OR Manager - September 2018 - 19

Patient safety
really have to look at the four levels
side by side to see any difference between
them. "
Simulation methodology
The simulation method was used
to test how a change of risk thresholds
affected patient risk levels. The
method allowed for exclusion of risk
factors having greater uncertainties
and compared two-level versus threelevel
outcomes.
" This simulation methodology was
a whole new world, a whole new language,
and a whole new method of testing
for me, " says Munro. It involved
building the Munro Scale into an Excel
spreadsheet that has the capability of
also inserting simulated patients based
on real patient data.
" Once the information is there, you
can run analyses on a real patient
population or in a statistical fashion
to determine numerical calculations
of each risk factor and test changes
to the Munro Scale thresholds, " she
says.
An analysis of 1,000 simulated patients
on a two-level outcome determined
a minimum high-risk threshold of:
* 9 for the preoperative phase
* 23 for the intraoperative phase
* 27 for the postoperative phase.
" My model can now create a simulated
population up to 10,000 patients
that is based on real patient data and
characteristics, " says Munro. " It is a
tool that is alive and can strengthen the
validity of the model itself " (sidebar, p
18).
Statistical model results
Using the statistical model of multivariate
logistic regression, Munro
compared the Munro Scale (ie, count
method) statistics that were generated
from simulated patients to the regression
method (ie, characteristics of real
patients), which showed agreement in
the results. Risk factors were weighted
using the simulated patient data and
www.ormanager.com
Refinements will
help distinguish
low vs high risk for
pressure ulcers.
then applied to real patient data for adjustment
of the thresholds.
" In other words, " says Munro,
" they confirmed each other-the
count method matched the regression
method. This was a form of validity for
the Munro Scale with the two-level outcomes, "
she says.
Next steps
" The two-level risk outcomes should
streamline the assessment scale and
improve the differentiation of low and
high risk, " Munro says.
The next steps will include:
* determining which risk factors contribute
the most to a patient's risk
and, therefore, should be retained in
the model
* determining weighting of risk factors
that will best predict risk
* deciding how the model can be appropriately
calibrated so that it produces
a balanced mix of low- and
high-risk results.
Future testing with the simulation
model is pending. ✥
-Judith M. Mathias, MA, RN
References
AORN. Guideline for positioning the
patient. 2018 Guidelines for Perioperative
Practice. Pp 673-744.
AORN. Prevention of perioperative
pressure injury tool kit. https://
www.aorn.org/guidelines/clinicalresources/tool-kits/prevention-ofperioperative-pressure-injury-tool-kit.
Joint
Commission Resources. Under
pressure: Preventing perioperative
pressure injuries. The SourceTM.
2017:15(11);1, 12-15, 20-21.
Bundled payments
Continued from page 17
Liao J M, Emanuel E J, Whittington
G L, et al. Physician practice
variation under orthopedic bundled
payment. Am J Managed Care.
2018;24(6):287-293.
McKesson Health Solutions. Journey
to value: the state of value-based
reimbursement in 2016. https://
www.changehealthcare.com/blog/
wp-content/uploads/vbr-study2016v3.pdf.
Navathe
A S, Anastos-Wallen R
E, Emanuel E J, et al. What's
in a name: Will BPCI-advanced
hold back or advance bundled
payment policy? Health Affairs
Blog. 2018. https://www.
healthaffairs.org/do/10.1377/
hblog20180131.50449/full/.
Navathe A S, Liao J M, Polsky D, et al.
Comparison of hospitals participating
in Medicare's voluntary and mandatory
orthopedic bundle programs.
Health Aff. 2018;37(6):854-863.
Navathe A S, Troxel A B, Liao J M, et
al. Cost of joint replacement using
bundled payment models. JAMA
Intern Med. 2017;177(2):214-222.
https://jamanetwork.com/journals/
jamainternalmedicine/
fullarticle/2594805.
Sullivan R, Jarvis L D, O'Gara T, et
al. Bundled payments in total
joint arthroplasty and spine surgery.
Curr Rev Musculoskelt Med.
2017;10(2):218-223.
UnitedHealthcare's value-based care
program for knee, hip and spine
procedures demonstrates improved
health outcomes and reduced
costs. 2018. https://newsroom.
uhc.com/news-releases/UnitedHealthcare-Value-Based-ProgramFor-Joint-and-Spine-DemonstratesImproved-Health-Outcomes-andReduced-Costs.html.
What
are bundled payments? NEJM
Catalyst. 2018. https://catalyst.
nejm.org/what-are-bundled-payments/.
OR
Manager | September 2018
19

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OR Manager - September 2018

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