Orthopedic Surgery without Opioids

Speaker 1All right, let's get started. Thanks everybody for uh taking some time here on a

Speaker 1Thursday afternoon to, uh, to join us for a, a webinar topic we think is of a great importance and, uh, hopefully you'll agree, if not now, at least by the end of our 30 minutes together. Uh, my name is Brand New and. I'm the CEO and uh co-founder of Goldfinch Health. I'll moderate the panel today. We, we wanted to bring together some perspectives, both from the patient side of, uh, Orthopedic Surgery, uh, and Surgery generally.

Speaker 1And, and the use of opioids around Surgery as well as the physician perspective. So, we'll, uh, throughout the course of our time together, hopefully connect some dots on status quo experience versus uh what's possible today and why that matters, not only to patients, but uh obviously to those who are paying uh a lot of the, the bill of the healthcare that's delivered in America, the employers and insurers.

Speaker 1One note before we uh dive in here to, um, beginning with the patient uh perspective. If you have questions or comments throughout, uh, please use the chat function. We'll get to those questions and, uh, we'll certainly, if we don't get to them at the, the segment that we're on, we'll certainly hit them at the end. Uh, we'll also be recording this, uh, session, so we'll have a recording that's available for everybody when we wrap up. Uh, with that, I want to, uh,

Speaker 1Introduce and welcome to our discussion, uh, two patients, both with, uh, some perspectives in, uh, recent surgeries. It's a husband and wife, David and Mary Ellen, welcome to you. Uh it's, uh, Dave and Marilyn are a married couple who live just outside of Omaha, Nebraska, uh, close to my hometown, and, uh, they were, uh, interested and willing to share their perspectives and experiences recently with Surgery. So, Marilyn, if, uh, you're OK, I'd like to start with you, if you don't mind and

Speaker 1I, I know you've had a, uh, a few surgeries recently and it starts with a Shoulder Surgery, correct? A Rotator Cuff. Could you talk a little bit about that experience and the, uh, the lead up to and recovery from and opioid experience around that.

Speaker 2Sure. Um, well, like you said, I was, I first had a Rotator Cuff, and I was given opioids, um, to take home and actually quite a large number, I think 70 to take home with me. And after the first day or first day and a half, my husband called our daughter and said something is not right. She can't even hold her head up. Um,

Speaker 2Couldn't stay awake, wasn't making any sense. They called the pharmacist who said,

Speaker 2You know, take her off this or that because I was given way too much. Um, so then I just, um, powered through and really didn't have anything after the, probably the 3rd or 4th day because I just didn't wanna feel like that.

Speaker 2Um, then, the second one I had was a bunionectomy, which I had heard from the start was terribly painful Surgery. And it really turned out to be a fiasco because, I mean, the bunionectomy worked, but I was once again given opioids even though my husband had said, please do not give her um a bunch of opioids again because she had struggled staying awake, etc.

Speaker 2Well, this time, um, they gave me a combination of opioids. And after, I think it was the 1st night, wasn't it? Or 2nd night? 2nd night, I started telling him, I felt like I couldn't breathe very well and that I was just gonna go lay down and go to bed.

Speaker 2Um, fortunately, our daughter called around 10 o'clock that night to check on me, or they said I probably would not have awakened because I went into respiratory depression. And, um, as my husband gets me out to the car and we go speeding to the closest hospital, um, my respiratory rate, when we got to the hospital, I think it was around 70.

Speaker 2Wow. So then I ended up, uh, overnight in the hospital and transferred by ambulance and $22,000 later of tests and stuff to make sure that it was indeed just caused by the medication, um.

Speaker 2Uh, it, it was a scary event to say the least.

Speaker 1Mary Ellen, in either of those two, surgeries, the Shoulder Surgery or the bunionectomy, did you have any Pain medication prior to Surgery? Or was the, uh, was the whole Approach after Surgery?

Speaker 2Everything was after Surgery. And um my final Surgery, which I had just 7 weeks ago, was an anterior dissection and surgical or cervical fusion. And um with that one, I followed the protocol that um Goldfinch gave me. And, and I was

Speaker 2Anxious to try it because you'll hear in my husband's experience, he had followed the goldfinch um protocol previously and had tremendous success. So we decided to give it a try on my um neck Surgery.

Speaker 2And I had one opioid and after that, I had nothing but um Tylenol.

Speaker 2And I prepared for Surgery, um, using the protocol and went in hydrated, uh, etc. and I had my first, um,

Speaker 2Uh, meeting, follow-up meeting with, um, the, uh, res, or with the therapist and Physical therapy, and they, um, said they were amazed at the range of motion I had and said that it was, she started to say it's one of the best, and then she corrected and said, You are the best I have ever seen with range of motion. Then when I went in to talk with the, um,

Speaker 2The doctor, he said that I was more like a 6 to 9 month patient.

Speaker 2With how well I was doing so.

Speaker 1So Mariella, just one last question before we um

Speaker 1Move over to Dave's experience. On the, on the last Surgery, the, uh, the cervical Surgery, did you, so you did have Pain medication prior to Surgery in that case? Did, and what were some of the Other, uh, what were some of the Other differences between your first two surgeries and this last one?

Speaker 3Tylenol,

Speaker 2uh, the Tylenol and keeping hydrated. I mean, I had, um, prior to, I had some Celebrex and, um, and the Lyrica, which was different from the time before.

Speaker 2But afterwards, I had, like I said, they sent me home on one pill, I think. And then after that, I didn't feel the need for any.

Speaker 2And I came through like a champ. It was, it was really very easy. I couldn't believe it.

Speaker 1Well, that's fantastic. I'm glad to hear that, uh, the recovery is going so well on the, uh, recent Surgery, and, uh, it's just great news. So, Dave, let's turn the, uh, turn the tables over to you. So you've had a, uh, a couple of recent surgeries also, and, uh, including two Shoulder surgeries. That's correct. You want to, uh, share with everyone the, the experience of the first Surgery and the lead up to and kind of how that played out, and then what happened with the second Surgery.

Speaker 3Well,

Speaker 3um,

Speaker 3Yeah, I, I did have a gallbladder taken out. I had a gallbladder attack, ended up in the emergency room last December. But again, following the protocol, and gallbladder, you know, is a little bit different from the Shoulder Surgery, and I came through that without anything, and that was kind of a breeze. But yeah. My first Shoulder Surgery, um, was in March, March 9th, and, um, Rotator Cuff.

Speaker 3You know, it's kind of interesting, even uh the pre-op nurse told me uh what I should be getting off of and not taking and I uh

Speaker 3had been in communication from the gallbladder time uh with Goldfinch, and they just encouraged me to give a little bit of pushback on what they recommended I take for a few days prior to.

Speaker 3So, I said, this is what I'd like to take, and if you need to talk to the doctor, you go ahead, but I had this for my gallbladder, and this is the protocol I plan on taking. And they were a little bit hesitant, but they checked with the surgeon, called me back a short time later and said he's fine with it. So it was really that easy to just give gentle push back and, and they were all about it, um.

Speaker 3So after my Surgery, again, I told them I did not want any opioids because of the experience my wife had, which was very frightening. And uh but they sent me home with some.

Speaker 330, I believe. And uh I took none. I, I did the 3 or 4-day workup that Goldfinch had um suggested I do and the hydration and then followed that protocol a couple of days post-op, but it was nothing but extra strength Tylenol and, and truly got along great. I mean, I had, my Pain scores were

Speaker 3I may have told them 11 time, but that was nothing. Discomfort, yes, Pain, no. So then I had to have my left one done. I knew this, um, going in at the end of June. So obviously, I followed the same thing, got the same type of pushback, and I said, no, just check with them. This is what I did before. And, um, and again,

Speaker 3I, I'm not sure I even took extra strength Tylenol, you know, but maybe 2 days post-op, so got along great, doing good.

Speaker 1And 11 of the interesting things that, uh, Dave, I think played out with your two, your two scenarios is there was a change to the, the uh pre-surgery instructions, as I understand it, between your first Shoulder Surgery and the second. Can you talk a bit about that? Yeah,

Speaker 3there was indeed, uh, the, um, pre-op nurse was telling me what to expect, um, when I went home and everything to make sure I took my opioids and I explained to her what I was planning on doing.

Speaker 3Uh, which was what Goldfinch had.

Speaker 3You know, suggested I do. And she kind of chastised me a little bit not to be thinking I'm not taking any opioids, and I'd get behind the curve and would be in Pain. Um, she happened to be the one that called me a day or two postoperatively and asked me how I was doing. I said, great. And by the way, I took none of these, which she was astounded with. And the pre-op instructions, um, that you get mailed.

Speaker 3To you prior to, uh, there was a change before the second one, and that had to do with, um, you know, with taking opioids and the fact that, you know, the, you may be sent home with something, but the patient is in charge of how much of that they take or how much of that they need.

Speaker 3And which I was very happy to see that at least there was, obviously had been some discussion.

Speaker 3On, on opioids and the effect they can have or not have, and that, you know, if a patient has those, and you really need those, then by all means, take one or two, but not a month or two's worth. So, um, that, that was nice to see.

Speaker 1And Dave, how are the shoulders doing now?

Speaker 3Great. They, uh,

Speaker 3Um,

Speaker 3Chipping and putting and, and getting along good and I can, I can sleep on both shoulders. Uh, yeah, I couldn't be happier. No problems at all.

Speaker 1How long, how long would you say it took you to be back in a position where you're back to your normal life?

Speaker 1After, uh, after your Shoulder surgeries.

Speaker 3Well, I mean, it, it truly wasn't, wasn't long at all. I'm, I mean, I know on this second one, you know, I had it propped up a little bit, but as far as comfort, I was actually able to sleep in my own bed like 2 days post-op, and sitting up, which was different from the first one.

Speaker 3But Other than having my arm in a sling and being careful, you know, to do things just one arm, um, I went about it very quickly. I'd say even within maybe the 1st, 1st week, first.

Speaker 3Yeah, I mean, I got up and I was moving after just a few days, so that's not, yeah, no big deal.

Speaker 2And I was on my, with my neck brace. I had my neck brace off after one week.

Speaker 2And I slept in bed the first night. And then um after two weeks, I was driving all over and

Speaker 2Um, it's crazy. It doesn't even feel like I had.

Speaker 3Now we gotta be, uh, we've been careful. So I mean, she was driving, but, but carefully, but at least you can get on and live your life.

Speaker 1Yeah, great. Thank you both for, uh, for sharing your perspective. I wanted to, uh,

Speaker 1To uh convert over to transition over to Doctor Dasa, and I'll introduce uh

Speaker 1Doctor Vendasa is an orthopedic surgeon and associate professor of clinical Orthopedics at LSU Health in New Orleans, and glad to have you today, Doctor Dasa. I've, uh, got a few questions for you. Um, it's, there's a, uh, there's a lot to talk about and I think some great, uh, some great experiences highlighted by, uh, by Dave and Mary Ellen. Before we get there, I just want to, um, point out a few things and kind of set the stage here. So,

Speaker 1It, it's the, it's the, um, it is the situation that somewhere between 7 and even I've seen as high as 20% of, of surgical patients, not just Orthopedics, but surgical patients end up as persistent opioid users and Surgery has been characterized as the number one gateway to persistent opioid use and addiction.

Speaker 1In recent, recent, uh, Research has shown that despite everything that's been said about opioids and the opioid epidemic and all of the news coverage that in certain places, in certain surgeries, opioid use is not only not going down, it's going up. In fact, there was a, there was a recent uh orthopedic related study that showed that as many as 60% of patients, uh, one month post-op were still using an opioid. Um, and that's in, in this scenario where

Speaker 1Um, persistence can set in as soon as day 5 post-op. So, all of that is to say,

Speaker 1How did we get here with, uh, with opioid use in Surgery?

Speaker 4All right. So let's go back to that slide. Um, so this is a recent, uh, Research paper that was done in JAMA. And what they looked at was the impact of what the physician does in the Surgery and what the hospital does. And what we found is about 25% of the success of the Surgery, believe it or not, is physician-related. You may intuitively think it should be higher. 75% of the success of Surgery is somewhat managed by the hospital.

Speaker 4Now, a majority of the processes managed today by the hospital have been optimized over the past 10 years, because hospitals as part of the ACA and the, and the changes in value-based care have been incentivized to really uh get those processes down. So whether it's patient education, you know, ensuring it's the right site Surgery, uh, uh, the post-operative Physical therapy, you know, those kinds of things.

Speaker 4Uh, have been optimized quite a bit. But when we look at the actual physician and the performance of the individual physician, and if we look and see what the physician can influence, that aspect of Surgery has really not been optimized to the extent that it can be.

Speaker 4And so what does a surgeon touch? They touch the type of analgesia or Pain control, uh, both pre-op or before Surgery, around the time of Surgery, and then afterwards. Uh, we influence the type of anesthesia that's given. I'm gonna give you a story in a minute around that. Um, the location and types of our incisions, uh, surgical technologies that we adopt, uh, or not adopt, uh, robots being kind of the, the hot ones right now.

Speaker 4Uh, during Surgery, obviously, there's various techniques that we can do, uh, to tackle the same issue. And some surgeons will do, uh, a Surgery this way, and some surgeons will do a Surgery that way, which is why we see a tremendous amount of variation in some of these outcomes. And then post-operatively, you know, how aggressively do we start the Physical therapy? When do we start Physical therapy? How often do we do therapy? Do we even care?

Speaker 4Do we have our PA manage everything and, and I just check out and, you know, uh, put in my professional fee and, and off we go and, and I get my Reimbursement, right? So surgeons obviously control a fair amount here and the system in which we're in influences how much of that uh I can, I can manage. So I did a Knee Replacement about I wanna say 6 or 9 months ago.

Speaker 4It was a, it was a patient that had a complex uh Knee Replacement where I actually needed to do the Surgery with uh a plastic surgeon. So I had to tag team the Surgery because we had to do a flap and some Other things. Now, the challenge was the plastic surgeon didn't come to my hospital where I work, and I've got kind of my system set, set up and, and it's kind of uh an, an automated thing and I've optimized most everything around uh Knee replacements here. But I had to go to the, the hospital where the plastic surgeon was.

Speaker 4Um, because I had privileges there, but he didn't have privileges here. So I went there and, you know, I said, we did all my typical preoperative routine. Um, and right before Surgery, you know, you have to go sign, uh, the patient's, uh, leg. Uh, we have to initial it and make sure everything's good. And I talked to the anesthesiologist, just met them that day. And the anesthesiologist asked me, you know, how, what kind of anesthesia I want. And I said, you know, I want to do A, B, C, and D. He says, well, we can do A, B, and C, but we don't do D.

Speaker 4I said, uh, OK, uh, I wanna do this nerve block. That's, that's my standard routine. I said, that's how we do it at my hospital. So, yeah, but we don't really do that here. I said, all right.

Speaker 4You may not do it, but I want you to do it. Uh, he said, well, we haven't really done it, so I can't do it. So I said, OK, I guess we're not doing it. And, you know, because we're about to roll, uh, to the operating room. So needless to say, what happened was after Surgery is the patient got admitted, um, and she needed opiates after Surgery, and she was miserable, and she was, she had a lot of Pain, right?

Speaker 4Um, because I didn't have complete control over that aspect of care, uh, he, the anesthesiologist was able to deliver probably about 75% or 80% of what I was expecting and what I wanted, but not the balance of it, right? And so you'd start to see where variation starts coming into play, and how much influence and how much control I have as a surgeon and what the system is able to deliver, uh, to what I need.

Speaker 4And so in our program here, we're now, we've started doing, we have been doing Outpatient total Knee replacements since 2013. Uh, we've dropped our opiate use over time to the point where now about 50% to 2/3 of our total Knee replacements, Knee Replacement patients are opiate free.

Speaker 4And that's because I've been able to, to, to manage uh their Pain and their function with an ecosystem of solutions, innovations, partnering with our anesthesia department, working with them to develop best Practices, you know, utilizing these Enhanced Recovery Protocols to the point now where.

Speaker 4In the state of Louisiana, you can see we get these uh uh dashboards now that the state sends to us. They monitor our narcotic use and prescriptions as physicians. Uh, you can see I'm in the blue column here. My peers, my peer group, Other orthopedic surgeons doing total joint replacements are the purple line. And so you can see uh where we fall in terms of the blue columns relative to my peer group.

Speaker 4So we are prescribing uh less than 50%. And now, uh, again, this stopped reporting in June 30th. Uh, but since then, we've actually done opiate-free for our total joint replacements. And the point here is what I'm doing and what a lot of surgeons are doing that are utilizing these enhanced programs, it's not magic. It's not, you know, this kind of uh pixie dust that.

Speaker 4We're sprinkling on our patients it's basically a systematic way of engaging all the stakeholders to drive these these outcomes and so it's finding those physicians, it's finding those places that have these pathways in place so we can drive patients to get these optimized outcomes like you've heard before.

Speaker 4And so the aspects of these enhanced programs is kind of what intuitively you would think, right? So patient education, patient engagement is extremely important. It's utilizing and understanding kind of the novel approaches to enhancing Pain management, both before Surgery. So, for example,

Speaker 4In our case, we're using some new Technology called Aovera. So a week before Surgery, we actually freeze the nerves around the Knee, and we published a paper in 2016 showing when we did that, we dropped narcotic use by almost 50% by addressing the patient's Pain well upstream, well before Surgery.

Speaker 4Around Surgery, it's using Multimodal analgesia. So you heard about Celebrex and Lyrica. It's utilizing uh uh uh medications to drop, uh, the amount of blood loss that we, that we have. So there's something called tranexamic acid that we use during Total joint replacement patients. There are surgeons, and, and there's now dozens of papers showing how useful it is to reduce the amount of blood loss during Surgery, but there are still surgeons that aren't using it despite, you know, what the Research shows, um.

Speaker 4It's partnering with anesthesia to use what we call neuroaxial analgesia. So spinal analgesia, anesthesia instead of general Surgery. Believe it or not, there are, I don't, you may or may not realize, but doing general anesthesia for a Total Knee Replacement is unusual. But there are still a lot of places that do it, um, where most of us are doing spinals and nerve blocks. And there's some places that still aren't doing nerve blocks, right? So, you would think, you know, why aren't surgeons, why aren't physicians doing what should be normal.

Speaker 4The problem is, is, you know, and I'm gonna be a little crude and a little crass here, what's in it for me?

Speaker 4Right? And so as a surgeon, if that volume is coming to me, then why do I need to, why do I need to change? I'm busy. I'm doing all these cases. So, you know, whether or not the patient goes home, or I mean, goes back to work at 30 days, 60 days, 90 days as a surgeon, honestly, what do I care?

Speaker 4Right? Because it doesn't impact me. And so it's not that we're, we're formally like we're thinking ha ha ha, let me keep the ser the patient out of work for as long as I can. It's, it's not top of mind because it's not a priority.

Speaker 4And, you know, so utilizing and going after these Enhanced Recovery Protocols, the surgeons that are doing it are really because we want to do it, but we're not incentivized to do it. Because if you're reaching the minimum threshold of acceptance and quality, you're getting the referrals. It's not a big deal. So if I'm employed, uh, I'm an employed surgeon at a large health system, I'm getting fed the patients because all the Primary care physicians are employed by the health system.

Speaker 4So whether I'm prescribing 50 narcotics or 10 narcotics or 100 narcotics doesn't really matter because they're feeding me because the hospital needs me to be busy. I'm the surgeon and I'm bringing home the bacon, right? And so there's really no quality control in the sense that going from good to great to excellent. We're good at weeding out bad to good, but good to excellent to elite, it's all one. It's all one big.

Speaker 4Bag of physicians and so a good physician may get you back to work at 3 months, whereas a great physician may be 60 days, and an elite surgeon, it may be 30 days or 2 weeks, right?

Speaker 4And so you can start to see how the system is set up. It's not incentivized and it's not driven to get those really, really high-end outcomes. It's really built to prevent the catastrophes, OK? And so again, there's no distinction in the system, whether I'm prescribing 50 narcotics or 100 narcotics. It's all the same.

Speaker 4And so when you look here at this slide, kind of how physicians react to this, what we need is really the market to start dictating and forcing the issue because up until now, the market has not demanded or expected that level of outcomes and so to get to Outpatient opiate-free Knee Replacement where patients are back to work in 3 weeks or 4 weeks instead of 3 months or 4 months, the market has to demand that.

Speaker 4OK, so you're not gonna expect surgeons or hospitals to do this out of the goodness of their heart. We'll get around to it. Give me another 10 years, and yeah, we'll get to that. But if you want that today, you have to demand it. The market has to put in place those incentives, uh, uh, to really drive us to get there.

Speaker 4And I think that's where Goldfinch really has found the opportunity here where how do we go from good to great to excellent and then even higher to elite so we can get the patients to those facilities, to those physicians, to those places that have the workflows and processes so we can get these patients back to where they need to be to drive costs down, to drive the quality that we want to get the outcomes that everybody hopes and expects.

Speaker 4And so, again, on the left here, you can see the 5 percenters, you know, the, and again, typical bell shape, right? You've got folks on the front end, you've got folks on the back end, uh, that you really don't want to see. You've got folks on the front end that everybody's hoping, uh, uh, you, you can see. But again, it's luck of the draw because we have no good way of identifying the top performers. And then the bulk of the people are in the middle 80% that are kind of just, you know, coming to work, doing their thing.

Speaker 4Uh, they'll get around to improving care, you know, I'll start thinking about doing a, a new block, or I'll start thinking about doing a new surgical technique, but that's a lot of effort, right? So why, why am I gonna do that? You know, when am I gonna get around to doing that and, and reading that Research and adopting those new pathways and Protocols? And, and the ones that do do it.

Speaker 4They'll do it because either they, they drift there or there's an incentive.

Speaker 4And so what we're seeing a lot is with uh some of the evolving payment models that are out there, we're slowly starting to put carrots out there and some sticks out there to start driving physicians to go there, but it's, it's really, uh really uh not well defined.

Speaker 4And so I think what Goldfinch is doing is really getting all, getting their hands around this opportunity and then being able to get and number one, get you to those positions and then identify who those high performers are so we can get the outcomes that everybody wants.

Speaker 1Doctor Dassa, well said. Thank you for, uh, thank you for your comments, and I'll just wrap things up here. Uh, thanks, everybody, if you've, uh, stayed with us for a few extra minutes. I think we, uh, we got, uh, we got interrupted there a bit, but we, we, we certainly got to the meat of the, uh, the matter here. So, the bottom line is there's a formula that exists for better Surgery and recovery today. That formula is enhanced recoveries. You heard about it from Doctor Dassa, you heard about it from Mary Ellen and Dave, that, the experience that they had is dramatically different.

Speaker 1From status quo. Uh, it's meaningful. Uh, it's meaningful not only to patients, it's meaningful financially to employers and insurers in terms of healthcare costs and labor costs and recovery time.

Speaker 1Um, the problem is this better experience, it's just very difficult to find on your own. There was a survey in 2019 that, uh, that showed only 5% of surgeons had adopted Enhanced Recovery after Surgery, care pathways, or plan to do so in the next year. And that's really the inspiration behind what we're doing with Goldbench, put the pieces together in a meaningful way.

Speaker 1To make the, the kind of experience that Marilyn and Dave are talking about, the type of work that Doctor Doss is, is, uh, performing on a daily basis for his patients to make that the standard of care and to ensure that your folks never experience a suboptimal Surgery. So if you're interested in more information about that, uh, please reach out to us, visit us online, Goldfinchhealth.com. And, uh, thanks again for joining. Apologize for the uh slight technical delay, but uh I appreciate you joining and look forward to talking to you soon.

Speaker 1Thank you.