is in some ways less dynamic, it can be very difficult to navigate without strong carrier relationships across multiple companies. Be sure to reach out to a specialist before your renewal, even if it is only to review your current policy and confirm you are receiving all the new discounts available.

For more information on your insurance options, please contact Jenn Negley, Vice President, Risk Strategies Company at 267-251-2233 or JNegley@Risk-Strategies.com.

Jenn will be at the NY MGMA convention in Verona June 29–July 1.

Patient-Centered Care

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By Kathy Ruscitto, Advisor

Friday, June 17, 2022

We have made many advancements in health care these days. Whether this involves staffing, healthcare delivery and access, or new technology and a growing sophistication with vaccines, all of these milestones benefit the patient.

Patient-centered care has emerged as the preferred healthcare framework for providing services that are effective and produce the best outcomes. Patient-centered care is more than listening and engaging the patient in their care. It also involves developing processes and making administrative decisions that improve the overall patient experience — from how a reception area is designed and how patient data is analyzed to education and communication about a diagnosis and even how a bill is explained. Most importantly, patient- or people-centered care means how the elements of the care team and social determinants are connected across time, place and discipline. That collaboration is what is so important to patients.

Connecting the Dots

We have developed a high level of specialized clinical expertise, but often the parts don’t connect. A patient with MS sees a neurologist for falls, an orthopedic surgeon for joint pain and a primary care physician for general concerns. Without some way to integrate all of this care, the patient is often left navigating a system they don’t entirely understand.

Kathy Ruscitto, Advisor

Health care must be evidence-based and patient-centered, which can be a complicated balancing act. But if the clinician understands the standards of care and how to effectively communicate them, the patient feels listened to and can better address all of their needs with the provider.

The World Health Organization has commenced a worldwide initiative to introduce patient-centered approaches in every country, meaning patient-centered care is now internationally accepted as a best practice framework.

However, to every clinician, every practice and every organization, the words patient-centered care may take on a different meaning. For example, clinical approaches to diagnosing and treating Lyme disease differ between the Infectious Disease Society of America and the International Lyme and Associated Diseases Society. The patient-centered approach calls for any clinician to listen to where the patient is with symptoms and offer care that considers all approaches.

The Institute of Medicine defines patient-centered care as: “Providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” It starts with listening deeply to the challenges and needs of every patient, particularly of those with chronic conditions.

Patient-centered care helps set up a collaborative dynamic that meets patients’ needs. When done well, it’s a win for clinicians, a win for patients and a win for payers because this care model improves health outcomes.

Finally, and probably worthy of another discussion itself, how can we use technology to create virtual care teams around chronic conditions and improve our care plans?

Resources

  1. Institute for Patient and Family Centered Care (ipfcc.org/)
  2. Patient Engagement HIT (patientengagementhit.com/news/what-does-patient-centered-care-truly-mean)

Kathryn Ruscitto, Advisor can be reached at linkedin.com/in/kathrynruscitto or at krusct@gmail.com.