Correlation between physician specific discharge costs, LOS, and 30-day readmission rates: an analysis of 1,831 cases

Association of functional and cognitive impairment severity with discharge to long-term care facilities in older patients admitted to a general acute care hospital from home

BACKGROUND

The early recognition of hospitalized patients at risk of being discharged to long-term care facilities (LTCFs) may help to identify those who require transitional care programs and interventions that support discharge to home. We examined the association of functional and cognitive impairment severity with discharge to LTCFs among older hospitalized patients.

METHODS

In this retrospective cohort study, we used an administrative claims database linked with geriatric assessment data from a general acute care hospital in Japan. We analyzed patients aged ≥65 years discharged between July 2016 and December 2018. The severity of functional and cognitive impairments was assessed using the Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) scale. Based on their DASC-8 scores, patients were designated as Category I (no impairment), Category Ⅱ (mild impairment), or Category III (moderate/severe impairment). We conducted logistic regression analyses to examine the association between the severity of impairments and discharge to LTCFs after adjusting for patient-level factors.

RESULTS

We analyzed 9,060 patients (mean age: 79.4 years). Among the 112 patients (1.2%) discharged to LTCFs, 62.3%, 18.6%, and 19.2% fell under Category I, Category Ⅱ, and Category III, respectively. Category II was not significantly associated with discharge to LTCFs. However, Category III had a significantly higher odds of discharge to LTCFs than Category I (Adjusted odds ratio: 2.812, 95% confidence interval: 1.452-5.449).

CONCLUSION

Patients identified as Category III by the DASC-8 on admission may benefit from enhanced transitional care and interventions that promote discharge to home.

Machine Learning With Electronic Health Record Data Outperforms a Risk Assessment Prediction Tool in Predicting Discharge Disposition After Total Joint Arthroplasty

The Risk Assessment Prediction Tool (RAPT) predicts discharge disposition after total joint arthroplasty with only 75% accuracy. The goal of this study was to evaluate whether higher accuracy can be achieved with basic electronic health record (EHR) data combined with machine learning (ML) algorithms. Three ML analysis models were developed: model 1 (M1) evaluated the accuracy of predicted discharge disposition in concordance with the RAPT; model 2 (M2) used the RAPT questionnaire to develop an ML algorithm to predict the likelihood of discharge to home vs facility; and model 3 (M3) was developed with non-RAPT data (age, surgeon, and discharge preference) with the same ML training process as M2. Evaluation metrics included accuracy for home discharge (HD), positive predictive value for HD (PPV-HD), negative predictive value for HD (NPV-HD), sensitivity, specificity, and area under the receiver operating curve (AUROC). A total of 1405 patients were included. With M1, the overall accuracy for HD was 83.5%, PPVHD was 92.1%, NPV-HD was 45%, sensitivity was 0.88, and specificity was 0.56. With M2, the overall accuracy for HD decreased to 82.8%, PPV-HD was 91.7%, NPV-HD was 43.1%, sensitivity was 0.87, specificity was 0.53, and mean AUROC was 0.87±0.03. With M3, overall accuracy for HD increased to 90.3%, PPV-HD was 95.2%, NPV-HD was 68.6%, sensitivity was 0.93, specificity was 0.76, and AUROC was 0.91±0.02. The use of basic EHR data combined with ML can exceed the accuracy of the RAPT. Applying big data on an individual level for this purpose may allow for safer and more appropriate discharge planning. [Orthopedics. 2022;45(4):e211-e215.].

Preoperative Emergency Department Visits Are Predictive of 90-Day Postoperative Emergency Department Visits and Discharge Disposition in Total Knee Arthroplasty Patients

The increasing number of patients undergoing total knee arthroplasty (TKA) has resulted in efforts to better understand patient utilization of healthcare services in the 90-day postoperative period. The primary purpose of this study was to examine whether emergency department (ED) visits in the year prior to elective TKA were predictive of postoperative ED visits in the 90-day global period following surgery. A retrospective chart review was performed for all patients undergoing TKA from June 1, 2011 to December 31, 2015 at a Veterans Affairs hospital. Total number of ED visits in the year prior to surgery and 90 days following surgery were tabulated. Binary and ordinal logistic regression analyses were utilized to determine if preoperative ED visits were predictive of postoperative ED visits. The significance level was set to α = 0.05. Overall, 611 eligible TKA procedures were performed. The logistic regression model for postoperative ED visits was significant (p < 0.001), with the number of preoperative ED visits (1 vs. 0: p < 0.001; 2 vs. 1: p = 0.012) and presence of diabetes (p = 0.007) both predicting the likelihood of a postoperative ED visit. Healthcare changes that are redefining the concept of quality of care to include the postoperative care episode, coupled with an increasingly aging population in need of TKA, will continue to challenge orthopaedic surgeons to provide safe, competent, and cost-effective care to patients. The results of this study demonstrate that a patient's propensity to visit the ED prior to TKA is predictive of a tendency to do so postoperatively and is of use to surgeons when evaluating and counselling patients who will be undergoing a TKA.

Demand Matching Total Joint Replacement Patients Results in Reduction of Post-Discharge Costs

BACKGROUND

The shift from fee-for-service to value-based care has focused payers and providers on resource utilization. One important component of value-based care is to reduce the use of post-discharge (PD) services in a clinically appropriate manner following total joint arthroplasty (TJA). Demand matching in healthcare is the process of tailoring appropriate medical care to a patient with respect to that patient's specific medical needs and social determinants. Outcomes following the implementation of a demand-matching algorithm for coordinating PD services after TJA were analyzed in this study.

METHODS

Payment data from all Medicare patients undergoing primary unilateral TJA between July 2014 and December 2018 from a single orthopedic practice were included. These payments were separated into acute and PD care. The initial acute and PD costs were compared to costs at the end of the 4-year study period using multiple linear regression and chi-square.

RESULTS

A total of 9,638 patients (4,212 total hip arthroplasties and 5,430 total knee arthroplasties) were included. Acute costs of TJA were stable averaging $13,712.00. PD costs fell steadily from a baseline average of $7,319.00 in July 2014 to $4,678.00 in December 2018 (P < .001), representing a 36.1% decline. Discharge to home increased steadily from 45.8% to 79.9% during the same interval (P < .001.) CONCLUSION: Our results demonstrate a statistically significant reduction in PD costs over a 4-year period using a demand-matching strategy to align with the Centers for Medicare and Medicaid Services mandate for value-based care. Based on these data, we conclude that thoughtful preoperative assessment of patient factors such as social determinants and medical comorbidities could allow for cost reduction through better utilization of PD services.

The Analysis of Hospital Readmission Rates After the Implementation of Hospital Readmissions Reduction Program

OBJECTIVES

This study aims to analyze the impact of Hospital Readmissions Reduction Program (HRRP) on the nationwide optimization efforts of length of stay (LOS) and readmissions in the United States.

METHODS

We use the Nationwide Readmission Database between 2010 and 2016 provided in the Healthcare Cost and Utilization Project by the Agency for Healthcare Research and Quality. The study focuses on acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure (CHF), pneumonia monitored by the HRRP and 2 conditions, septicemia, and mood disorders that were not monitored by the HRRP but had among the highest readmissions. Patient demographics and readmissions were analyzed based on insurance type, LOS, and Charlson Comorbidity Index.

RESULTS

The readmissions vary by conditions, LOS, and insurance types. Congestive heart failure has the highest readmissions among the 6 analyzed conditions at approximately 25%. The readmission rate of CHF rises to 30% for the Medicaid patients and varies between 30% and 35% by LOS. Patients with CHF with higher Charlson Comorbidity Index demonstrates the highest readmissions among 6 conditions. The patients with longer LOSs had higher readmissions, and Medicare patients have a higher reduction in readmissions in acute myocardial infarction and mood disorders compared with the other forms of payments.

CONCLUSIONS

Our figures show that targeted programs, such as HRRP, may have a positive impact on readmission rates. We, however, observe some graphical evidence that nontargeted conditions could exhibit similar trends. Because of heterogeneity in hospital and patient characteristics, it is pivotal for researcher to consider them in formal analyses.

Pre-Operative Predictors for Discharge to Post-Acute Care Facilities After Total Knee Arthroplasty

BACKGROUND

Joint replacement surgery is in increasing demand and is the most common inpatient surgery for Medicare beneficiaries. The venue for post-operative rehabilitation, including early outpatient therapy after surgery, influences recovery and quality of life. As part of a comprehensive total joint program at Kaiser Permanente Colorado, we developed and validated a predictive model to anticipate and plan the disposition for rehabilitation of our patients after total knee arthroplasty (TKA).

METHODS

We analyzed data for TKA patients who completed a pre-operative Total Knee Risk Assessment in 2017 (the model development cohort) or during the first 6 months of 2018 (the model validation cohort). The Total Knee Risk Assessment, which is used to guide disposition for rehabilitation, included questions in mobility, social, and environment domains. Multivariable logistic regression was used to predict discharge to post-acute care facilities (PACFs) (ie, skilled nursing facilities or acute rehabilitation centers).

RESULTS

Data for a total of 1481 and 631 patients who underwent TKA were analyzed in the development and validation cohorts, respectively. Ninety-three patients (6.3%) in the development cohort and 22 patients (3.5%) in the validation cohort were discharged to PACFs. Eight risk factors for discharge to PACFs were included in the final multivariable model. Patients with a diagnosis of neurological disorder and with a mobility/balance issue had the greatest chance of discharge to PACFs.

CONCLUSION

This validated predictive model for discharge disposition following TKA may be used as a tool in shared decision-making and discharge planning for patients undergoing TKA.

Impact of Neuraxial Versus General Anesthesia on Discharge Destination in Patients Undergoing Primary Total Hip and Total Knee Replacement

BACKGROUND

Total knee replacement (TKR) and total hip replacement (THR) are 2 of the most common orthopedic surgical procedures in the United States. These procedures, with fairly low mortality rates, incur significant health care costs, with almost 40% of the costs associated with post acute care. We assessed the impact of general versus neuraxial anesthesia on discharge destination and 30-day readmissions in patients who underwent total knee and hip replacement in our health system.

METHODS

This was a retrospective cohort study of 24,684 patients undergoing total knee or hip replacement in 13 hospitals of a large health care network. Following propensity score matching, we studied the impact of type of anesthetic technique on discharge destination (primary outcome) and postoperative complications including readmissions in 8613 patients who underwent THR and 13,004 patients for TKR.

RESULTS

Our results showed that in patients undergoing THR and TKR, neuraxial anesthesia is associated with higher odds of being discharged from hospital to home versus other facilities compared to general anesthesia (odds ratio [OR] = 1.63, 95% confidence interval [CI], 1.52-1.76; P < .01) and (OR = 1.58, 95% CI, 1.49-1.67; P < .01), respectively.

CONCLUSIONS

Our results suggest an association between use of neuraxial anesthesia for total joint arthroplasty and a higher probability of discharge to home and a reduction in readmissions.

Which Patient Factors Best Predict Discharge Destination After Primary Total Knee Arthroplasty? The ARISE Trial

BACKGROUND

The role of inpatient rehabilitation after total knee arthroplasty (TKA) remains uncertain, with evidence suggesting no better functional outcomes for those who discharge to rehabilitation to those who discharge home. The aim of this study is to develop and implement a pre-operative predictive tool, ARISE (Arthroplasty Rehabilitation Initial Screening Evaluation), that incorporated psychological, functional, and socio-demographic factors to determine discharge destination.

METHODS

One week prior to TKA, the ARISE tool was administered to 100 patients, in addition to an EQ-5D-5L survey and other demographic data being recorded. The primary outcome was discharge destination. An enhanced recovery pathway, which included an anesthetic protocol designed to optimize early mobilization, was utilized. Univariable and multivariable logistic regression analysis was performed to determine the likelihood of discharge destination.

RESULTS

Patients in the rehabilitation group were, on average, 4.5 years older than the home group (P = .036). After multivariable regression, ARISE questions were predictive of discharge destination related to beliefs around the superiority of inpatient rehabilitation (odds ratio = 9.9 [2.6-37.9]) and post-discharge level of support (odds ratio = 6.3 [1.5-26.8]). No question around self-reported physical function was predictive.

CONCLUSION

Pre-operative patient beliefs regarding rehabilitation and future home support are highly predictive of discharge destination after primary TKA. Pre-operative patient-reported functional status and demographic variables, with the exception of increasing age, were not shown to be predictive. Predicting those that are most likely to discharge to rehabilitation allows for early, targeted interventions to optimize resources and increase likelihood of home discharge.

Intrinsic patient factors predictive of inpatient rehabilitation facility discharge following primary total knee arthroplasty: a systematic review and meta-analysis

Background

Total Knee Arthroplasty (TKA) reduces pain and improves function in those suffering from severe osteoarthritis. A significant cost of TKA is post-acute care, however, current evidence suggests that discharge to an Inpatient Rehabilitation Facility (IRF) has inferior outcomes to home discharge, with no greater benefit in physical function. Only individual studies have investigated TKA patient characteristics predictive of discharge destination, therefore, the aim is to systematically review the literature and meta-analyse intrinsic patient factors predictive of IRF discharge. If predictive factors are known, then early discharge planning and intervention strategies could be implemented.

Methods

Databases PubMed, CINAHL, Embase, Cochrane, and Pedro were searched up to October 2019 for all studies investigating pre-operative intrinsic patient factors predictive of IRF discharge. For assessing the methodological quality of included studies, the Quality In Prognosis Studies (QUIPS) tool was used. Statistical analysis and graphical reporting were conducted in R statistical software. To assess the effect of predictors of discharge destination, odds ratios with the corresponding 95%CI were extracted from the results of univariate and multivariable analyses.

Results

A total of 9 articles published between 2011 to 2018 with 218,151 TKA patients were included. Of the 13 intrinsic patient factors reported, 6 met the criteria for synthesised review: age, obesity, comorbidity, gender, SF-12/VR-12 survey, and smoking. Due to the heterogeneity of statistical analysis and reporting 2 variables could undergo meta-analysis, gender and smoking. Female gender increased the likelihood of IRF discharge by 78% (OR = 1.78; 95%CI = 1.43–2.20; I2 = 33.3%), however, the relationship between smoking status and discharge destination was less certain (OR = 0.80; 95%CI = 0.42–1.50; I2 = 68.5%).

Conclusion

In this systematic literature review and meta-analysis female gender was shown to be predictive of IRF discharge after total knee arthroplasty. There was also a trend for those of older age and increased comorbidity, as measured by the Charlson Comorbidity Index, or the severely obese to have an increased likelihood of IRF discharge. The marked heterogeneity of statistical methods and reporting in existing literature made pooled analysis challenging for intrinsic patient factors predictive of IRF discharge after TKA. Further, high quality studies of prospective design on predictive factors are warranted, to enable early discharge planning and optimise resource allocation on post-acute care following TKA.

Trial registration

This review was registered with PROSPERO (CRD42019134422).

Development and Validation of a Model for Predicting Rehabilitation Care Location Among Patients Discharged Home After Total Knee Arthroplasty

BACKGROUND

Demand for joint replacement is increasing, with many patients receiving postsurgical physical therapy (PT) in non-inpatient settings. Clinicians need a reliable tool to guide decisions about the appropriate PT setting for patients discharged home after surgery. We developed and validated a model to predict PT location for patients in our health system discharged home after total knee arthroplasty.

METHODS

We analyzed data for patients who completed a preoperative total knee risk assessment in 2017 (model development cohort) or during the first 6 months of 2018 (model validation cohort). The initial total knee risk assessment, to guide rehabilitation disposition, included 28 variables in mobility, social, and environment domains, and on patient demographics and comorbidities. Multivariable logistic regression was used to identify factors that best predict discharge to home health service (HHS) vs home with outpatient PT. Model performance was assessed by standard criteria.

RESULTS

The development cohort included 259 patients (19%) discharged to HHS and 1129 patients (81%) discharged to home with outpatient PT. The validation cohort included 609 patients, with 91 (15%) discharged to HHS. The final model included age, gender, motivation for outpatient PT, and reliable transportation. Patients without motivation for outpatient PT had the highest probability of discharge to HHS, followed by those without reliable transportation. Model performance was excellent in the development and validation cohort, with c-statistics of 0.91 and 0.86, respectively.

CONCLUSION

We developed and validated a predictive model for total knee arthroplasty PT discharge location. This model includes 4 variables with accurate prediction to guide patient-clinician preoperative decision making.

Discharge Home is Associated With Decreased Early Complications Following Primary Total Joint Arthroplasty

BACKGROUND

Primary total hip (THA) and total knee arthroplasty (TKA) volume has increased over the past decade. Patients discharged home (HD) have demonstrated improved postoperative outcomes compared with non-home discharge (NHD) patients. We reviewed trends in HD over the past decade and compared complication rates between HD and NHD primary total joint arthroplasty (TJA) patients.

METHODS

Retrospective analysis of the National Surgical Quality Improvement Program was performed on TJA cases and patients were grouped by discharge type. Trends in the prevalence of HD were compared by chi-square test, from 2011 to 2016. Univariate and bivariate statistics were performed. Multivariate logistic and propensity score-matched analyses were used to control for confounding variables.

RESULTS

During the 6-year review, HD increased significantly for THA (71.2% to 83.6%) and TKA (65.6% to 80.7%). Overall HD was 75.4% of THA and 71.0% of TKA patients. Propensity matching identified 16,580 THA pairs and 34,952 TKA pairs. Compared with NHD patients, HD patients had shorter operative times, were younger, and had shorter lengths of stay. Controlling for confounders, the HD patients had lower risk of death within 30 days, lower risk of major medical morbidity, decreased risk of reoperation, and decreased risk of readmission compared with NDH patients. Multivariate models demonstrated similar findings.

CONCLUSION

HD in both THA and TKA independently predicts decreased early (30-day) postoperative complications after controlling for confounding variables. Given the improved outcomes, we advocate for continued emphasis on HD rather than NHD when clinically appropriate.

How Much Does a Readmission Cost the Bundle Following Primary Hip and Knee Arthroplasty?

BACKGROUND

As alternative payment models increase in popularity for total joint arthroplasty (TJA), providers and hospitals now share the financial risk associated with unexpected readmissions. While studies have identified postacute care as a driver for costs in a bundle, the fiscal burden associated with specific causes of readmission is unclear. The purpose of this study is to quantify the additional costs associated with each of the causes of readmission following primary TJA.

METHODS

We reviewed a consecutive series of primary TJA patients at our institution from 2015 to 2016 using claims data from the Centers for Medicare and Medicaid Services and Medicare Advantage patients from a single private insurer. We collected demographic data, medical comorbidities, 90-day episode-of-care costs, and readmissions for all patients. Medical records for each readmission were reviewed and classified into 1 of 11 categories. We then compared the mean facility readmission costs, postacute care costs, and overall 90-day episode-of-care costs between the reasons for readmission.

RESULTS

Of the 4704 patients, there were 325 readmissions in 286 patients (6.1%), with 50% being readmitted to a different facility than their index surgery hospital. The mean additional cost was $8588 per readmission. Medical reasons accounted for the majority of readmissions (n = 257, 79.1%). However, patients readmitted for revision surgery (n = 68, 20.9%) had the highest mean readmission cost ($15,356, P < .001). Furthermore, readmissions for revision surgery had the highest mean postacute care ($37,207, P = .002) and overall episode-of-care costs ($52,162, P = .003). Risk factors for readmission included age >75 years (odds ratio [OR], 1.85; P < .001), body mass index >35 kg/m² (OR, 1.63; P = .004), history of congestive heart failure (OR, 2.47; P = .002), diabetes mellitus (OR, 2.0; P < .001), and renal disease (OR, 2.28; P = .005).

CONCLUSION

Providers participating in alternative payment models should be cognizant of the increased bundle costs attributed to readmissions, especially due to revision surgery. Improved communication with patients and close postoperative monitoring may help minimize the large percentage of readmissions at different facilities.

Adoption of New Medical Technologies: The Case of Customized Individually Made Knee Implants

OBJECTIVES

To investigate the impact of insurance coverage on the adoption of customized individually made (CIM) knee implants and to compare patient outcomes and cost effectiveness of off-the-shelf and CIM implants.

METHODS

A system dynamics simulation model was developed to study adoption dynamics of CIM and meet the research objectives. The model reproduced the historical data on primary and revision knee replacement implants obtained from the literature and the Nationwide Inpatient Sample. Then the dynamics of adoption of CIM implants were simulated from 2018 to 2026. The rate of 90-day readmission, 3-year revision surgery, recovery period, time savings in operating rooms, and the associated cost within 3 years of primary knee replacement implants were used as performance metrics.

RESULTS

The simulation results indicate that by 2026, an adoption rate of 90% for CIM implants can reduce the number of readmissions and revision surgeries by 62% and 39%, respectively, and can save hospitals and surgeons 6% on procedure time and cut down cumulative healthcare costs by approximately $38 billion.

CONCLUSIONS

CIM implants have the potential to deliver high-quality care while decreasing overall healthcare costs, but their adoption requires the expansion of current insurance coverage. This work presents the first systematic study to understand the dynamics of adoption of CIM knee implants and instrumentation. More broadly, the current modeling approach and systems thinking perspective could be used to consider the adoption of any emerging customized therapies for personalized medicine.

Discharge to inpatient facilities after lumbar fusion surgery is associated with increased postoperative venous thromboembolism and readmissions

BACKGROUND CONTEXT

Postdischarge care is a significant source of cost variability after posterior lumbar fusion surgery. However, there remains limited evidence associating postdischarge inpatient services and improved postoperative outcomes, despite the high cost of these services.

PURPOSE

To determine the association between posthospital discharge to inpatient care facilities and postoperative complications.

STUDY DESIGN

A retrospective review of all 1- to 3-level primary posterior lumbar fusion cases in the 2010-2014 National Surgical Quality Improvement Program registry was conducted. Propensity scores for discharge destination were determined based on observable baseline patient characteristics. Multivariable propensity-adjusted logistic regressions were performed to determine associations between discharge destination and postdischarge complications, with adjusted odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

A total of 18,652 posterior lumbar fusion cases were identified, 15,234 (82%) were discharged home, and 3,418 (18%) were discharged to continued inpatient care. Multivariable propensity-adjusted analysis demonstrated that being discharged to inpatient facilities was independently associated with higher risk of thromboembolic complications (OR [95% CI]: 1.79 [1.13-2.85]), urinary complications, (1.79 [1.27-2.51]), and unplanned readmissions (1.43 [1.22-1.68]).

CONCLUSIONS

Discharge to continued inpatient care versus home after primary posterior lumbar fusion is independently associated with higher odds of certain major complications. To optimize clinical outcomes as well as cost savings in an era of value-based reimbursements, clinicians and hospitals should consider further investigation into carefully investigating which patients might be better served by home discharge after surgery.

The Risk Assessment and Prediction Tool Is Less Accurate in Extended Length of Stay Patients Following Total Joint Arthroplasty

BACKGROUND

Although preoperative risk assessment tools have been effective in predicting discharge disposition after total joint arthroplasty (TJA), studies reporting on discharge planning in extended length of stay (ELOS), >3 days, patients are lacking. The purpose of this study was to describe the predictive utility of the Risk Assessment and Prediction Tool (RAPT) for discharge disposition in ELOS patients.

METHODS

Our study included 260 patients with LOS >3 days who underwent primary TJA between 2014 and 2016. Patients were separated into 3 cohorts, based on their RAPT score: low risk (9-12), medium risk (6-9), and high risk for discharge to a facility (1-6). Scores were compared among cohorts and correlated with discharge disposition for patients who stayed beyond 3 days.

RESULTS

In ELOS, RAPT had a higher utility in predicting discharge disposition in the low-risk (76.5% to home) and high-risk (62.9% to facility) patient cohorts, while medium-risk patients (56.5% to home) were the least accurate. Responses that significantly correlated with discharge home included male gender (odds ratio [OR], 1.81; P < .05), ambulation without walking aids (OR, 2.94; P < .01) or a single-point cane (OR, 2.95; P < .0001), <1 community support visit per week preoperatively (OR, 1.86; P < .05), and having support from someone at home (OR, 3.43; P < .0001).

CONCLUSION

The RAPT score in ELOS patients is better correlated with the low-risk and high-risk cohorts than in medium-risk patients. Conversely, medium-risk ELOS patients constituted 56.8% of our sample size, but only predicted 56.5% of discharge dispositions correctly. Future discharge disposition risk assessment tools are needed to stratify medium-risk patients.

2018 John Charnley Award: Analysis of US Hip Replacement Bundled Payments: Physician-initiated Episodes Outperform Hospital-initiated Episodes

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) initiative in 2013 to create incentives to improve outcomes and reduce costs in various clinical settings, including total hip arthroplasty (THA). This study seeks to quantify BPCI initiative outcomes for THA and to determine the optimal party (for example, hospital versus physician group practice [PGP]) to manage the program.

QUESTIONS/PURPOSES

(1) Is BPCI associated with lower 90-day payments, readmissions, or mortality for elective THA? (2) Is there a difference in 90-day payments, readmissions, or mortality between episodes initiated by PGPs and episodes initiated by hospitals for elective THA? (3) Is BPCI associated with reduced total Elixhauser comorbidity index or age for elective THA?

METHODS

We performed a retrospective analysis on the CMS Limited Data Set on all Medicare primary elective THAs without a major comorbidity performed in the United States (except Maryland) between January 2013 and March 2016, totaling more than USD 7.1 billion in expenditures. Episodes were grouped into hospital-run BPCI (n = 42,922), PGP-run BPCI (n = 44,662), and THA performed outside of BPCI (n = 284,002). All Medicare Part A payments were calculated over a 90-day period after surgery and adjusted for inflation and regional variation. For each episode, age, sex, race, geographic location, background trend, and Elixhauser comorbidities were determined to control for major confounding variables. Total payments, readmissions, and mortality were compared among the groups with logistic regression.

RESULTS

When controlling for demographics, background trend, geographic variation, and total Elixhauser comorbidities in elective Diagnosis-Related Group 470 THA episodes, BPCI was associated with a 4.44% (95% confidence interval [CI], -4.58% to -4.30%; p < 0.001) payment decrease for all participants (USD 1244 decrease from a baseline of USD 18,802); additionally, odds ratios (ORs) for 90-day mortality and readmissions were unchanged. PGP groups showed a 4.81% decrease in payments (95% CI, -5.01% to -4.61%; p < 0.001) after enrolling in BPCI (USD 1335 decrease from a baseline of USD 17,841). Hospital groups showed a 4.04% decrease in payments (95% CI, -4.24% to 3.84%; p < 0.01) after enrolling in BPCI (USD 1138 decrease from a baseline of USD 19,799). The decrease in payments of PGP-run episodes was greater compared with hospital-run episodes. ORs for 90-day mortality and readmission remained unchanged after BPCI for PGP- and hospital-run BPCI programs. Patient age and mean Elixhauser comorbidity index did not change after BPCI for PGP-run, hospital-run, or overall BPCI episodes.

CONCLUSIONS

Even when controlling for decreasing costs in traditional fee-for-service care, BPCI is associated with payment reduction with no change in adverse events, and this is not because of the selection of younger patients or those with fewer comorbidities. Furthermore, physician group practices were associated with greater payment reduction than hospital programs with no difference in readmission or mortality from baseline for either. Physicians may be a more logical group than hospitals to manage payment reduction in future healthcare reform.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

Post-acute Transitional Journey: Caring for Orthopedic Surgery Patients in the United States

As the geriatric population in the United States continues to age, there will be an increased demand for total hip and total knee arthroplasties (THAs and TKAs). Older patients tend to have more comorbidities and poorer health, and will require post-acute care (PAC) following discharge. The most utilized PAC facilities following THA and TKA are skilled nursing facilities (SNFs), in-patient rehabilitation facilities (IRFs), and home with home health care (HHC). Coordination of care between hospitals and PACs, including the complete transfer of patient information, continues to be a challenge which impacts the quality of care provided by the PACs. The increased demand of hospital resources and PACs by the geriatric population necessitates an improvement in this transition of care process. This review aims to examine the transition of care process currently utilized in the United States for orthopedic surgery patients, and discuss methods for improvement. Employing these approaches will play a key role in improving patient outcomes, decreasing preventable hospital readmissions, and reducing mortality following THA and TKA. The extensive nature of this topic and the ramification of different types of healthcare systems in different countries were the determinant factors limiting our work.

Bundled Payment Arrangements: Keys to Success

The Centers for Medicare & Medicaid Services is committed to moving 50% of its fee-for-service care to value-based alternative payment models by 2018. The Comprehensive Care for Joint Replacement model is a mandatory agency program that bundles lower extremity joint arthroplasties into episodes of care that extend from the index admission to 90 days after discharge. This program, which began on April 1, 2016, includes many of the hospitals that perform total joint arthroplasties. As with other bundled payment arrangements, this model is built around seven principles that orthopaedic surgeons should be familiar with to maximize participation.

Skilled Nursing Facility Star Rating, Patient Outcomes, and Readmission Risk After Total Joint Arthroplasty

BACKGROUND

This study examined the correlation between publicly reported indicators of skilled nursing facility (SNF) quality and clinical outcomes after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

This retrospective analysis used Medicare claims from the Centers for Medicare and Medicaid Services 100% Standard Analytic File (2014-2015) that were linked to SNF quality star ratings from the Centers for Medicare and Medicaid Services Nursing Home Compare database. Overall SNF rating and subcomponents of the rating were evaluated for correlation to 30-day and 90-day risk of readmission. Ratings were based upon a 5-star rating system (1 representing the lowest quality). Cox proportional hazards regressions controlled for age, race, census division, hospital location, comorbidities, and SNF length of stay.

RESULTS

A total of 9418 SNFs, 58,064 TKA patients, and 26,837 THA patients met criteria. As SNF overall star rating increased from 1 to 5, incidence of all-cause 30-day readmission decreased from 6.4% to 5.0% for TKA (relative reduction [RR] 22%; P < .001) and from 9.1% to 6.2% for THA (RR 32%; P < .001). As nurse staffing rating increased, incidence of all-cause readmission decreased from 6.8% to 4.7% for the TKA cohort (30.9% RR; P < .001), and from 7.7% to 6.0% for the THA cohort (22.1% RR; P = .003). Regression analysis demonstrated that a higher star rating was associated with decreased risk of readmission (both cohorts P < .05).

CONCLUSIONS

For patients undergoing TKA or THA, the overall SNF star rating, nurse staffing ratios, and physical therapy intensity were significantly correlated with risk of readmission within 30 days of SNF admission.

The Cost-Effectiveness of Total Hip Arthroplasty in Patients 80 Years of Age and Older

BACKGROUND

This study investigates the cost-effectiveness of total hip arthroplasty (THA) in patients 80 years old.

METHODS

A Markov, state-transition model projecting lifetime costs and quality-adjusted life years (QALYs) was constructed to determine cost-effectiveness from a societal perspective. Costs (in 2016 US dollars), health state utilities, and state transition probabilities were obtained from published literature. Primary outcome was incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate parameter assumptions.

RESULTS

At our base-case values, THA was cost-effective compared to non-operative treatment with a total lifetime accrued cost of $186,444 vs $182,732, and a higher lifetime accrued utility (5.60 vs 5.09). Cost per QALY for THA was $33,318 vs $35,914 for non-operative management, and the incremental cost-effectiveness ratio was $7307 per QALY. Sensitivity analysis demonstrated THA to be cost-effective with a utility of successful primary THA above 0.67, a peri-operative mortality risk below 0.14, and a risk of primary THA failure below 0.14. Analysis further demonstrated that THA is a cost-effective option below a base-rate mortality threshold of 0.19, corresponding to the average base-rate mortality of a 93-year-old individual. Markov cohort analysis indicated that for patients undergoing THA at age 80 there was an approximate 28% reduction in total lifetime long-term assisted living expenditure compared to non-operatively managed patients with end-stage hip osteoarthritis.

CONCLUSION

The results of our model demonstrate that THA is a cost-effective option compared to non-operative management in patients ≥80 years old. This analysis may inform policy regarding THA in elderly patients.

Hospital Discharge Within 1 Day After Total Joint Arthroplasty From a Veterans Affairs Hospital Does Not Increase Complication and Readmission Rates

BACKGROUND

Attempts to control costs associated with total joint arthroplasty have included efforts to shorten hospital length of stay (LOS). Concerns related to patient outcomes and safety with decreased LOS persist. The purpose of this study was to investigate whether discharge on postoperative day (POD) 1 after joint replacement is associated with increased rates of 90-day return to the operating room, and 30-day readmissions and emergency department (ED) visits.

METHODS

After chart review, 447 patients admitted between January 2, 2013 and September 16, 2016 met inclusion criteria. All patients underwent one total joint arthroplasty. Patients were either discharged on POD 1 (subgroup 1) or POD 2 or 3 (subgroup 2). Statistical evaluation was performed using Wilcoxon-Mann-Whitney tests for continuous variables, and Fisher exact tests for categorical and frequency data. Statistical significance was established at P ≤ .05.

RESULTS

Subgroup 1 had significantly fewer return trips to the operating room (P = .043) and significantly fewer 30-day readmissions (P = .033). ED visits were not significantly different between groups (P = .901).

CONCLUSION

Early discharge after joint arthroplasty appears to be a viable practice and did not result in increased rates of reoperation within the 90-day global period, or rates of 30-day readmission and ED visits. Our results support the utilization of an early discharge protocol on POD 1, with no evidence that shorter LOS results in higher rates of short-term complications.

Which Clinical and Patient Factors Influence the National Economic Burden of Hospital Readmissions After Total Joint Arthroplasty?

BACKGROUND

The Affordable Care Act of 2010 advanced the economic model of bundled payments for total joint arthroplasty (TJA), in which hospitals will be financially responsible for readmissions, typically at 90 days after surgery. However, little is known about the financial burden of readmissions and what patient, clinical, and hospital factors drive readmission costs.

QUESTIONS/PURPOSES

(1) What is the incidence, payer mix, and demographics of THA and TKA readmissions in the United States? (2) What patient, clinical, and hospital factors are associated with the cost of 30- and 90-day readmissions after primary THA and TKA? (3) Are there any differences in the economic burden of THA and TKA readmissions between payers? (4) What types of THA and TKA readmissions are most costly to the US hospital system?

METHODS

The recently developed Nationwide Readmissions Database from the Healthcare Cost and Utilization Project (2006 hospitals from 21 states) was used to identify 719,394 primary TJAs and 62,493 90-day readmissions in the first 9 months of 2013 based on International Classification of Diseases, 9th Revision, Clinical Modification codes. We classified the reasons for readmissions as either procedure- or medical-related. Cost-to-charge ratios supplied with the Nationwide Readmissions Database were used to compute the individual per-patient cost of 90-day readmissions as a continuous variable in separate general linear models for THA and TKA. Payer, patient, clinical, and hospital factors were treated as covariates. We estimated the national burden of readmissions by payer and by the reason for readmission.

RESULTS

The national rates of 30- and 90-day readmissions after THA were 4% (95% confidence interval [CI], 4.2%-4.5%) and 8% (95% CI, 7.5%-8.1%), respectively. The national rates of 30- and 90-day readmissions after primary TKA were 4% (95% CI, 3.8%-4.0%) and 7% (95% CI, 6.8%-7.2%), respectively. The five most important variables responsible for the cost of 90-day THA readmissions (in rank order, based on the Type III F-statistic, p < 0.001) were length of stay (LOS), all patient-refined diagnosis-related group (APR DRG) severity, type of readmission (that is, medical- versus procedure-related), hospital ownership, and age. Likewise, the five most important variables responsible for the cost of 90-day TKA readmissions were LOS, APR DRG severity, gender, hospital procedure volume, and hospital ownership. After adjusting for covariates, mean 90-day readmission costs reimbursed by private insurance were, on average, USD 1324 and USD 1372 greater than Medicare (p < 0.001) for THA and TKA, respectively. In the 90 days after TJA, two-thirds of the total annual readmission costs were covered by Medicare. In 90 days after THA, more readmissions were still associated with procedure-related complications, including infections, dislocations, and periprosthetic fractures, which in aggregate account for 59% (95% CI, 59.1%-59.6%) of the total readmission costs to the US healthcare system. For TKA, 49% of the total readmission cost (95% CI, 48.8%-49.6%) in 90 days for the United States was associated with procedure issues, most notably including infections.

CONCLUSIONS

Hospital readmissions up to 90 days after TJA represent a massive economic burden on the US healthcare system. Approximately half of the total annual economic burden for readmissions in the United States is medical and unrelated to the joint replacement procedure and half is related to procedural complications.

CLINICAL RELEVANCE

This national study underscores LOS during readmission as a primary cost driver, suggesting that hospitals and doctors further optimize, to the extent possible, the clinical pathways for the hospitalization of readmitted patients. Because patients readmitted as a result of infection, dislocation, and periprosthetic fractures are the most costly types of readmissions, efforts to reduce the LOS for these types of readmissions will have the greatest impact on their economic burden. Additional clinical research is needed to determine the extent to which, if any, the LOS during readmissions can be reduced without sacrificing quality or access of care.

What Factors are Associated With 90-day Episode-of-care Payments for Younger Patients With Total Joint Arthroplasty?

BACKGROUND

Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most studies in this area have focused primarily on the Medicare population and rarely have characterized the younger commercially insured populations. Understanding the inpatient and postdischarge care service-component differences across 90-day episodes of care and factors associated with payments for younger patients is crucial for successful implementation of bundled payments in TJA in non-Medicare populations.

PURPOSE

(1) To assess the mean total payment for a 90-day primary TJA episode, including the proportion attributable to postdischarge care, and (2) to evaluate the role of procedure, patient, and hospital-level factors associated with 90-day episode-of-care payments in a non-Medicare patient population younger than 65 years.

METHOD

Claims data for 2008 to 2013 from Blue Cross Blue Shield of Texas were obtained for primary TJAs. A total of 11,131 procedures were examined by aggregating payments for the index hospital stay and any postacute care including rehabilitation services and unplanned readmissions during the 90-day postdischarge followup period. A three-level hierarchical model was developed to determine procedure-, patient-, and hospital-level factors associated with 90-day episode-of-care payments.

RESULTS

The mean total payment for a 90-day episode for TJA was USD 47,700 adjusted to 2013 USD. Only 14% of 90-day episode payments in our population was attributable to postdischarge-care services, which is substantially lower than the percentage estimated in the Medicare population. A prolonged length of stay (rate ratio [RR], 1.19; 95% CI, 1.15-1.23; p ≤ 0.001), any 90-day unplanned readmission (RR, 1.64; 95% CI, 1.57-1.71; p ≤ 0.001), computer-assisted surgery (RR, 1.031; 95% CI, 1.004-1.059; p ≤ 0.05), initial home discharge with home health component (RR, 1.029; 95% CI, 1.013-1.046; p ≤ 0.001), and very high patient morbidity burden (RR, 1.105; 95% CI, 1.062-1.150; p ≤ 0.001) were associated with increased TJA payments. Hospital-level factors associated with higher payments included urban location (RR, 1.29; 95% CI, 1.17-1.42; p ≤ 0.001), lower hospital case mix based on average relative diagnosis related group weight (RR, 0.94; 95% CI, 0.89-0.95; p ≤ 0.001), and large hospital size as defined by total discharge volume (RR, 1.082; 95% CI, 1.009-1.161; p ≤ 0.05). All procedure, patient, and hospital characterizing factors together explained 11% of variation among hospitals and 49% of variation among patients.

CONCLUSION

Inpatient care contributed to a much larger proportion of total payments for 90-day care episodes for primary TJA in our younger than 65-year-old commercially insured population. Thus, inpatient care will continue to be an essential target for cost-containment and delivery strategies. A high percentage of hospital-level variation in episode payments remained unexplained by hospital characteristics in our study, suggesting system inefficiencies that could be suitable for bundling. However, replication of this study among other commercial payers in other parts of the country will allow for conclusions that are more robust and generalizable.

LEVEL OF EVIDENCE

Level II, economic analysis.

Femoral Nerve Catheters Improve Home Disposition and Pain in Hip Fracture Patients Treated With Total Hip Arthroplasty

BACKGROUND

Opioids have been the mainstay of treatment in the physiologically young geriatric hip fracture patient undergoing total hip arthroplasty (THA). However opioid-related side effects increase morbidity. Regional anesthesia may provide better analgesia, while decreasing opioid-related side effects. The goal of this study was to examine the effect of perioperative continuous femoral nerve blockade with regards to pain scores, opioid-related side effects and posthospital disposition in hip fracture patients undergoing THA.

METHODS

Twenty-nine consecutive geriatric hip fracture patients (22 women/7 men) underwent THA. Average follow-up was 8.3 months (6 weeks-39 months). Fifteen patients were treated with standard analgesia (SA). Fourteen patients received an ultrasound-guided insertion of a femoral nerve catheter after radiographic confirmation of a hip fracture. All complications and readmissions that occurred within 6 weeks of surgery were noted.

RESULTS

Continuous femoral nerve catheter (CFNC) patients were discharged home more frequently than SA patients (43% for CFNC vs 7% for SA; P = .023). CFNC patients reported lower average pain scores preoperatively (P < .0001), on postoperative day 1 (P = .005) and postoperative day 2 (P = .037). Preoperatively, CFNC patients required 61% less morphine equivalent (P = .007). CFNC patients had a lower rate of opioid-related side effects compared with SA patients (7% vs 47%; P = .035).

CONCLUSION

CFNC patients were discharged to home more frequently. Use of a CFNC decreased daily average patient-reported pain scores, preoperative opioid usage, and opioid-related side effects after THA for hip fracture. Based on these data, we recommend routine use of perioperative CFNC in hip fracture patients undergoing THA.

Continued Inpatient Care After Primary Total Knee Arthroplasty Increases 30-Day Post-Discharge Complications: A Propensity Score-Adjusted Analysis

BACKGROUND

Discharge destination, either home or skilled care facility, after total knee arthroplasty (TKA) may be associated with significant variation in postacute care outcomes. The purpose of this study was to characterize the 30-day postdischarge outcomes after primary TKA relative to discharge destination.

METHODS

All primary unilateral TKAs performed for osteoarthritis from 2011-2014 were identified in the National Surgical Quality Improvement Program database. Propensity scores based on predischarge characteristics were used to adjust for selection bias in discharge destination. Propensity-adjusted multivariable logistic regressions were used to examine associations between discharge destination and postdischarge complications.

RESULTS

Among 101,256 primary TKAs identified, 70,628 were discharged home and 30,628 to skilled care facilities. Patients discharged to facilities were more frequently were female, older, higher body mass index class, higher Charlson comorbidity index and American Society of Anesthesiologists scores, had predischarge complications, received general anesthesia, and classified as nonindependent preoperatively. Propensity adjustment accounted for this selection bias. Patients discharged to skilled care facilities after TKA had higher odds of any major complication (odds ratio = 1.25; 95% confidence interval, 1.13-1.37) and readmission (odds ratio = 1.81; 95% confidence interval, 1.50-2.18). Skilled care was associated with increased odds for respiratory, septic, thromboembolic, and urinary complications. Associations with death, cardiac, and wound complications were not significant.

CONCLUSION

After controlling for predischarge characteristics, discharge to skilled care facilities vs home after primary TKA is associated with higher odds of numerous complications and unplanned readmission. These results support coordination of care pathways to facilitate home discharge after hospitalization for TKA whenever possible.

Discharge to Inpatient Facilities After Total Hip Arthroplasty Is Associated With Increased Postdischarge Morbidity

BACKGROUND

Discharge disposition accounts for significant variability in costs after elective total hip arthroplasty (THA). Therefore, institutions must evaluate the short-term clinical outcomes associated with postdischarge care options. The present study intends to characterize the associations between short-term morbidity after primary THA and discharge destination.

METHODS

Primary elective unilateral THA cases performed for osteoarthritis were identified in the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2014. Propensity scores were used to adjust for selection bias in discharge destination, based on demographics, obesity class, preoperative functional status, modified Charlson comorbidity index, American Society of Anesthesiologists (ASA) class, and the presence of predischarge complications. Propensity-adjusted multivariate logistic regressions were used to examine associations between discharge destination and postdischarge complications, controlling for selection bias based on observable patient characteristics.

RESULTS

Among 54,837 THA cases included in the study, 40,576 (74%) were discharged home, and 14,261 (26%) were discharged to inpatient facilities. In multivariate propensity-adjusted analyses, patients discharged to continued inpatient care after THA were more likely to have septic complications (odds ratio, 2.34; 95% confidence interval, 1.58-3.45), urinary complications (1.51; 1.21-1.90), readmission (1.44; 1.29-1.59), wound complications (1.31; 1.09-1.57), and respiratory complications (1.93; 1.21-3.07).

CONCLUSION

Discharge to continued inpatient care following THA is associated with increased odds of postdischarge morbidity and unplanned readmission, after propensity score adjustment for predischarge characteristics. Additional research is needed on the impact of devoting resources toward facilitating discharge to home after THA.

Can an arthroplasty risk score predict bundled care events after total joint arthroplasty?

Background

The validated Arthroplasty Risk Score (ARS) predicts the need for postoperative triage to an intensive care setting. We hypothesized that the ARS may also predict hospital length of stay (LOS), discharge disposition, and episode-of-care cost (EOCC).

Methods

We retrospectively reviewed a series of 704 patients undergoing primary total hip and knee arthroplasty over 17 months. Patient characteristics, 90-day EOCC, LOS, and readmission rates were compared before and after ARS implementation.

Results

ARS implementation was associated with fewer patients going to a skilled nursing or rehabilitation facility after discharge (63% vs 74%, P = .002). There was no difference in LOS, EOCC, readmission rates, or complications. While the adoption of the ARS did not change the mean EOCC, ARS >3 was predictive of high EOCC outlier (odds ratio 2.65, 95% confidence interval 1.40-5.01, P = .003). Increased ARS correlated with increased EOCC (P = .003).

Conclusions

Implementation of the ARS was associated with increased disposition to home. It was predictive of high EOCC and should be considered in risk adjustment variables in alternative payment models.

What is the Long-term Economic Societal Effect of Periprosthetic Infections After THA? A Markov Analysis

BACKGROUND

Current estimates for the direct costs of a single episode of care for periprosthetic joint infection (PJI) after THA are approximately USD 100,000. These estimates do not account for the costs of failed treatments and do not include indirect costs such as lost wages.

QUESTIONS/PURPOSES

The goal of this study was to estimate the long-term economic effect to society (direct and indirect costs) of a PJI after THA treated with contemporary standards of care in a hypothetical patient of working age (three scenarios, age 55, 60, and 65 years).

METHODS

We created a state-transition Markov model with health states defined by surgical treatment options including irrigation and débridement with modular exchange, single-stage revision, and two-stage revision. Reoperation rates attributable to septic and aseptic failure modes and indirect and direct costs were calculated estimates garnered via multiple systematic reviews of peer-reviewed orthopaedic and infectious disease journals and Medicare reimbursement data. We conducted an analysis over a hypothetical patient's lifetime from the societal perspective with costs discounted by 3% annually. We conducted sensitivity analysis to delineate the effects of uncertainty attributable to input variables.

RESULTS

The model found a base case cost of USD 390,806 per 65-year-old patient with an infected THA. One-way sensitivity analysis gives a range of USD 389,307 (65-year-old with a 3% reinfection rate) and USD 474,004 (55-year-old with a 12% reinfection rate). Indirect costs such as lost wages make up a considerable portion of the costs and increase considerably as age at the time of infection decreases.

CONCLUSIONS

The results of this study show that the overall treatment of a periprosthetic infection after a THA is markedly more expensive to society than previously estimated when accounting for the considerable failure rates of current treatment options and including indirect costs. These overall costs, combined with a large projected increase in THAs and a steady state of septic failures, should be taken into account when considering the total cost of THA. Further research is needed to adequately compare the clinical and economic effectiveness of alternative treatment pathways.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

Medical Comorbidities Impact the Episode-of-Care Reimbursements of Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) costs are a source of great interest in the currently evolving health care market. The initiation of a bundled payment system has led to further research into costs drivers of this commonly performed procedure. One aspect that has not been well studied is the effect of comorbidities on the reimbursements of THA. The purpose of this study was to determine if common medical comorbidities affect these reimbursements.

METHODS

A retrospective, level of evidence III study was performed using the PearlDiver supercomputer to identify patients who underwent primary THA between 2007 and 2015. Patients were stratified by medical comorbidities and compared using the analysis of variance for reimbursements of the day of surgery, and over the 90-day postoperative period.

RESULTS

A cohort of 250,343 patients was identified. Greatest reimbursements on the day of surgery were found among patients with a history of cirrhosis, morbid obesity, obesity, chronic kidney disease (CKD) and hepatitis C. Patients with cirrhosis, hepatitis C, chronic obstructive pulmonary disease, atrial fibrillation, and CKD incurred in the greatest reimbursements over the 90-day period after surgery.

CONCLUSION

Medical comorbidities significantly impact reimbursements, and inferentially costs, after THA. The most costly comorbidities at 90 days include cirrhosis, hepatitis C, chronic obstructive pulmonary disease, atrial fibrillation, and CKD.

Comparison of adverse events rates and hospital cost between customized individually made implants and standard off-the-shelf implants for total knee arthroplasty

Background

This study compares selected hospital outcomes between patients undergoing total knee arthroplasty (TKA) using either a customized individually made (CIM) implant or a standard off-the-shelf (OTS) implant.

Methods

A retrospective review was conducted on 248 consecutive TKA patients treated in a single institution, by the same surgeon. Patients received either CIM (126) or OTS (122) implants. Study data were collected from patients' medical record or the hospital's administrative billing record. Standard statistical methods tested for differences in selected outcome measures between the 2 study arms.

Results

Compared with the OTS implant study arm, the CIM implant study arm showed significantly lower transfusion rates (2.4% vs 11.6%; P = .005); a lower adverse event rate at both discharge (CIM 3.3% vs OTS 14.1%; P = .003) and 90 days after discharge (CIM 8.1% vs OTS 18.2%; P = .023); and a smaller percentage of patients were discharged to a rehabilitation or other acute care facility (4.8% vs 16.4%; P = .003). Total average real hospital cost for the TKA hospitalization between the 2 groups were nearly identical (CIM $16,192 vs OTS $16,240; P = .913). Finally, the risk-adjusted per patient total cost of care showed a net savings of $913.87 (P = .240) per patient for the CIM-TKA group, for bundle of care including the preoperative computed tomography scan, TKA hospitalization, and discharge disposition.

Conclusions

Patients treated with a CIM implant had significantly lower transfusion rates, fewer adverse event rates, and were less likely to be discharged to a rehabilitation facility or another acute care facility. These outcomes were achieved without increasing costs.

Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital

BACKGROUND

Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model.

METHODS

Using a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013.

RESULTS

In total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period.

CONCLUSION

Increasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission.

It Is a Brave New World: Alternative Payment Models and Value Creation in Total Joint Arthroplasty: Creating Value for TJR, Quality and Cost-Effectiveness Programs

BACKGROUND

The increasing cost of our country's healthcare is not sustainable. To address this crisis, the federal government is transiting healthcare reimbursement from the traditional volume-based system to a value-based system. As such, increasing healthcare value has become an essential point of discussion for all healthcare stakeholders.

METHODS

The purpose of this study is to discuss the importance of healthcare value as a means to achieve this goal of value-based medicine and 3 methods to create value in total joint arthroplasty.

RESULTS

These methods are to: (1) improve outcomes greater than the increased costs to achieve this improvement, (2) decrease costs without affecting outcomes, and (3) decrease costs while simultaneously improving outcomes.

CONCLUSION

Following these guidelines will help practitioners thrive in a bundled care environment.

The Cost-Effectiveness of Dual Mobility Implants for Primary Total Hip Arthroplasty: A Computer-Based Cost-Utility Model

BACKGROUND

Dislocation remains a clinically important problem following primary total hip arthroplasty, and it is a common reason for revision total hip arthroplasty. Dual mobility (DM) implants decrease the risk of dislocation but can be more expensive than conventional implants and have idiosyncratic failure mechanisms. The purpose of this study was to investigate the cost-effectiveness of DM implants compared with conventional bearings for primary total hip arthroplasty.

METHODS

Markov model analysis was conducted from the societal perspective with use of direct and indirect costs. Costs, expressed in 2013 U.S. dollars, were derived from the literature, the National Inpatient Sample, and the Centers for Medicare & Medicaid Services. Effectiveness was expressed in quality-adjusted life years (QALYs). The model was populated with health state utilities and state transition probabilities derived from previously published literature. The analysis was performed for a patient's lifetime, and costs and effectiveness were discounted at 3% annually. The principal outcome was the incremental cost-effectiveness ratio (ICER), with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to explore relevant uncertainty.

RESULTS

In the base case, DM total hip arthroplasty showed absolute dominance over conventional total hip arthroplasty, with lower accrued costs ($39,008 versus $40,031 U.S. dollars) and higher accrued utility (13.18 versus 13.13 QALYs) indicating cost-savings. DM total hip arthroplasty ceased being cost-saving when its implant costs exceeded those of conventional total hip arthroplasty by $1,023, and the cost-effectiveness threshold for DM implants was $5,287 greater than that for conventional implants. DM was not cost-effective when the annualized incremental probability of revision from any unforeseen failure mechanism or mechanisms exceeded 0.29%. The probability of intraprosthetic dislocation exerted the most influence on model results.

CONCLUSIONS

This model determined that, compared with conventional bearings, DM implants can be cost-saving for routine primary total hip arthroplasty, from the societal perspective, if newer-generation DM implants meet specific economic and clinical benchmarks. The differences between these thresholds and the performance of other contemporary bearings were frequently quite narrow. The results have potential application to the postmarket surveillance of newer-generation DM components.

LEVEL OF EVIDENCE

Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

What is the Best Strategy to Minimize After-Care Costs for Total Joint Arthroplasty in a Bundled Payment Environment?

BACKGROUND

The post-acute care strategies after lower extremity total joint arthroplasty including the use of post-acute rehabilitation centers and home therapy services are associated with different costs. Providers in bundled payment programs are incentivized to use the most cost-effective strategies.

METHODS

We used decision analysis to examine the impact of extending the inpatient hospital stay to avoid discharge of patients to a post-acute rehabilitation facility.

RESULTS

The results of this decision analysis show that extended acute hospital care for up to 5.2 extra days to allow for home discharge, rather than discharge to a post-acute inpatient facility can be financially preferable, provided quality is not negatively impacted.

CONCLUSION

The data demonstrate that because the cost of additional acute care hospital days is relatively small and because the cost of an extended post-acute inpatient rehabilitation facility is high, keeping patients in the acute facility for a few extra days and then discharging them directly to home may result in an overall lower cost than discharge after a shorter hospital stay to an expensive post-acute facility. However, this approach will have challenges, and future studies are needed to evaluate this change in strategy.

In-hospital costs for total hip replacement performed using the supercapsular percutaneously-assisted total hip replacement surgical technique

PURPOSE

The supercapsular percutaneously-assisted total hip (SuperPath) surgical technique for total hip replacement (THR) is a tissue-sparing approach that has been shown to improve key variables associated with the economic burden of THR (e.g., length of stay, readmissions). To date, no studies have examined the economic impact of using this technique in the United States. The objective of this study was to compare the in-hospital costs of this technique to all other THRs performed in a large hospital system in the United States.

METHODS

The costing database for a large hospital system was retrospectively searched for all in-hospital costs associated with primary THRs performed between January 2013 and September 2015. Data for all SuperPath THRs (group A) were compared to that of all other THRs performed at centres within the hospital system (group B).

RESULTS

Use of the SuperPath technique resulted in significant overall in-hospital cost reductions of 15.0 % (p < 0.000), including reductions in operating room costs of 17.3 % (p < 0.000), physical/occupational therapy costs of 26.8 % (p = 0.005), and pharmacy costs of 25.3 % (p < 0.000). Length of stay (1.2 vs. 2.6 days), transfusion rates (1.9 vs. 15.8 %), and 30-day readmission rates (0.4 vs. 2.9 %) were also lower in group A.

CONCLUSIONS

The use of this tissue-sparing surgical technique resulted in reductions in in-hospital costs, length of stay, and readmissions when compared to all other THRs performed in a large hospital system in the United States.

Clinical Outcomes and Costs Within 90 Days of Primary or Revision Total Joint Arthroplasty

BACKGROUND

This study evaluated the factors and costs associated with discharge destination and readmission, within 90 days of surgery, for primary or revision total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

This retrospective database analysis used health care claims from the Truven MarketScan Database (2009-2013). Patients were selected if aged ≥18 years, with continuous health plan enrollment from 3-month baseline through 3-month follow-up. Logistic regression and Cox proportional hazard models were used to analyze factors associated with discharge destination and risk of readmission. Total 90-day costs were calculated for different patient pathways of care, dependent on complications, discharge destination, and readmission status.

RESULTS

A total of 323,803 primary TKA, 25,354 revision TKA, 159,390 primary THA, and 17,934 revision THA cases met selection criteria. All-cause complications occurred in 2.5%, 37.2%, 2.6%, and 35.0% of each cohort. Complications, transfusions, and length of stay ≥3 days were associated with greater odds of discharge to home with home health services or skilled nursing facility (SNF) vs home under self-care (P < .001 all cohorts), whereas discharge to home with home health services or SNF was associated with greater risk of readmission (P < .05 for all cohorts except one). The ratio of total 90-day costs for the highest- (revision, SNF, readmission) vs lowest-cost (primary, home under self-care, no readmission) care pathways ranged from 1.8 to 2.2.

CONCLUSION

As Medicare payment policy for total joint arthroplasty shifts toward bundling, an awareness of factors associated with outlier costs will be requisite to remain profitable.

You Want a Successful Bundle: What About Post-discharge Care?

BACKGROUND

The postacute care strategies after total joint arthroplasty, including the use of postacute rehabilitation centers and home therapy services are associated with different costs. Providers in bundled payment programs are incentivized to use the most cost-effective strategies while maintaining quality and value for patients.

METHODS

We discuss the impact of postacute care on a bundled payment program and strategies for optimizing the value of this component of the care episode using the experience of a large academic urban medical center participating in the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement Initiative.

RESULTS

The results of this analysis show that efforts to increase the use of home discharge and decrease the use of postacute facilities after elective primary total hip and knee arthroplasties can lead to cost-effective quality care with a high degree of patient satisfaction.

CONCLUSION

The postdischarge period is a significant part of a bundled payment episode. To manage a successful bundled payment program in total joint arthroplasty, significant efforts to coordinate care during this episode are needed for patients to receive quality care that meets their expectations.

Thirty-day readmission rate and discharge status following total hip arthroplasty using the supercapsular percutaneously-assisted total hip surgical technique

PURPOSE

Recent studies have reported nearly 40% of costs associated with a 30-day episode-of-care for total joint replacements are due to post-discharge activities and 81% of those are specifically due to unplanned readmissions and discharging patients to post-acute care facilities. The purpose of this study was to determine these two key variables for total hip arthroplasty (THA) patients implanted using a tissue-sparing surgical technique and to see how these values compare to those previously reported in the United States.

METHODS

The healthcare databases at three institutions were searched for primary THA patients implanted using the supercapsular percutaneously-assisted total hip (SuperPath) surgical technique between January 2013 and July 2014. Data elements included 30-day all-cause readmission rate, discharge status, transfusion rate, complications, and length of stay (LOS).

RESULTS

Data were available for 479 THAs. The 30-day all-cause readmission rate, transfusion rate, and average LOS was 2.3, 3.3%, and 1.6 days, respectively. Over 91% of patients were discharged routinely home, 4.1% to skilled nursing facilities, 3.8% to home health care, and 0.6% to inpatient rehabilitation facilities. Complications included dislocation (0.8%), periprosthetic fracture (0.8%), and deep vein thrombosis (0.2 %). There were no infections reported.

CONCLUSIONS

Patients implanted using this tissue-sparing technique experienced reduced 30-day all-cause readmission rates (2.3% vs. 4.2%) and more were routinely discharged home (91.5% vs. 27.3%) than have been previously reported for patients in the United States. Use of this tissue-sparing technique has the potential to significantly reduce post-discharge costs.