Musculoskeletal Quality Collaborative Improves Value-Based Health Care Delivery Across Hospital System

ABSTRACT

Objectives: Rising health care costs necessitate value-based health care (VBHC) initiatives. Large hospital systems offer a platform for surgeon collaboration in developing standardized, interdisciplinary orthopedic care. This study evaluates the formation, implementation, and outcomes of the Musculoskeletal Quality Collaborative (MSKQC) across a hospital system.

Methods: Established in 2019, the MSKQC comprises physician, quality, and nursing leaders from 14 hospitals. Using the Delphi method, surgeons identified VBHC interventions, leading to protocols for antibiotic-infused bone cement (AIBC), povidone-iodine irrigation, and negative pressure wound therapy (NPWT) dressings, implemented in May 2023. Usage was tracked across hospitals and reviewed quarterly from June 2023 to June 2024. Total hip arthroplasty and total knee arthroplasty (TKA) standardized infection ratios (SIRs) were calculated using National Healthcare Safety Network (NHSN) baselines. Surgeons performing more than 30 cases annually with more than 30% utilization of a target consumable were deemed high utilizers.

Results: The systemwide savings opportunity exceeded $800,000 annually. AIBC use dropped from 19.6% to 5.5%. Two high-use hospitals showed gradual improvement, and 7 high-use surgeons were identified. NPWT usage remained stable at less than 5%. Sterile iodine irrigation decreased by 51.6% to less than 10%. TKA infections occurred in 18 of 6592 (0.27%) surgeries in 2023, compared with 14 of 5955 (0.24%) in 2022. The NHSN SIR was 0.906.

Conclusions: The MSKQC successfully reduced high-cost consumable use while maintaining low infection rates. Regular protocol distribution and surgeon-specific feedback proved effective in advancing VBHC initiatives. This model offers a scalable approach for orthopedic VBHC implementation in the absence of national guidelines.

Am J Manag Care. 2026;32(Spec. No. 6):SP269-SP275. https://doi.org/10.37765/ajmc.2026.89966

National health care expenditures reached $4.5 trillion in 2022 and are projected to grow 5.6% annually through 2032, highlighting the need for cost-effective health care solutions.^1-3 Value-based health care (VBHC) initiatives, defined as health outcomes per dollar spent, have become a key strategy to address these increases.⁴ In orthopedics, VBHC initiatives include bundled payment models such as the Bundled Payments for Care Improvement and Comprehensive Care for Joint Replacement programs, which consolidate reimbursement across an entire episode of care and incentivize coordination while limiting unnecessary services.^2,5-7 Other core elements include systematic collection of patient-reported outcomes, integration of cost accounting, and use of dashboards to compare value across providers.^5,8-10 Despite these efforts, challenges persist in aligning incentives, ensuring access for vulnerable populations, and promoting surgeon adoption of cost-based changes.

Within the domain of total hip and knee arthroplasty (THA and TKA, respectively), surgical outcomes improve with higher case volume, motivating surgeon collaboration when evaluating best practices.^11,12 Concurrently, hospital consolidation into systems provides a platform for specialist and interdisciplinary collaboration across facilities.¹³ However, low-value interventions, defined as practices that provide little or no benefit relative to cost, persist in arthroplasty, including the use of high-cost consumables such as antibiotic-infused bone cement (AIBC) and negative pressure wound therapy (NPWT). A 2020 American Academy of Orthopaedic Surgeons review emphasized the importance of collaborative, data-driven approaches to address these practices,¹⁴ yet studies report that up to 75% of arthroplasty procedures still involve low-value interventions.¹⁵ Surgeon reluctance to adopt cost-based changes underscores the importance of data-driven protocols, as these initiatives have higher rates of adoption and sustainability.¹⁶

In 2019, the Musculoskeletal Quality Collaborative (MSKQC) was established across a large Massachusetts hospital system. Comprising 14 hospitals and 68 arthroplasty surgeons, the MSKQC aims to survey the best practices of orthopedic surgeons, leveraging the favorable outcomes and expertise of an orthopedic specialty center, to enhance care through standardizing protocols, reducing costs, and limiting practices that are not evidence-based. Surgeons from various employment models, including private practice, hospital-employed, and multispecialty groups, collaborated in this effort. The study aims to detail the methodology, implementation, and financial and clinical outcomes of the MSKQC.

METHODS

Formation of the MSKQC

The MSKQC was established in March 2019 at an orthopedic specialty hospital to align protocolized orthopedic care with VBHC principles while reducing costs and patient outmigration. Membership included orthopedic surgeons, nursing leadership, quality and safety officers, and administrative teams. Protocol development and consensus-building occurred between 2022 and 2023. Systemwide implementation of the cost-reduction protocols occurred between June 2023 and June 2024.

The MSKQC employed a triad model, with leadership including the hospital’s chief medical officer, chief operating officer, chief nursing officer, chairman, chief of arthroplasty, and executive vice president of nursing (Figure 1). Quarterly meetings facilitated discussions on quality, cost, product analysis, and research. A panel of 11 arthroplasty specialists guided protocol development.

Identification of System Costs

The MSKQC’s initial focus was on implementing evidence-based practices to improve the quality of care, starting with surgical site infection (SSI) prevention. By 2023, the system demonstrated significant reduction in SSIs and expanded to address alternative challenges. Unlike previous SSI projects, the implementation of policies limiting high-cost, low-value interventions lacked national guidelines. Peer discussion and collaboration became vital to the establishment of new value-driven protocols. The Delphi method was used to poll total joint arthroplasty (TJA) experts and identify targets for cost reduction.¹⁷ This approach was vital to the founding pillars of the MSKQC, as research shows that when participants have true agency in shaping change, they are significantly more likely to support it.¹⁸ Costs were estimated from actual acquisition expenses, and systemwide consensus guided intervention strategies. In May 2023, 3 primary cost contributors with uncertain clinical benefits were identified, as follows:

1. AIBC. Whereas standard bone cement typically costs $150 to $250 per packet, antibiotic-loaded formulations range from $650 to $1200 per packet, representing an incremental added cost of $400 to $1050per case. AIBC is often used prophylactically, but routine use in primary TJA lacks clinical support.^19-21 Estimated cost savings per infection prevented are $120,000,¹⁹ making it the first identified low-value target.

2. NPWT dressings. Standard dressings (gauze, foam, or occlusive) typically cost $10 to $50 per case. In contrast, NPWT/vacuum-assisted closure systems are substantially more expensive, with single-use disposable units costing $400 to $600 and traditional reusable pump systems with consumables reaching $1000 to $2000 per episode of use. NPWT can therefore be 8 to 200 times more expensive than standard dressings. It can be effective in chronic wounds and revision TJA,^22,23 but its high cost limits routine use in low-risk primary TJA.^23,24

3. Intraoperative povidone-iodine irrigation (Aplicare, Surgiphor) and commercially available chlorhexidine alternatives (Irrisept). Compared with saline, commercially available irrigation products introduce an incremental added cost of $80 to $110 per case. Studies indicate no significant reduction in infection compared with saline,^25,26 and national guidelines lack clear recommendations.^27,28

Development of Intervention Protocols

The MSKQC developed protocols through expert panel consensus to restrict or eliminate the use of these targets. Inclusion criteria determined which patients might benefit from use of these supplies, whereas other protocols outright excluded items. Thus, protocols were categorized into 2 frameworks: (1) restricted use-case, where utilization was limited to predefined high-risk patients, and (2) complete exclusion, where consumables were eliminated. Outcomes were tracked separately for each framework (eAppendix Table 1 [eAppendix available at ajmc.com]). The guidelines, outlined in eAppendix Table 1, were distributed across all hospitals in the system. For each restricted consumable, appropriate alternatives were available within existing protocols. For example, standard dressings replaced NPWT in low-risk primary TJA, and saline irrigation was used in place of povidone-iodine.

Intervening on High Utilizers

Surgeons performing more than 30 cases annually with more than 30% utilization of a target consumable were deemed high utilizers. High-use hospitals were identified as any institution employing 1 or more high-use surgeons. Surgeons received targeted communications and peer benchmarking data directly from physician leadership. The reporting strategy leveraged social psychology principles and public reporting.²⁹ Social identity theory suggests that individuals are more likely to change behavior when personally addressed, and public reporting has been shown to enhance health care quality. Although one study highlighted concerns that naming individuals could be confrontational and disruptive to team dynamics,³⁰ in a culture of mutual respect, it can serve as a valuable strategy for improvement. Direct conversations allowed surgeons to learn from peers and appreciate the importance of team-driven policy changes.³⁰

Measuring Outcomes Following Protocol Implementation

The MSKQC tracked high-cost consumable utilization and infection rates across 10,657 TJA procedures (6042 TKA and 4615 THA) from June 2023 to June 2024. Of the total cases, 4675 (43.9%) were conducted at the orthopedic specialty hospital. Savings were calculated based on reductions in target consumable usage, with a projected annual savings exceeding $800,000. Pre-/post analyses across the system served as an internal benchmark, comparing utilization and outcomes before and after protocol implementation. An external comparison group was not available because all system hospitals available for analysis participated in the initiative.

Surgical outcomes, including SSIs, were tracked alongside target consumable usage. The MSKQC defined SSIs per the National Healthcare Safety Network (NHSN) criteria, including only deep incisional primary and organ/space SSIs within 90 days of surgery. Data from 14 hospitals were obtained directly from NHSN surveillance, including postoperative admissions to outside hospitals. Standardized infection ratios (SIRs) for THA and TKA were calculated using the 2015 NHSN baseline.³¹

RESULTS

AIBC use in TKA decreased from 13.3% (66 of 495 cases in month 1) to 2.0% (8 of 404 cases in month 12) at the orthopedic specialty hospital and from 19.6% (181 of 925 cases in month 1) to 5.5% (47 of 855 cases in month 12) across the system. This reduction corresponded to a 71.9% realization of the projected 65% cost-savings opportunity, totaling approximately $160,000 (Figure 2). However, 2 high-use hospitals exhibited a slower reduction, with usage decreasing from 94% to 78% and 94% to 85%, respectively. Despite guideline recommendations, 5 of 7 identified high-utilizing surgeons continued AIBC use in more than 50% of cases.

NPWT dressing utilization remained stable across the system, yet overall projected spending decreased by 26.6%, leading to cost savings of $44,000. Nonetheless, one hospital maintained usage rates exceeding 40% despite targeted reduction efforts.

Povidone-iodine irrigation usage also declined, by 51.6%. Although Irrisept usage initially increased, subsequent reinforcement of protocols led to a 24% reduction and yielded a total savings of $256,000. Three high-utilizing surgeons were identified, with the orthopedic specialty center exhibiting the highest initial use but ultimately achieving a 59.6% reduction. Of note, only 1 hospital in the system increased sterile iodine utilization over the study period, and this facility had a low surgical throughput relative to other hospitals in the system, completing fewer than 30 cases per month. Although Irrisept irrigation utilization decreased or remained at 0% in 11 of 12 hospitals across the system, the orthopedic specialty center reported an increased utilization rate, from 0% to 14.85%.

SSI rates remained low, continuing the downward trend initiated by prior MSKQC prevention initiatives. In 2023, 18 infections were recorded among 6592 TKAs (0.27%), comparable to the 2022 rate of 14 infections in 5955 TKAs (0.24%). The annual SIR for 2023, as calculated by NHSN, was 0.906 (detailed breakdown by quarter in eAppendix Table 2).

DISCUSSION

Adoption of VBHC is essential to improving orthopedic care. This study outlines how the MSKQC identified low-value consumables and implemented protocols to reduce their use. These results demonstrate the efficacy of targeted interventions in reducing high-cost, low-value practices while sustaining low infection rates, reinforcing the MSKQC’s role in advancing VBHC.

The most significant adoption of the MSKQC Indications for Use protocol occurred at the orthopedic specialty hospital, where AIBC use declined by 84.3% over 13 months. Systemwide, utilization dropped by 71.9%, leading to a 75.3% cost reduction per case. The specialty hospital’s early success likely stemmed from its leadership in generating initiatives. As noted by Boguslavsky et al, effective change leadership necessitates structured implementation, clear communication, and shared responsibility.³² As such, the specialty hospital acted as a leader in the systemwide implementation of protocols.

Variation in AIBC adoption compared with other MSKQC initiatives may be linked to the lack of national guidelines and to literature questioning AIBC’s efficacy and safety in preventing prosthetic joint infection.²¹ In the absence of standardized guidance, system-specific protocols—grounded in peer consensus—can effectively guide practice. Furthermore, the MSKQC’s prior success in reducing SSIs fostered trust in its leadership, creating a receptive environment for cost-reduction efforts.

A subanalysis of 7 high-use physicians showed that although 3 reduced AIBC usage, 4 maintained high rates despite reminders. This resistance underscores the challenges in altering ingrained surgical behaviors. Physicians often resist externally imposed changes due to perceived threats to professional autonomy. The MSKQC mitigated this by integrating physician-led protocols, fostering a multidisciplinary approach to high-value care.

NPWT usage remained stable at approximately 3% (± 2%), with spending reduced by 26.6%. Ten of 12 hospitals showed declines, although 1 facility—hospital B—increased use. As the system’s sole Level 1 trauma center, hospital B likely treated a higher proportion of patients who met the MSKQC criteria for NPWT, such as revision or high-risk cases. Nevertheless, the MSKQC identified the center as a target for future initiatives.

Competing concurrent VBHC initiatives were a challenge to NPWT implementation. Lansdaal et al emphasize that dividing focus across too many projects can dilute resources and hinder effectiveness.³⁰ This is especially true in busier hospitals, where competing quality initiatives may further strain limited capacity and resources. To address this, the MSKQC must directly engage leadership to prioritize NPWT regulation among multiple initiatives.

Overall sterile iodine irrigation decreased by 51.6%, although Irrisept usage increased from 4.36% in 2023 to 7.69% in 2024. This initiative originated from the FDA’s 2023 reclassification of Aplicare, necessitating a transition from iodine to saline or alternative commercial irrigation. A concurrent initiative reviewed iodine use across surgical disciplines and, based on internal and external data, recommended saline as a replacement rather than adopting high-cost alternatives such as the povidone-iodine solution BD Surgiphor.^25,26 At the time of this transition, however, small amounts of chlorhexidine irrigation (Irrisept) were still available. The consequent increases in Irrisept usage, although present, were not equal to the overall decrease in sterile iodine. Broader irrigation guidelines, beyond povidone-iodine alone, were later introduced to clarify usage and reduce reliance on high-cost alternatives.

Some low-throughput facilities showed higher iodine use, likely due to limited quality improvement infrastructure and lower perceived financial impact. With fewer than 140 annual cases, one such hospital did not significantly impact systemwide metrics, but still highlighted challenges unique to smaller hospitals. Because the total dollars spent are relatively low at low-throughput hospitals, these centers may have resistance to change due to lower perceived need.

The complete removal of povidone-iodine irrigation may also have faced challenges due to the policy structure. Incrementalism posits that groups are more likely to adopt small, gradual changes than radical ones because incremental initiatives may be perceived as more similar to current practices.³³ Some surgeons, particularly in high-risk cases, preferred retaining the option, underscoring the dominance of surgical preference in decision-making.

The MSKQC aimed to establish a nationally leading, patient-centered system for musculoskeletal care. Its diverse membership, including surgeons from independent practices, faculty positions, and hospital administrators, facilitated collaboration. Although the lack of direct reporting lines initially posed enforcement challenges, it also fostered an open exchange of ideas. The principles underlying the MSKQC, including peer accountability, public reporting, and consensus-driven protocols, may be applicable to other surgical specialties facing similar challenges with low-value interventions, even though they were developed within arthroplasty. For example, comparable frameworks could be applied to spine, sports, or trauma surgery, where high-cost technologies are often introduced prior to definitive evidence of efficacy. Broader adoption of such collaborative models, however, will require adaptation to the unique clinical and organizational contexts of each specialty.

Over 1 year, the MSKQC initiatives saved more than $500,000. Restrictive and exclusionary protocols allowed for critical evaluation of technologies while preserving high-value technologies. Real-world postmarket experience is crucial in orthopedics, where FDA clearance often precedes definitive evidence of efficacy. The MSKQC’s methodology allowed for assessment of new technologies while holding surgeons accountable for cost-conscious decision-making. The nuanced approach to VBHC—balancing cost control with clinical autonomy—helped drive sustainable change.

Although the MSKQC model demonstrates the effectiveness of collaborative, data-driven protocols, it is important to acknowledge potential downsides. Risk aversion, particularly in high-stakes clinical settings, may lead surgeons to continue using familiar consumables even when evidence suggests limited benefit. Similarly, resistance to standardization can arise from concerns about loss of professional autonomy. The MSKQC sought to mitigate these risks by employing a surgeon-led governance structure, peer-to-peer benchmarking, and incremental adoption strategies that respected clinical judgment while fostering accountability. These elements were critical in achieving sustained engagement.

Limitations to the MSKQC model included its database-driven nature for initiative tracking, which lacks granular, case-specific detail regarding supply use and does not capture patient demographic information that might explain high-use scenarios. Additionally, the MSKQC’s structure requires a culture of transparency where surgeons are willing to have their supply usage and prices shared with colleagues, with individual surgeons identified by name. This structure may be difficult to execute in systems where multiple private physicians operate independently or are not unified by a single organization and goal. Finally, it must be emphasized that this analysis reflects the experience of a single health system. Although the large sample size and diverse hospital network enhance the robustness of the findings, generalizing beyond this system must be done with caution. Variations in payer mix, institutional culture, and regional practice norms may influence the feasibility and effectiveness of similar collaboratives in other contexts. Recognizing this limitation is critical when considering how the MSKQC model may inform broader VBHC initiatives.

CONCLUSIONS

The implementation of the MSKQC decreased the utilization of high-cost consumables across a large hospital system while maintaining low infection rates. Through continuous initiatives, the MSKQC demonstrated the value of a physician-driven approach to VBHC, reinforcing the importance of collaborative, data-driven quality improvement in modern health care.

Author Affiliations: New England Baptist Hospital (HIT, MK, NP, TI, BLH, ELS), Boston, MA; Tufts Medical Center (JM), Boston, MA.

Source of Funding: None.

Author Disclosures: Dr Hollenbeck reports receiving grant funding from Adaptive Phage Therapeutics. Dr Smith reports board membership with the American Academy of Orthopaedic Surgeons, the American Association of Hip and Knee Surgeons, and the Massachusetts Orthopaedic Association; consultancies or paid advisory roles with Pacira BioSciences and Conformis; and receipt of royalties from and stock ownership in Conformis. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (HIT, MK, JM, NP, TI, BLH, ELS); acquisition of data (HIT, TI, BLH, ELS); analysis and interpretation of data (HIT, MK, JM, NP, TI, BLH, ELS); drafting of the manuscript (HIT, MK, JM, NP, TI, BLH, ELS); critical revision of the manuscript for important intellectual content (HIT, MK, JM, NP, TI, BLH, ELS); statistical analysis (HIT, BLH, ELS); provision of study materials or patients (HIT); obtaining funding (HIT); administrative, technical, or logistic support (HIT, BLH, ELS); and supervision (HIT, TI, BLH, ELS).

Send Correspondence to: Hannah I. Travers, MS, New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120. Email: htravers@nebh.org.

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