Effect of Bundled Payments and Health Care Reform as Alternative Payment Models in Total Joint Arthroplasty: A Clinical Review

Outliers of total shoulder arthroplasty in the bundled payment era

BACKGROUND

The Centers for Medicare & Medicaid Services implemented the Bundled Payments for Care Improvement Advanced (BPCIA) Model that covers 90-day care episodes after select orthopedic procedures including anatomic or reverse ball-and-socket total shoulder arthroplasty (TSA/rTSA). This study investigated whether patients undergoing TSA/rTSA for nondegenerative processes incur higher costs than patients undergoing arthroplasty for degenerative processes.

METHODS

A retrospective review was conducted of all patients at a single academic medical center enrolled in the BPCIA model for TSA/rTSA from October 1, 2018, through December 31, 2022. We investigated whether patients undergoing arthroplasty for nondegenerative indications accrued more 90-day postoperative costs compared to patients undergoing arthroplasty for degenerative processes. A Break-even ratio was calculated to determine the number of degenerative TSA/rTSA that would need to be performed to account for the increased expenditures associated with nondegenerative TSA/rTSA.

RESULTS

One hundred patients met inclusion criteria during the study period. Costs for TSA/rTSA due to nondegenerative indications exceeded bundle payment amounts at a significantly higher rate compared to degenerative indications (43% vs. 18%, P = .021). TSA/rTSA for nondegenerative indications was also associated with significantly higher total costs ($27,100 vs. $22,200, P = .014), significantly more postoperative emergency department visits (43% vs. 18%, P = .035), and longer hospital length of stay (2.2 vs. 1.6 days, P = .121). Break-even ratio analysis demonstrated 1.22-1.54 TSA/rTSA for degenerative indications need to be performed to equal the total spending of one TSA/rTSA for nondegenerative indications.

CONCLUSIONS

Patients undergoing shoulder arthroplasty for nondegenerative indications within the Centers for Medicare & Medicaid Services BPCIA bundled payments program were at greater risk for incurring higher costs than allocated target payments, as well as significantly higher costs when compared to patients undergoing arthroplasty for degenerative processes. We may need to consider the roles bundled-payment programs have for these patients.

Are Commercial Value-Based Care Programs Still Viable for Hip and Knee Arthroplasty: An Analysis of a Single Institution

BACKGROUND

Unlike Medicare bundled payment programs for total hip arthroplasty and total knee arthroplasty, which have little variance in facility reimbursements, few publications have studied value-based care (VBC) partnerships with commercial insurers. Specifically, VBC partnerships incentivize practices to maximize revenue surpluses by providing high-value care at decreased costs. Surgical facility choice can reduce costs with more procedures shifting to lower-cost specialty hospitals and ambulatory surgery centers. This study aimed to determine whether demand matching appropriate patients to lower-cost facilities reduced costs in our commercial VBC program.

METHODS

We reviewed a consecutive series of 4,285 primary total hip arthroplasty and total knee arthroplasty patients between January 2020 and April 2023 as part of a single-payer VBC program, including both commercial and Medicare Advantage (MA) plans. Demographics, facility, and 90-day episode-of-care claims data were collected from our clinical and payor cost databases. Surgical facility utilization, total costs, and revenue surpluses were stratified by insurance type (commercial versus MA), and trends were compared over the 4-year study period. There were 1,369 patients (32%) who had MA and 2,916 (68%) who had commercial insurance.

RESULTS

Among commercially insured patients, the mean total ($33,455 versus $27,433, P < 0.001) and facility costs ($25,068 versus $18,385, P < 0.001) both declined from 2020 to 2023, whereas the revenue surpluses ($6,216 versus $13,090, P < 0.001) increased. Among MA patients, mean total ($17,809 versus $17,235, P < 0.001) and facility costs ($13,491 versus $13,151, P < 0.001) had only minimal decreases, whereas revenue surpluses declined ($7,928 versus $4,073, P < 0.001). Utilization of ambulatory surgery centers increased among both groups from 2020 to 2023 (1 versus 20% for commercial, 0.3 versus 12% for MA, P < 0.001).

CONCLUSIONS

Practices can still have successful VBC partnerships with private insurers by demand matching appropriate patients to lower-cost facilities. Our cost-reduction efforts did not have the same success with MA plans. Further studies should evaluate whether continued cuts to MA programs will threaten access.

Frailty Is Strongest Need Factor Among Predictors of Prehabilitation Utilization for Total Hip or Knee Arthroplasty in Fee-for-Service Medicare Beneficiaries

OBJECTIVE

Prehabilitation may have benefits for total hip arthroplasty (THA) and total knee arthroplasty (TKA), given an aging population with multimorbidity and the growth of value-based programs that focus on reducing postoperative costs. This study aimed to describe prehabilitation use and examine predictors of utilization in fee-for-service Medicare beneficiaries.

METHODS

This retrospective cohort study using the Medicare Limited Data Set included fee-for-service Medicare beneficiaries who were ≥66 years old and who underwent inpatient elective THA or TKA between January 1, 2016, and September 30, 2021. The study assessed predictors of receiving preoperative physical therapist services within 90 days of surgery (prehabilitation) using a mixed-effects generalized linear model with a binary distribution and logit link. Adjusted odds ratios (ORs) were reported.

RESULTS

Of 24,602 THA episodes, 18.5% of patients received prehabilitation; of 38,751 TKA episodes, 17.8% of patients received prehabilitation. For both THA and TKA, patients with medium or high (vs low) frailty were more likely to receive prehabilitation (OR = 1.72-2.64). Male (vs female) patients, Black (vs White) patients, those with worse county-level social deprivation, those with dual eligibility, and those living in rural areas were less likely to receive prehabilitation before THA or TKA (OR = 0.65-0.88). Patients who were ≥85 years old (vs 66-69 years old) and who underwent THA were also less likely to receive services (OR = 0.84). Additionally, there were geographic differences in prehabilitation utilization and increased utilization in more recent years.

CONCLUSION

The need factor of frailty was most strongly associated with increased prehabilitation utilization. The variation in utilization by predisposing factors (eg, race) and enabling factors (eg, county-level social deprivation) suggests potential disparities.

IMPACT

The findings describe prehabilitation use in a large cohort of fee-for-service Medicare beneficiaries. Although services seem to be targeted to those at greater risk for adverse outcomes and high spending, potential disparities related to access warrant further examination.

The Financial Burden of Patient Comorbidities on Total Knee Arthroplasty Procedures: A Matched Cohort Analysis of Patients Who Have a High and Non-High Comorbidity Burden

BACKGROUND

Recent literature suggests a trend toward a higher comorbidity burden in patients undergoing total knee arthroplasty (TKA). However, the impact of increased comorbidities on the cost-effectiveness of TKA is underexplored. This study aimed to compare the financial implications and perioperative outcomes of patients with and without a high comorbidity burden (HCB).

METHODS

We retrospectively reviewed 10,647 patients who underwent elective, unilateral TKA between 2012 and 2021 at a single academic health center with available financial data. Patients were stratified into HCB (Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiology scores of 3 or 4) and non-HCB groups. A 1:1 propensity match was performed based on baseline characteristics, resulting in 1,536 matched patients (768 per group). Revenue, costs, and contribution margins (CM) of the inpatient episode were compared between groups. Ninety-day readmissions and revisions were also analyzed.

RESULTS

The HCB patients had significantly higher total (P < 0.001) and direct (P < 0.001) costs, while hospital revenue did not differ between cohorts (P = 0.638). This disparity resulted in a significantly decreased CM for the HCB group (P = 0.009). Additionally, HCB patients had a longer length of stay (P < 0.001) and a higher rate of 90-day readmissions (P = 0.005).

CONCLUSIONS

Increased inpatient costs for HCB patients undergoing TKA were not offset by proportional revenue, leading to a decreased CM. Furthermore, higher 90-day readmissions exacerbate the financial burden. These findings highlight potential challenges for hospitals in covering indirect expenses, which could jeopardize accessibility to care for HCB patients. Reimbursement models should be revised to better account for the increased financial burden associated with managing HCB patients.

LEVEL OF EVIDENCE

III.

Improved outcomes with perioperative dietitian-led interventions in patients undergoing total joint arthroplasty: A systematic review

Background

Nutritional assessment is important for optimization of patients undergoing elective total joint arthroplasty (TJA). Preoperative nutritional intervention is a potentially modifiable optimization target, but the outcomes of such intervention are not well-studied. The purpose of this study is to assess the impact of nutritional interventions on elective TJA outcomes.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to perform a systematic review of the Ovid Medline, Embase, and Cochrane Library systems. Included studies were comprised of patients greater than 18 years of age undergoing a primary unilateral TJA who received a perioperative dietitian-led intervention. Data analyzed included nutritional intervention protocol, patient demographics, length of stay (LOS), postoperative labs and complications, among others.

Results

Our initial search identified a total of 1766 articles. Four studies representing 5006 patients met inclusion criteria. The studies utilized a protein-dominant diet, with or without a carbohydrate solution accompanied by dietitian assessment or education. The 4 studies found that the intervention group had significantly decreased LOS, fewer albumin infusions, less wound drainage, lower rates of hypocalcemia and hypokalemia, reduced C-reactive protein (CRP) values, improved time out of bed, and decreased overall costs.

Conclusion

The findings support the potential benefits of perioperative dietitian-led intervention on key outcomes for patients undergoing primary TJA. Surgeons should consider nutritional intervention in their preoperative optimization protocols. Future studies could help elucidate the optimum nutritional regimens and monitoring for idealized intervention and surgical timing.

Prospero registration number

CRD4202338494.

The Impact of Outpatient Physical Therapy on Patient-Reported Outcomes After Lumbar Fusion: Perspective from A Bundled Care Dataset

OBJECTIVE/BACKGROUND

As value-based care grows in popularity across the United States, more payers have turned toward bundled payment models for surgical procedures. Though episode costs in spine are highly variable, physical therapy (PT) has been identified as a driver of 90-day cost. The goal of this study is to assess the impact of postoperative PT on patient-reported outcomes and cost after lumbar fusion surgery using bundled insurance data.

METHODS

Bundled payment information of lumbar fusion episodes-of-care (EOC) from 2019 to 2021 was reviewed at a single, urban, tertiary care center. EOC comprised a 210-day period surrounding the date of the procedure, beginning 30 days preoperatively and ending 180 days postoperatively. Patients were grouped into physical therapy (PT) and no physical therapy (no PT) groups based on the presence of PT claims.

RESULTS

Bivariate analysis of surgical outcomes revealed similar overall complication rates (P = 0.413), 30-day readmissions (P = 0.366), and 90-day readmissions (P = 0.774). Patients who did not participate in postoperative PT had significantly better preoperative physical component score (PCS) (P = 0.003), 6-month postoperative PCS (P = 0.001), and 6-month ΔPCS (P = 0.026) compared with patients who participated in postoperative PT. At 1-year follow-up, patients who did not participate in PT had less leg pain (P = 0.041) than those who did participate in PT.

CONCLUSIONS

Our study finds that PT after lumbar fusion is not associated with significant improvement in Oswestry Disability Index, PCS, mental component score, or visual analog scale pain scores. Additionally, the number of PT sessions a patient attends has no correlation with improvement in these outcomes.

Is It Getting More Expensive to Treat Patients Who Have a High Comorbidity Burden? Financial Trends in Total Knee Arthroplasty From 2013 to 2021

BACKGROUND

Utilization of total knee arthroplasty (TKA) continues to rise among patients who have a high comorbidity burden (HCB). With changes in reimbursement models over the past decade, it is essential to assess the financial impact of HCB TKA on healthcare systems. This study aimed to examine trends in revenue and costs associated with TKA in HCB patients over time.

METHODS

Of 14,978 TKA performed at a large, urban academic medical center between 2013 and 2021, we retrospectively analyzed HCB patients (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores of 3 or 4). A total of 1,156 HCB TKA patients who had complete financial data were identified. Patient demographics, perioperative data, revenue, costs, and contribution margin were collected for each patient. Changes in these financial values over time, as a percentage of 2013 values, were analyzed. Linear regression was performed with a trend analysis to determine significance.

RESULTS

From 2013 to 2021, the percentage of HCB TKAs per year increased from 4.2% in 2013 to 16.5% in 2021 (P < .001). The revenue of TKA in HCB patients remained steady (P = .093), while direct costs increased significantly (32.0%; P = .015), resulting in a decline of contribution margin to a low of 82.3% of 2013 margins. There was no significant change in rates of 90-day complications or home discharge following HCB TKA during the study period.

CONCLUSIONS

The results of this study indicate a major rise in cost for TKA among HCB patients, without a corresponding rise in revenue. As more patients who have HCB become candidates for TKA, the negative financial impact on institutions should be considered, as payments to institutions do not adequately reflect patient complexity. A re-evaluation of institutional payments for medically complex TKA patients is warranted to maintain patient access among at-need populations.

New reimbursement models to promote better patient outcomes and overall value in laboratory medicine and healthcare

The most widespread healthcare reimbursement models, including diagnostic laboratory services, are Fee-for-Service, Reference Pricing and Diagnosis-Related Groups. Within these models healthcare providers are remunerated for each specific service or procedure they operate. Healthcare payers are increasingly exploring alternative models, such as bundled payments or value-based reimbursement to encourage value of patient care rather than the simple amount of delivered services. These alternative models are advised, as they are more efficient in promoting cost-effective, high-quality laboratory testing, thereby improving patient health outcomes. If outcomes-based evaluation is a pillar in a new vision of "Value-Based Healthcare", an active policy of Value-Based Reimbursement in laboratory medicine will assure both an efficiency-based sustainability and a high-quality effectiveness-based diagnostic activity. This review aims to evaluate current and alternative reimbursement models, to support a wider agenda in encouraging more Value-Based Healthcare and Value-Based Reimbursement in laboratory medicine.

Medicare's Post-Acute Care Reimbursement Models as of 2023: Past, Present, and Future

ABSTRACT

The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices.This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting.

Frailty is a risk factor for intracranial abscess and is associated with longer length of stay: a retrospective single institution case-control study

BACKGROUND

Intracranial abscess (IA) causes significant morbidity and mortality. The impact of baseline frailty status on post-operative outcomes of IA patients remains largely unknown. The present study evaluated if frailty status can be used to prognosticate outcomes in IA patients.

METHODS

We retrospectively reviewed all IA patients undergoing craniotomy at our institution from 2011 to 2018 (N.=18). These IA patients were age and gender matched with patients undergoing craniotomy for intracranial tumor (IT), an internal control for comparison. Demographic and clinical data were collected to measure frailty, using the modified frailty index-11 (mFI-11) and pre-operative American Society of Anesthesiologists Physical Status Classification System (ASA). Post-operative complications were measured by the Clavien-Dindo Grade (CDG).

RESULTS

No significant difference in mFI-11 or ASA score was observed between the IA and IT groups (P=0.058 and P=0.131, respectively). IA patients had significantly higher CDG as compared with the control IT patients (P<0.001). There was a trend towards increasing LOS in the IA group as compared to the IT group (P=0.053). Increasing mFI and ASA were significant predictors of LOS by multiple linear regression in the IA group (P=0.006 and P=0.001, respectively), but not in the control IT group. Neither mFI-11 nor ASA were found to be predictors for CDG in either group. Within this case-control group of patients, we found an increase for odds of having IA with increasing mFI (OR=1.838, 95% CI: 1.016-3.362, P=0.044).

CONCLUSIONS

Frail IA patients tend to have more severe postoperative complications. The mFI-11 seems to predict increased resource utilization in the form of LOS. This study provides the initial retrospective data of another neurosurgical pathology where frailty leads to significantly worse outcomes. We also found that mFI may serve as a potential risk factor for severe disease.

Preoperative Depression Screening for Primary Total Knee Arthroplasty: An Evaluation of Its Modifiability on Outcomes in Patients Who Have Depression

BACKGROUND

Few studies have evaluated preoperative depression screenings in patients who have depression. We studied whether depression screenings before total knee arthroplasty (TKA) were associated with lower: 1) medical complications; 2) emergency department (ED) utilizations and readmissions; 3) implant complications; and 4) costs.

METHODS

A nationwide sample from January 1, 2010, to April 30, 2021, was collected using an insurance database. Depression patients were 1:1 propensity-score matched based on those who had (n = 29,009) and did not have (n = 29,009) preoperative depression screenings or psychotherapy visits within 3 months of TKA. A case-matched population who did not have depression was compared (n = 144,994). A 90-day period was used to compare complications and health-care utilization and 2-year follow-up for periprosthetic joint infections (PJIs) and implant survivorship. Costs were 90-day reimbursements. Logistic regression models computed odds ratios (ORs) of depression screening on dependent variables. P values less than .001 were significant.

RESULTS

Patients who did not receive preoperative screening were associated with higher medical complications (18.7 versus 5.2%, OR: 4.15, P < .0001) and ED utilizations (11.5 versus 3.2%, OR: 3.93, P < .0001) than depressed patients who received screening. Patients who had screening had lower medical complications (5.2 versus 5.9%, OR: 0.88, P < .0001) and ED utilizations compared to patients who did not have depression (3.2 versus 3.8%, OR: 0.87, P = .0001). Two-year PJI incidences (3.0 versus 1.3%, OR: 2.63, P < .0001) and TKA revisions (4.3 versus 2.1%, OR: 2.46, P < .0001) were greater in depression patients who were not screened preoperatively versus screened patients. Depression patients who had screening had lower PJIs (1.3 versus 1.8%, OR: 0.74, P < .0001) compared to nondepressed patients. Reimbursements ($13,949 versus $11,982; P < .0001) were higher in depression patients who did not have screening.

CONCLUSIONS

Preoperative screening was associated with improved outcomes in depression patients.

LEVEL OF EVIDENCE

III.

Hospital teaching status is an independent predictor of surgical intervention of distal radius fractures

Background

Distal radius fractures are among the most common orthopaedic injuries and are managed both surgically and non-surgically. To date, no study has examined the role hospital teaching status plays in the rates of surgical intervention.

Methods

The Nationwide Inpatient Sample (NIS) was queried for years 2003-2014. Patients with a distal radius fracture were identified using International Classification for Disease, Ninth Revision (ICD-9) disease codes. Surgical intervention was determined using ICD-9 procedure codes. Exclusion criteria were patients younger than age 18, polytrauma, open fractures, records with missing data, and records where the primary procedure was something other than open reduction of a radius or ulna fracture, closed reduction of a radius or ulna fracture, or blank. Chi-squared tests were run for demographic and socioeconomic data to identify significant variables. Significant variables were then included alongside hospital teaching status in a binomial logistic regression model. Significance was defined as P < 0.05.

Results

A weighted total of 98,831 patients were included in the study. Of those, 45,234 (45.8 %) were treated at teaching hospitals. Patients in teaching hospitals were more likely to be younger, male, non-white, and non-Medicare insured than non-teaching hospitals. Injuries were treated surgically in 64.6 % of total cases. Surgical intervention was more common in teaching hospitals than non-teaching hospitals (69.1 % vs. 60.8 %, P < 0.01). After controlling for demographic and socioeconomic factors, patients at teaching hospitals were 31 % more likely to undergo surgical treatment than those at non-teaching hospitals. Other factors that were independently predictive of surgical treatment were age, race, and insurance type.

Conclusion

In the setting of distal radius fractures, teaching hospitals have higher rates of surgical intervention than non-teaching hospitals. These results suggest that the involvement of medical trainees may play a role in the surgical decision-making process.

Projected volume of primary total joint arthroplasty in the USA from 2019 to 2060

INTRODUCTION

The global incidence of total joint arthroplasty (TJA) has consistently risen over time, and while various forecasts differ in magnitude, future projections suggest a continued increase in these procedures. Differences in future United States projections may arise from the modeling method selected, the nature of the national arthroplasty registry employed, or the representativeness of the specific hospital discharge records utilized. In addition, many models have not accounted for ambulatory surgery as well as all payer types. Therefore, to attempt to make a more accurate model, we utilized a national representative sample that included outpatient arthroplasties and all insurance types to predict the volumes of primary TJA in the USA from 2019 to 2060.

METHODS

A national, all-payer database was queried. All patients who underwent primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from January 1, 2010, to December 31, 2019, were identified using international classification of disease Ninth Revision (9) and Tenth Revision (10) codes and current procedure terminology codes. Absolute frequencies and incidence rates were calculated per 100,000 for both THA and TKA procedures, with 95% confidence intervals. Mean growth in absolute frequency and incidence rates were calculated for each procedure from 2010 to 2014, and 2010 to 2019, with 95% confidence intervals (CI).

RESULTS

The overall increase in THA and TKA procedures are expected to grow + 10 and + 36%, respectively, using linear regressions and + 9 and + 37%, respectively. The most positive mean growth in procedure frequency occurred from 2010 to 2014 for THA (+ 24, 95% Confidence Interval (CI): + 21, + 27) and 2010-2019 for TKA (+ 11%, 95% CI: + 9, + 14). There positive trend patterns in incidence rate growth for both procedures, with similar 2010-2019 incidence rates + 6%) for THA (+ 3%, 95% CI: + 0, + 6%) and TKA (+ 3%, 95% CI: + 1%, + 6%).

CONCLUSION

Utilizing a nationally representative database, we demonstrated that TJA procedures would continue with an increased growth pattern to 2060, though slightly decreased from the surge from 2014 to 2019. While this finding applies to the representativeness of the population at hand, the inclusion of outpatient arthroplasty and all payer types validates an approach that has not been undertaken in previous projection studies.

Early Readmission and Revision After Total Joint Arthroplasty: An Analysis of Cause and Cost

Background: Bundled payments for total joint arthroplasty (TJA) were instituted by the Centers for Medicare and Medicaid Services (CMS) to reimburse providers a lump sum for operative and 90-day postoperative costs. Gaining a better understanding of which TJA patients are at risk for early return to the operating room (OR) is critical in preoperative optimization of those with modifiable risks, which could improve bundled-payment performance. Purpose: We sought to identify the most common reason for readmissions, as well as patient characteristics and costs, associated with early return to the OR among TJA patients. Methods: This was a retrospective cohort study of Medicare patients who had undergone primary total hip or knee arthroplasty (THA or TKA) between 2013 and 2018 at a tertiary care hospital. We used the CMS research identifiable files database to identify the most common reasons for readmissions and revisions within 90 days of surgery. Total billing claims were used to determine the cost of early readmissions and revisions. Multivariate regression analysis was used to determine the characteristics associated with early readmission or revision. Results: Out of 20 166 primary TJA patients identified, we found 1349 readmissions (5.6%) and 163 (0.8%) revisions within 90 days of surgery. Dislocation was the most common indication for readmission, and periprosthetic joint infection was the most common indication for revision. Early return to the OR was associated with a mean $105,988 (standard deviation [SD] = $76,865) in CMS claims for the inpatient stay. Factors associated with a higher risk of early reoperation were female sex, THA, longer length of stay, and discharge to long-term care facility. Conclusions: This retrospective cohort study found that early return to the OR after TJA increased overall 90-day costs by 260%, suggesting that early reoperation might have a significant impact on bundled payments. Further study is warranted.

Early Discharge for Revision Total Knee and Hip Arthroplasty: Predictors of Success

BACKGROUND

The rate of revision total joint arthroplasties is expected to increase drastically in the near future. Given the recent pandemic, there has been a general push toward early discharge. This study aimed to assess for predictors of early postoperative discharge after revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA).

METHODS

There were 77 rTKA and 129 rTHA collected between January 1, 2019 and December 31, 2021. Demographic data, comorbidities, a comorbidity index, the modified frailty index (mFI-5), and surgical history were collected. The Common Procedural Terminology codes for each case were assessed. Patients were grouped into 2 cohorts, early discharge (length of stay [LOS] <24 hours) and late discharge (LOS >24 hours).

RESULTS

In the rTHA cohort, age >65 years, a history of cardiac or liver disease, an mFI-5 of >1, a comorbidity index of >2.7, a surgical time >122 minutes, and the need for a transfusion were predictors of prolonged LOS. Only the presence of a surgical time of >63 minutes or an mFI-5 >1 increased patient LOS in the rTKA cohort. In both rTHA and rTKA patients, periprosthetic joint infection resulted in a late discharge for all patients, mean 4.8 and 7.1 days, respectively. Dual component revision was performed in 70.5% of rTHA. Only 27.6% of rTKA were 2-component revisions or placements of an antibiotic spacer.

CONCLUSIONS

Several patient and surgical factors preclude early discharge candidacy. For rTHA, an mFI-5 of >2/5, comorbidity index of >4, or a surgical time of >122 minutes is predictive of prolonged LOS. For rTKA, an mFI-5 of >2/5, Charlson Comorbidity Index of >5, or a surgical time of >63 minutes predicts prolonged LOS.

Comparing financing models for supplementary healthcare in appendectomy: activity-based costing (fee-for-service) vs. diagnosis related group remuneration (bundled payment) - a systematic review and meta-analysis

PURPOSE

In Brazil, healthcare services traditionally follow a fee-for-service (FFS) payment system, in which each medical procedure incurs a separate charge. An alternative reimbursement with the aim of reducing costs is diagnosis related group (DRG) remuneration, in which all patient care is covered by a fixed amount. This work aimed to perform a systematic review followed by meta-analysis to assess the effectiveness of the Budled Payment for Care Improvement (BPCI) versus FFS.

METHODS

Our work was performed following the items of the PRISMA report. We included only observational trials, and the primary outcome assessed was the effectiveness of FFS and DRG in appendectomy considering complications. We also assessed the costs and length of hospital stay. Meta-analysis was performed with Rev Man version 5.4.

RESULTS

Out of 735 initially identified articles, six met the eligibility criteria. We demonstrated a shorter hospital stay associated with the DRG model (mean difference = 0.39; 95% confidence interval - 95%CI - 0.38-0.40; p < 0.00001; I2 = 0%), however the hospital readmission rate was higher in this model (odds ratio = 1.57; 95%CI 1.02-2.44, p = 0.04; I2 = 90%).

CONCLUSIONS

This study reveals a potential decrease in the length of stay for appendectomy patients using the DRG approach. However, no significant differences were observed in other outcomes analysis between the two approaches.

Is Tomorrow's Health Care Today: A Look at Current Payment Models for the Future?

The promise of controlling spending and improving the quality of care incentivizes health care providers to prioritize value through alternative payment models. Findings regarding improved value and cost savings of the Comprehensive Care for Joint Replacement (CJR) redesign are consistent throughout selected metropolitan hospitals. Before refinement can take place, reporting on baseline financial status is a necessity to ensure the starting point of hospitals before CJR takes effect. Evidence-based protocols, outcomes-based measures to evaluate results, and cooperation across specialties to deliver high quality care will be necessary to insure improved care throughout the episode. This commentary reviews the CJR program and provides recommendations for the near future in order to best serve the needs of patients as we move forward in the bundled payments direction.

Chronic obstructive pulmonary disease is an independent risk factor for increased opioid use in total hip arthroplasty: A retrospective PearlDiver study

Background

Total hip arthroplasty (THA) has become an incredibly common procedure due to its' predictability and high success rate. The success of surgery is related to strict indications and careful optimization of medical comorbidities to decrease risk and improve outcomes. Chronic obstructive pulmonary disease (COPD) has been associated with increased medical and surgical complications. A regulatory focus on opioid utilization does not usually consider COPD as a risk factor, but limited research exists on the impact of COPD on outcomes and risks after THA.

Methods

Retrospective all-inclusive database analysis of Medicare patients who had undergone THA between 2007 and 2017 included in the PearlDiver Database were studied. Postoperative opioid usage was examined at 1-, 3-, 6-, and 12 months, along with surgical infection, implant complications, and revisions. Post-operative complications within 30 days, either medical or implant related, were identified. Controlling for comorbidities, age, and sex, odds ratios were calculated using multivariable logistic regression with a significant α value of 0.05.

Results

COPD patients had significantly higher rates of opioid usage postoperatively. COPD patients also had an increased rate of readmissions, medical/implant complications, and revision surgeries.

Discussion

This is the only study raising concern regarding opioid use in COPD patients after total hip arthroplasty, which may be critical considering the associated respiratory depression further exacerbating the COPD. Considering the evidence of poor outcomes associated with COPD in arthroplasty, appropriately screening for COPD and counseling or planning for post-operative pain control and complications is paramount.

Outpatient Versus Inpatient Total Shoulder Arthroplasty: A Matched Cohort Analysis of Postoperative Complications, Surgical Outcomes, and Reimbursements

INTRODUCTION

There has been a trend toward performing arthroplasty in the ambulatory setting. The primary purpose of this study was to compare outpatient and inpatient total shoulder arthroplasties (TSAs) for postoperative medical complications, healthcare utilization outcomes, and surgical outcomes.

METHODS

Patients who underwent outpatient TSA or inpatient TSA with a minimum 5-year follow-up were identified in the PearlDiver database. These cohorts were propensity-matched based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index > 30). All outcomes were analyzed using chi square and Student t-tests where appropriate.

RESULTS

Outpatient TSA patients had markedly lower rates of various 90-day medical complications. Outpatient TSA patients had lower risk of aseptic loosening at 2 years postoperation and lower risk of periprosthetic joint infection at 5 years postoperation relative to inpatient TSA patients. Outpatient TSA reimbursements were markedly lower than inpatient TSA reimbursements at the 30-day, 90-day, and 1-year postoperative intervals.

CONCLUSION

This study found patients undergoing outpatient TSA to be at lowers odds for both postoperative medical and surgical complications compared with those undergoing inpatient TSA. Despite increased risk of postoperative healthcare utilization for readmissions and emergency department visits, outpatient TSA was markedly less expensive at every postoperative time point assessed.

Value-based Reimbursement as a Mechanism to Achieve Social and Financial Impact in the Healthcare System

Value-based reimbursement strategies have been considered in the continuous search for establishing a sustainable healthcare system. For models that have been already implemented, success is demonstrated according to specific details of the patients' consumption profile based on their clinical condition and the risk balance among all the stakeholders. From fee-for-service to value-based bundled payment strategies, the manner in which accurate patient-level cost and outcome information are used varies, resulting in different risk agreements between stakeholders. A thorough understanding of value-based reimbursement agreements that views such agreements as a mechanism for risk management is critical to the task of ensuring that the healthcare system generates social impacts while ensuring financial sustainability. This perspective article focuses on a critical analysis of the impact of value-based reimbursement strategies on the healthcare system from a social and financial perspective. A critical analysis of the literature about value-based reimbursement was used to identify how these strategies impact healthcare systems. The literature analysis was followed by the conceptual description of value-based reimbursement agreements as mechanisms for achieving social and financial impacts on the healthcare system. There is no single successful path toward payment reform. Payment reform is used as a strategy to re-engineer the way in which the system is organized to provide care to patients, and its successful implementation leads to cultural, social, and financial changes. Stakeholders have reached consensus regarding the claim that the use of value reimbursement strategies and business models could increase efficiency and generate social impact by reducing healthcare inequity and improving population health. However, the successful implementation of such new strategies involves financial and social risks that require better management by all the stakeholders. The use of cutting-edge technologies are essential advances to manage these risks and must be paired with strong leadership focusing on the directive to improve population health and, consequently, value. Payment reform is used as a mechanism to re-engineer how the system is organized to deliver care to patients, and its successful implementation is expected to result in social and financial modifications to the healthcare system.

Variation in Ischemic Stroke Payments in the USA: A Medicare Beneficiary Study

INTRODUCTION

The growing cost of stroke care has created the need for outcome-oriented and cost-saving payment models. Identifying imbalances in the current reimbursement model is an essential step toward designing impactful value-based reimbursement strategies. This study describes the variation in reimbursement fees for ischemic stroke management across the USA.

METHODS

This Medicare Fee-For-Service claims study examines USA beneficiaries who suffered an ischemic stroke from 2021Q1 to 2022Q2 identified using the Medicare-Severity Diagnosis-Related Groups (MS-DRGs). Demographic national and regional US data were extracted from the Census Bureau. The MS-DRG codes were grouped into four categories according to treatment modality and clinical complexity. Our primary outcome of interest was payments made across individual USA and US geographic regions, assessed by computing the mean incremental payment in cases of comparable complexity. Differences between states for each MS-DRG were statistically evaluated using a linear regression model of the logarithmic transformed payments.

RESULTS

227,273 ischemic stroke cases were included in our analysis. Significant variations were observed among all DRGs defined by medical complexity, treatment modality, and states (p < 0.001). Differences in mean payment per case with the same MS-DRG vary by as high as 500% among individual states. Although higher payment rates were observed in MS-DRG codes with major comorbidities or complexity (MCC), the variation was more expressive for codes without MCC. It was not possible to identify a standard mean incremental fee at a state level. At a regional level, the Northeast registered the highest fees, followed by the West, Midwest, and South, which correlate with poverty rates and median household income in the regions.

CONCLUSIONS

The payment variability observed across USA suggests that the current reimbursement system needs to be aligned with stroke treatment costs. Future studies may go one step further to evaluate accurate stroke management costs to guide policymakers in introducing health policies that promote better care for stroke patients.

Trends in Distal Radius Fixation Reimbursement, Charge, and Utilization in the Medicare Population

Background  Distal radius fractures (DRF) are the second most common fragility fracture experienced by the elderly, and surgical management constitutes an appreciable sum of Medicare expenditure for upper extremity surgery. Using Medicare data from 2012 to 2017, our primary aim was to describe temporal changes in surgical treatment, physician payment, and patient charges for DRF fixation. Methods  We examined surgical volumes and retrospective patient charge (services billed by surgeon) and surgeon payment (professional fee) data from 2012 to 2017 for four DRF surgeries: closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) of extra-articular fractures, ORIF of intra-articular (IA) (2-fragment) fractures, and ORIF of IA (> 3 fragments) fractures. The reimbursement ratio was defined and calculated as the ratio of charges to payment. Rates were adjusted for inflation using the annual consumer-price index. Results  For these four surgeries from 2012 to 2017, total patient charges grew by 64% from $117 to 193 million, while surgeon payment grew by 42% from $30 to 42 million. CRPP cases fell by 47%, while ORIF increased by 17, 14, and 45% for extra-articular, IA (2-fragment), and IA (> 3 fragments) surgeries, respectively. After adjusting for inflation, payment to physicians increased by more than or equal to 16% for all procedures except for CRPP, which fell by 2%. Charges during this same period increased from 13 to 38%. Reimbursement ratios declined from -9.2% to -13% for each procedure. Conclusion  From 2012 to 2017, while charges have outpaced surgeon payment, payment has outpaced inflation for all forms of distal radius ORIF, aside from CRPP. There has been a continued sharp decline of CRPP. Level of Evidence is III, economic.

A Model for Evaluating Total Costs of Care and Cost Savings of Specialty Condition-Based Care for Hip and Knee Osteoarthritis in an Integrated Practice Unit

OBJECTIVES

The viability of specialty condition-based care via integrated practice units (IPUs) requires a comprehensive understanding of total costs of care. Our primary objective was to introduce a model to evaluate costs and potential costs savings using time-driven activity-based costing comparing IPU-based nonoperative management with traditional nonoperative management and IPU-based operative management with traditional operative management for hip and knee osteoarthritis (OA). Secondarily, we assess drivers of incremental cost differences between IPU-based care and traditional care. Finally, we model potential cost savings through diverting patients from traditional operative management to IPU-based nonoperative management.

METHODS

We developed a model to evaluate costs using time-driven activity-based costing for hip and knee OA care pathways within a musculoskeletal IPU compared with traditional care. We identified differences in costs and drivers of cost differences and developed a model to demonstrate potential cost savings through diverting patients from operative intervention.

RESULTS

Weighted average costs of IPU-based nonoperative management were lower than traditional nonoperative management and lower in IPU-based operative management than traditional operative management. Key drivers of incremental cost savings included care led by surgeons in partnership with associate providers, modified physical therapy programs with self-management, and judicious use of intra-articular injections. Substantial savings were modeled by diverting patients toward IPU-based nonoperative management.

CONCLUSIONS

Costing models involving musculoskeletal IPUs demonstrate favorable costs and cost savings compared with traditional management of hip or knee OA. More effective team-based care and utilization of evidence-based nonoperative strategies can drive the financial viability of these innovative care models.

Risk Should Not Be a "Four-Letter Word" in Healthcare. Risk and the Future of Musculoskeletal Care

Orthopaedics has seen a rapid transition to value-based care. As we transition away from fee-for-service models, healthcare systems, groups, and surgeons are being asked to take on an increasing amount of risk. While on the surface risk may have a negative connotation, managing risk allows surgeons to maintain autonomy while taking on value-based care to the next level. The purpose of this paper, the first in a series of 2, is to walk through the impact that value-based care has had on musculoskeletal surgeons, to understand the continued movement healthcare is making into risk sharing models, and to introduce the concept of surgeon specialist-led care.

1.5-Stage Versus 2-Stage Exchange Total Hip Arthroplasty for Chronic Periprosthetic Joint Infections: A Comparison of Survivorships, Reinfections, and Patient-Reported Outcomes

BACKGROUND

Management of periprosthetic joint infection after total hip arthroplasty (THA) has traditionally consisted of a 2-stage approach. However, 1.5-stage exchange has garnered recent interest. We compared 1.5-stage to 2-stage exchange recipients. Specifically, we assessed (1) infection-free survivorship and risk factors for reinfection; (2) 2-year surgical/medical outcomes (eg, reoperations, readmissions); (3) Hip Disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR); and (4) radiographic outcomes (ie, progressive radiolucent lines, subsidences, and failures).

METHODS

We reviewed a consecutive series of 1.5-stage or planned 2-stage THAs. A total of 123 hips were included (1.5-stage: n = 54; 2-stage: n = 69) with mean clinical follow-up of 2.5 years (up to 8 years). Bivariate analyses assessed incidences of medical and surgical outcomes. Additionally, HOOS-JR scores and radiographs were evaluated.

RESULTS

The 1.5-stage exchange had 11% greater infection-free survivorship at final follow-up compared to 2 stages (94% versus 83%, P = .048). Morbid obesity was the only independent risk factor demonstrating increased reinfection among both cohorts. No differences in surgical/medical outcomes were observed between groups (P = .730). HOOS-JR scores improved markedly for both cohorts (1.5-stage difference = 44.3, 2-stage difference = 32.5; P < .001). A total of 82% of 1.5-stage patients did not demonstrate progressive femoral or acetabular radiolucencies, while 94% of 2-stage recipients did not have femoral radiolucencies and 90% did not have acetabular radiolucencies.

CONCLUSION

The 1.5-stage exchange appeared to be an acceptable treatment alternative for periprosthetic joint infections after THAs with noninferior infection eradication. Therefore, this procedure should be considered by joint surgeons for treatment of periprosthetic hip infections.

Lessons Learned From the Comprehensive Care for Joint Replacement Model at an Academic Tertiary Center: The Good, the Bad, and the Ugly

BACKGROUND

Our institution participated in the Comprehensive Care for Joint Replacement (CJR) model from 2016 to 2020. Here we review lessons learned from a total joint arthroplasty (TJA) care redesign at a tertiary academic center amid changing: (1) CJR rules; (2) inpatient only rules; and (3) outpatient trends.

METHODS

Quality, financial, and patient demographic data from the years prior to and during participation in CJR were obtained from institutional and Medicare reconciled CJR performance data.

RESULTS

Despite an increase in true outpatients and new challenges that arose from changing inpatient-only rules, there was significant improvement in quality metrics: decreased length of stay (3.48-1.52 days, P < .001), increased home discharge rate (70.2-85.5%, P < .001), decreased readmission rate (17.7%-5.1%, P < .001), decreased complication rate (6.5%-2.0%, P < .001), and the Centers for Medicare and Medicaid Services (CMS) Composite Quality Score increased from 4.4 to 17.6. Over the five year period, CMS saved an estimated $8.3 million on 1,486 CJR cases, $7.5 million on 1,351 non-CJR cases, and $600,000 from the voluntary classification of 371 short-stay inpatients as outpatient-a total savings of $16.4 million. Despite major physician time and effort leading to marked improvements in efficiency, quality, and large cost savings for CMS, CJR participation resulted in a net penalty of $304,456 to our institution, leading to zero physician gainsharing opportunities.

CONCLUSION

The benefits of CJR were tempered by malalignment of incentives among payer, hospital, and physician as well as a lack of transparency. Future payment models should be refined based on the successes and challenges of CJR.

Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: a qualitative analysis

BACKGROUND

Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders' perceptions regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care.

METHODS

This single-center, qualitative study was conducted within a tertiary care orthopedic department. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders' interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention.

RESULTS

Patients included 30 adults out of 85 approached (mean (SD) age 59 [14] years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person support from a mental health specialist into orthopedic care.

CONCLUSIONS

Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients.

TRIAL REGISTRATION

Not applicable.

Utilization, Complications, and Costs of Inpatient versus Outpatient Total Elbow Arthroplasty

BACKGROUND

Although total hip and knee arthroplasty have largely moved to the outpatient setting, total elbow arthroplasty (TEA) remains a predominantly inpatient procedure. Currently, evidence on the safety and potential cost savings of outpatient TEA is limited. Therefore, we aimed to compare the costs and complications associated with performing TEA in the inpatient versus outpatient setting.

METHODS

We identified patients who received elective TEA using the Truven Health MarketScan database. Outcomes of interest were 90-day complication rate, readmission rate, and procedure costs in the inpatient and outpatient settings. We used propensity score matching and logistic regression analysis to assess how patient comorbidities and surgical setting influenced complications and readmission rates. The median cost per patient was compared using the Mann-Whitney U test.

RESULTS

We identified 307 outpatient and 414 inpatient TEA procedures over a 9-year period. Elixhauser comorbidity scores were higher for the inpatient cohort. The incidence of surgical complications was significantly higher in the inpatient than the outpatient cohort (27% vs 9%). The odds of 90-day readmissions were similar in the 2 groups (37% vs 25%). In terms of cost, the median inpatient TEA was more expensive than outpatient TEA ($26 817 vs $18 412). However, the median cost for occupational therapy within 90 days of surgery was higher for outpatient TEA patients ($687 vs $571).

CONCLUSIONS

The results of this study demonstrate that surgeons can consider a transition toward outpatient TEA for patients without significant comorbidities, as this will substantially reduce health care costs.

Development and internal validation of machine learning algorithms for predicting complications after primary total hip arthroplasty

INTRODUCTION

Complications after total hip arthroplasty (THA) may result in readmission or reoperation and impose a significant cost on the healthcare system. Understanding which patients are at-risk for complications can potentially allow for targeted interventions to decrease complication rates through pursuing preoperative health optimization. The purpose of the current was to develop and internally validate machine learning (ML) algorithms capable of performing patient-specific predictions of all-cause complications within two years of primary THA.

METHODS

This was a retrospective case-control study of clinical registry data from 616 primary THA patients from one large academic and two community hospitals. The primary outcome was all-cause complications at a minimum of 2-years after primary THA. Recursive feature elimination was applied to identify preoperative variables with the greatest predictive value. Five ML algorithms were developed on the training set using tenfold cross-validation and internally validated on the independent testing set of patients. Algorithms were assessed by discrimination, calibration, Brier score, and decision curve analysis to quantify performance.

RESULTS

The observed complication rate was 16.6%. The stochastic gradient boosting model achieved the best performance with an AUC = 0.88, calibration intercept = 0.1, calibration slope = 1.22, and Brier score = 0.09. The most important factors for predicting complications were age, drug allergies, prior hip surgery, smoking, and opioid use. Individual patient-level explanations were provided for the algorithm predictions and incorporated into an open access digital application: https://sorg-apps.shinyapps.io/tha_complication/ CONCLUSIONS: The stochastic boosting gradient algorithm demonstrated good discriminatory capacity for identifying patients at high-risk of experiencing a postoperative complication and proof-of-concept for creating office-based applications from ML that can perform real-time prediction. However, this clinical utility of the current algorithm is unknown and definitions of complications broad. Further investigation on larger data sets and rigorous external validation is necessary prior to the assessment of clinical utility with respect to risk-stratification of patients undergoing primary THA.

LEVEL OF EVIDENCE

III, therapeutic study.

Cost Analysis of Conversion Total Knee Arthroplasty: A Multi-Institutional Database Study

BACKGROUND

Total knee arthroplasty (TKA) after prior knee surgery, also known as conversion TKA (convTKA), has been associated with higher complications, resource utilization, time, and effort. The increased surgical complexity of convTKA may not be reflected by the relative value units (RVUs) assigned under the current U.S. coding guidelines. The purpose of this study was to compare the RVUs of primary TKA and convTKA and to calculate the RVU per minute to account for work effort.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was analyzed for the years 2005 to 2020. Current Procedural Terminology (CPT) code 27447 alone was used to identify patients who underwent primary TKA, and 27447 plus 20680 were used to identify convTKA. After 1:1 propensity score matching, 1,600 cases were assigned to each cohort. The 2023 Medicare Physician Fee Schedule RVU-to-dollar conversion factor from the U.S. Centers for Medicare & Medicaid Services (CMS) was used to calculate RVU dollar valuations per operative time. Complication rates were compared using a multivariate logistic regression model controlling for baseline characteristics.

RESULTS

The mean operative time for TKA was 97.8 minutes, with a corresponding RVU per minute of 0.25, while the mean operative time for convTKA was 124.3 minutes, with an RVU per minute of 0.19 (p < 0.0001). Using the conversion factor of $33.06 per RVU, this equated to $8.11 per minute for TKA versus $6.39 per minute for convTKA. ConvTKA was associated with higher overall complication (10.9% versus 6.5%, p < 0.0001), blood transfusion (6.6% versus 3.7%, p < 0.01), reoperation (2.3% versus 0.94%, p < 0.0001), and readmission (3.7% versus 1.8%, p < 0.001) rates.

CONCLUSIONS

The current billing guidelines lead to lower compensation for convTKA despite its increased complexity. The longer operative time, higher complication rate, and increased resource utilization may incentivize providers to avoid performing this operation. CPT code revaluation is warranted to reflect the time and effort associated with this procedure.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty for hip fractures in patients older than 80 years of age: a retrospective matched cohort study

INTRODUCTION

Increasing age and hip fractures are considered risk factors for post-operative complications in total hip arthroplasty (THA). Consequently, older adults undergoing THA due to hip fracture may have different outcomes and require additional healthcare resources than younger patients. This study aimed to identify the influence of age on discharge disposition and 90-day outcomes of THA performed for hip fractures in patients ≥ 80 years to those aged < 80.

MATERIALS AND METHODS

A retrospective review of 344 patients who underwent primary THA for hip fracture from 2011 to 2021 was conducted. Patients ≥ 80 years old were propensity-matched to a control group < 80 years old. Patient demographics, length of stay (LOS), discharge disposition, and 90-day post-operative outcomes were collected and assessed using Chi-square and independent sample t tests.

RESULTS

A total of 110 patients remained for matched comparison after propensity matching, and the average age in the younger cohort (YC, n = 55) was 67.69 ± 10.48, while the average age in the older cohort (OC, n = 55) was 85.12 ± 4.77 (p ≤ 0.001). Discharge disposition differed between the cohorts (p = 0.005), with the YC being more likely to be discharged home (52.7% vs. 27.3%) or to an acute rehabilitation center (23.6% vs. 16.4%) and less likely to be discharged to a skilled nursing facility (21.8% vs. 54.5%). 90-day revision (3.6% vs. 1.8%; p = 0.558), 90-day readmission (10.9% vs. 14.5%; p = 0.567), 90-day complications (p = 0.626), and 90-day mortality rates (1.8% vs 1.8%; p = 1.000) did not differ significantly between cohorts.

CONCLUSION

While older patients were more likely to require a higher level of post-hospital care, outcomes and perioperative complication rates were not significantly different compared to a younger patient cohort. Payors need to consider patients' age in future payment models, as discharge disposition comprises a large percentage of post-discharge expenses.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Chronic Obstructive Pulmonary Disease Associated with Prolonged Opiate Use, Increased Short-Term Complications, and the Need for Revision Surgery following Total Knee Arthroplasty

Chronic obstructive pulmonary disease (COPD) is a condition which causes a substantial burden to patients, physicians, and the health care system at large. Medical comorbidities are commonly associated with adverse health outcomes in the postoperative period. Here, we present a large database review of patients undergoing total knee arthroplasty (TKA) to determine the effect of COPD on patient outcomes. The PearlDiver database was queried for all patients who underwent TKA between 2007 and the first quarter of 2017. Medical complications, surgical complications, 30-day readmission rates, revision rates, and opioid utilization were assessed at various intervals following TKA among patients with and without COPD. Multivariable regression was used to calculate adjusted odds ratios controlling for age, sex, and medical comorbidities. A total of 46,769 TKA patients with COPD and 120,177 TKA patients without COPD were studied. TKA patients with COPD experienced increased risk of 30-day readmission (40.8% vs. 32.2%, p < 0.0001), 30-day total medical complications (10.2% vs. 7.0%, p < 0.0001), prosthesis explanation at 6 months (0.4% vs. 0.2, p = 0.0130), 1 year (0.6% vs. 0.3%, p = 0.0005), and 2 years (0.8% vs. 0.5%, p = 0.0003), as well as an increased rate of revision (p < 0.0046) compared to TKA patients without COPD. Opioid utilization of TKA patients with COPD was greater significantly than that of TKA patients without COPD at 3, 6, and 12 months. Patients with COPD have an increased risk for medical and surgical complications, readmission, and prolonged opioid use following TKA.

Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: A qualitative analysis

BACKGROUND

Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders' perspectives regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care.

METHODS

This single-center, qualitative study was conducted within the orthopedic department of a tertiary care center. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders' interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention.

RESULTS

Patients included 30 adults out of 85 approached (mean (SD) age 59 (14) years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person mental health support into orthopedic care.

CONCLUSIONS

Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients.

TRIAL REGISTRATION

Not applicable.

Development of a Novel Prospective Model to Predict Unplanned 90-Day Readmissions After Total Hip Arthroplasty

BACKGROUND

For hospitals participating in bundled payment programs, unplanned readmissions after surgery are often termed "bundle busters." The aim of this study was to develop the framework for a prospective model to predict 90-day unplanned readmissions after elective primary total hip arthroplasty (THA) at a macroscopic hospital-based level.

METHODS

A national, all-payer, inpatient claims and cost accounting database was used. A mixed-effect logistic regression model measuring the association of unplanned 90-day readmissions with a number of patient-level and hospital-level characteristics was constructed.

RESULTS

Using 427,809 unique inpatient THA encounters, 77 significant risk factors across 5 domains (ie, comorbidities, demographics, surgical history, active medications, and intraoperative factors) were identified. The highest frequency domain was comorbidities (64/100) with malignancies (odds ratio [OR] 2.26), disorders of the respiratory system (OR 1.75), epilepsy (OR 1.5), and psychotic disorders (OR 1.5), being the most predictive. Other notable risk factors identified by the model were the use of opioid analgesics (OR 7.3), Medicaid coverage (OR 1.8), antidepressants (OR 1.6), and blood-related medications (OR 1.6). The model produced an area under the curve of 0.715.

CONCLUSION

We developed a novel model to predict unplanned 90-day readmissions after elective primary THA. Fifteen percent of the risk factors are potentially modifiable such as use of tranexamic acid, spinal anesthesia, and opioid medications. Given the complexity of the factors involved, hospital systems with vested interest should consider incorporating some of the findings from this study in the form of electronic medical records predictive analytics tools to offer clinicians with real-time actionable data.

Impact of Race/Ethnicity on Hospital Resource Utilization After Elective Anterior Cervical Decompression and Fusion for Degenerative Myelopathy

INTRODUCTION

With the advent of bundled care payments for spine surgery, there is increasing scrutiny on the costs and resource utilization associated with surgical care. The purpose of this study was to compare (1) the total cost of the hospital episode of care and (2) discharge destination between White, Black, and Hispanic patients receiving elective anterior cervical decompression and fusion for degenerative cervical myelopathy (DCM) in Medicare patients.

METHODS

The 2019 Medicare Provider Analysis and Review Limited Data Set and the 2019 Impact File were used for this project. Multivariate models were created for total cost and discharge destination, controlling for confounders found on univariate analysis. We then performed a subanalysis for differences in specific cost-center charges.

RESULTS

There were 11,506 White (85.4%), 1,707 Black (12.7%), and 261 Hispanic (1.9%) patients identified. There were 6,447 males (47.8%) and 7,027 females (52.2%). Most patients were between 65 to 74 years of age (n = 7,101, 52.7%). The mean cost of the hospital episode was $20,919 ± 11,848. Most patients were discharged home (n = 11,584, 86.0%). Race/ethnicity was independently associated with an increased cost of care (Black: $783, Hispanic: $1,566, P = 0.001) and an increased likelihood of nonhome discharge (Black: adjusted odds ratio: 1.990, P < 0.001, Hispanic: adjusted odds ratio: 1.822, P < 0.001) compared with White patients. Compared with White patients, Black patients were charged more for accommodations ($1808), less for supplies (-$1780), and less for operating room (-$1072), whereas Hispanic patients were charged more ($3556, $7923, and $5162, respectively, P < 0.05).

CONCLUSION

Black and Hispanic race/ethnicity were found to be independently associated with an increased cost of care and risk for nonhome discharge after elective anterior cervical decompression and fusion for DCM compared with White patients. The largest drivers of this disparity appear to be accommodation, medical/surgical supply, and operating room-related charges. Further analysis of these racial disparities should be performed to improve value and equity of spine care for DCM.

Preoperative Patient Expectation of Discharge Planning is an Essential Component in Total Knee Arthroplasty

Purpose

A better understanding of total knee arthroplasty (TKA) candidate expectations within the perioperative setting will enable clinicians to promote patient-centered practices, optimize recovery times, and enhance quality metrics. In the current study, TKA candidates were surveyed pre- and postoperatively to elucidate the relationship between patient expectations and length of stay (LOS).

Material and methods

This is a prospective study of patients undergoing TKA between December 2017 and August 2018. Patients were electronically administered surveys regarding their discharge plan 10 days pre-/postoperatively. All patients were categorized into three cohorts based on their LOS: 1, 2, and 3+ days. The effect of preoperative discharge education on patient postoperative satisfaction was evaluated.

Results

In total, 221 TKAs were included, of which 83 were discharged on postoperative day (POD) 1, 96 on POD-2, and 42 POD-3+. Female gender, increasing body mass index (BMI), and surgical time correlated with increased LOS. Preoperative discussions regarding LOS occurred in 84.62% (187/221) of patients but did correlate with differences in LOS. However, patients discharged on POD-1 were more inclined to same-day surgery preoperatively. Patients discharged on POD-3+ were found to be more uncomfortable regarding their discharge during the preoperative phase. Multivariable regressions demonstrated that preoperative discharge discussion was positively correlated with home discharge.

Conclusion

Physician-driven discussion regarding patient discharge did not alter patient satisfaction or length of stay but did correlate with improved odds of home discharge. These findings underscore the importance of patient education, shared decision-making, and managing patient expectations.

Drivers of inpatient hospitalization costs, joint-specific patient-reported outcomes, and health-related quality of life in shoulder arthroplasty for cuff tear arthropathy

BACKGROUND

Cuff tear arthropathy (CTA) can be successfully treated with various types of shoulder arthroplasty. While reverse total shoulder arthroplasty (RSA) is commonly used to treat CTA, CTA hemiarthroplasty (CTA-H, hemiarthroplasty with an extended humeral articular surface) can also be effective in patients with preserved glenohumeral elevation and an intact coracoacromial (CA) arch. As the value of arthroplasty is being increasingly scrutinized, cost containment has become a priority. The objective of this study was to assess hospitalization costs and improvements in joint-specific measures and health-related quality of life for these two types of shoulder arthroplasty in the management of CTA.

METHODS

Seventy-two patients (39 CTA-H and 33 RSA) were treated during the study time period using different selection criteria for each of the two procedures: CTA-H was selected in patients with retained active elevation, an intact CA arch, and an intact subscapularis, while RSA was selected in patients with pseudoparalysis or glenohumeral instability. The Simple Shoulder Test (SST) was used as a joint-specific patient-reported outcome measure. Improvement in quality-adjusted life years was measured using the Short Form 36. Costs associated with inpatient care were collected from hospital financial records. Univariate and multivariate analyses focused on determining predictors of hospitalization costs and improvements in patient-reported outcomes.

RESULTS

Significant improvements in SST and Short Form 36 physical component scores were seen in both groups. Inpatient hospitalization costs were significantly higher in the RSA group than that in the CTA-H group ($15,074 ± $1614 vs. $10,389 ± $1948, P < .001), driven primarily by supplies including the cost of the prosthesis ($9005 ± $2521 vs. $4715 ± $2091, P < .001). The diagnosis of diabetes was an independent predictor of higher inpatient hospitalization costs for both groups. There were no independent predictors for quality-adjusted life year improvements. SST improvement in the CTA-H group was significantly higher in patients with lower preoperative SST scores.

CONCLUSION

Using a standard algorithm of CTA-H for shoulders with retained active elevation and an intact CA arch and RSA for poor active elevation or glenohumeral instability, both procedures led to significant improvements in health-related quality of life and joint-specific measures. Costs were significantly lower for patients meeting the selection criteria for CTA-H. Further value analytics are needed to compare the relative cost effectiveness of RSA and CTA-H for patients with CTA having retained active elevation, intact CA arch, and intact subscapularis.

Prediction of Admission Costs Following Anterior Cervical Discectomy and Fusion Utilizing Machine Learning

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Predict cost following anterior cervical discectomy and fusion (ACDF) within the 90-day global period using machine learning models.

BACKGROUND

The incidence of ACDF has been increasing with a disproportionate decrease in reimbursement. As bundled payment models become common, it is imperative to identify factors that impact the cost of care.

MATERIALS AND METHODS

The Nationwide Readmissions Database (NRD) was accessed in 2018 for all primary ACDFs by the International Classification of Diseases 10th Revision (ICD-10) procedure codes. Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics, such as volume of procedures performed and wage index, were also queried. Readmissions within 90 days were identified, and cost of readmissions was added to the total admission cost to represent the 90-day healthcare cost. Machine learning algorithms were used to predict patients with 90-day admission costs >1 SD from the mean.

RESULTS

There were 42,485 procedures included in this investigation with an average age of 57.7±12.3 years with 50.6% males. The average cost of the operative admission was $24,874±25,610, the average cost of readmission was $25,371±11,476, and the average total cost was $26,977±28,947 including readmissions costs. There were 10,624 patients who were categorized as high cost. Wage index, hospital volume, age, and diagnosis-related group severity were most correlated with the total cost of care. Gradient boosting trees algorithm was most predictive of the total cost of care (area under the curve=0.86).

CONCLUSIONS

Bundled payment models utilize wage index and diagnosis-related groups to determine reimbursement of ACDF. However, machine learning algorithms identified additional variables, such as hospital volume, readmission, and patient age, that are also important for determining the cost of care. Machine learning can improve cost-effectiveness and reduce the financial burden placed upon physicians and hospitals by implementing patient-specific reimbursement.

Bundled Care in Elective Total Joint Replacement: Payment Models in Sweden, Canada, and the United States: A Critical Analysis Review

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Rising health-care expenditures and payer dissatisfaction with traditional models of reimbursement have driven an interest in alternative payment model initiatives.

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Bundled payments, an alternative payment model, have been introduced for total joint replacement in Sweden, the United States, and Canada to help to curb costs, with varying degrees of success.

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Outpatient total knee arthroplasty and total hip arthroplasty are becoming increasingly common and provide value for patients and payers, but have negatively impacted providers participating in bundled payment models due to considerable losses and decreased reimbursement.

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A fine balance exists between achieving cost savings for payers and enticing participation by providers in bundled payment models.

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The design of each model is key to payer, provider, and patient satisfaction and should feature comprehensive coverage for a full cycle of care whether it is in the inpatient or outpatient setting, is linked to quality and patient-reported outcomes, features appropriate risk adjustment, and sets limits on responsibility for unrelated complications and extreme outlier events.

Are Trends in Revision Total Joint Arthroplasty Sustainable? Declining Inflation-Adjusted Medicare Reimbursement for Hospitalizations

BACKGROUND

While the burden of revision total joint arthroplasty (TJA) procedures increases within the United States, it is unclear whether health care resource allocation for these complex cases has kept pace. This study examined the trends in hospital-level reimbursements for revision TJA hospitalizations.

METHODS

The Centers for Medicare and Medicaid Services (CMS) inpatient utilization and payment public use files from 2014 to 2019 were queried for diagnostic-related groups (DRGs) for revision TJA: DRG 467 (revision of hip or knee arthroplasty with complication or comorbidity [CC]) and DRG 468 (revision of hip or knee arthroplasty without CC or major CC). From 2014 to 2019, 170,808 revision TJA hospitalizations were billed to Medicare, and revision TJA procedures increased by 3,121 (10.7%). After adjusting to 2019 US dollars with the consumer price index, a multiple linear mixed-model regression analysis was performed. Analysis of covariance compared regressions from 2014 to 2019 for mean-adjusted Medicare payment and mean- adjusted charge were submitted for these DRGs.

RESULTS

Mean-adjusted average Medicare payment for DRG 467 decreased by $804.37 (-3.5%) from 2014 to 2019, whereas, that for DRG 468 decreased by $647.33 (-3.6%). The average inflation-adjusted Medicare payment for DRG 467 decreased at a greater rate during the study period, compared to that for DRG 468 (P = .02).

CONCLUSION

The decline in reimbursement for DRGs 467 and 468 reveals decreasing incentives for revision TJA hospitalizations. Further research should assess the efficacy of current Medicare payment algorithms and identify modifications which may provide for fair hospital level reimbursements.

The Cost-Effectiveness of Normal-Saline Pulsed Lavage for Infection Prophylaxis in Total Joint Arthroplasty

Background

Prosthetic joint infection (PJI) is a well-described complication after total joint arthroplasty which imposes a substantial burden of morbidity and mortality on the individual, as well as cost to the health-care system. This study used a break-even analysis to investigate the cost-effectiveness of pulsed saline lavage (PSL) for PJI prophylaxis after a primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Methods

An established model was used to calculate the minimum cost-effective absolute risk reduction of PSL for infection prophylaxis after a total joint arthroplasty. Baseline infection rates of TKA and THA and the cost of a revision surgery for PJI were derived from the literature while the cost of PSL implementation was obtained from institutional data.

Results

PSL is cost-effective at an initial infection rate of 1.10%, revision costs of $32,132 for TKA PJI, and a protocol cost of $38.28 if it reduces infection rates by 0.12% or prevents infection in 1 out of 839 patients. PSL is cost-effective at an initial infection rate of 1.63% and a revision cost of $39,713 for THA PJI if it reduces infection rates by 0.10% or prevents infection in 1 out of 1037 patients. The absolute risk reduction needed for economic viability did not change with varying baseline infection rates and did not exceed 0.38% for infection treatment costs as low as $10,000 and remained less than 0.47% even if PSL cost was as high as $150.

Conclusions

The use of PSL is a cost-effective protocol for PJI prophylaxis after TKAs and THAs.

Administrative Data Use in National Registry Efforts: Blessing or Curse?

"Big data" refers to a growing field of large database research. Administrative data, a subset of big data, includes information from insurance claims, electronic medical records, and registries that can be useful for investigating novel research questions. While its use provides salient advantages, potential researchers relying on big data would benefit from knowing about how these databases are coded, common errors they may encounter, and how to best use large data to address various research questions. In the first section of this paper, Dr. Nicholas A. Bedard addresses the four major pitfalls to avoid with diagnosis and procedure codes in administrative data. In the next section, Dr. Jeffrey N. Katz et al. focus on the strengths and limitations of administrative data, suggesting methods to mitigate these limitations. Lastly, Dr. Elena Losina et al. review the uses and misuses of large databases for cost-effectiveness research, detailing methods for careful economic evaluations.

Comparative Analysis of Outcomes in Medicare-Eligible Patients with a Hospital Stay Less than Two-Midnights versus Longer Length of Stay following Total Knee Arthroplasty: Implications for Inpatient-Outpatient Designation

The Centers for Medicaid and Medicare Services (CMS) removed primary total knee arthroplasty (TKA) from the inpatient-only list in January 2018. This study aims to compare outcomes in Medicare-aged patients who underwent primary TKA and had an in-hospital stay spanning less than two-midnights to those with a length of stay greater than or equal to two-midnights. We retrospectively reviewed 4,138 patients ages ≥65 who underwent primary TKA from 2016 to 2020. Two cohorts were established based on length of stay (LOS), those with an LOS <2 midnights were labeled outpatient and those with an LOS ≥2 midnights were labeled inpatient as per CMS designation. Demographic, clinical data, knee injury and osteoarthritis outcome score for joint replacement (KOOS, JR), and veterans RAND 12 physical and mental components (VR-12 PCS & MCS) were collected. Demographic differences were assessed with Chi-square and independent sample t-tests. Clinical data and KOOS, JR and VR-12 PCS and MCS scores were compared by using multilinear regression analysis, controlling for demographic differences. There were 841 (20%) patients with a LOS < 2 midnights and 3,297 (80%) patients with a LOS ≥ 2 midnights. Patients with a LOS < 2 midnights were significantly younger (71.70 vs. 73.06; p < 0.001), more likely male (42.1 vs. 25.7%; p < 0.001), Caucasian (68.8 vs. 57.7%; p <0.001), have lower BMI (30.80 vs. 31.92; p < 0.001), Charlson Comorbidity Index (CCI; 4.62 vs. 4.96; p < 0.001), and American Society of Anesthesiologists (ASA) class II or higher (p < 0.001). These patients were more likely to be discharged home compared to patients with LOS ≥ 2 midnights (95.8 vs. 73.1%; p < 0.001). Patients who stayed ≥ 2 midnights reported lower patient-reported outcome scores at all time-periods (preoperatively, 3 months and 1 year), but these differences did not exceed the minimum clinically important difference. Mean improvement preoperatively to 1 year postoperatively in KOOS, JR (22.53 vs. 25.89; p < 0.001), and VR-12 PCS (12.16 vs. 11.49; p = 0.002) was statistically higher for patients who stayed < 2 midnights, though these differences were not clinically significant. All-cause ED visits (p = 0.167), 90-day all-cause readmissions (p = 0.069) and revision (p = 0.277) did not statistically differ between the two cohorts. TKA patients classified as outpatient had similar quality metrics and saw similar clinical improvement following TKA with respect to most patient reported outcome measures, although they were demographically different. Outpatient classification is more likely to be assigned to younger males with higher functional scores, lower BMI, CCI, and ASA class compared with inpatients. This Retrospective Cohort Study shows level III evidence.

Serum Glucose Variability Increases the Risk of Complications Following Aseptic Revision Hip and Knee Arthroplasty

BACKGROUND

Increased serum glucose variability has been proposed as a risk factor for perioperative morbidity and mortality. Given the greater surgical complexity and complication risk of revision total joint arthroplasty (TJA), previous findings may not be generalizable to the revision population. The purpose of this study was to investigate the association between glucose variability and postoperative complications following aseptic revision TJA.

METHODS

We identified 1,983 patients who underwent an aseptic revision TJA (636 total knee arthroplasties [TKAs] and 1,347 total hip arthroplasties [THAs]) from 2001 to 2019. Patients with ≥2 postoperative glucose values per day or ≥3 values during hospitalization were included in this study. Glucose variability was assessed using the coefficient of variation (COV). Outcomes included length of hospital stay, 90-day complications, mortality, and periprosthetic joint infection (PJI) as defined by the 2018 International Consensus Meeting criteria. Multivariate regression was used to determine the association between glucose variability and each end point, using COV as continuous and categorical variables (that is, COV tertiles).

RESULTS

Patients with high glycemic variability were at 1.7 times greater risk for 90-day complications (odds ratio [OR], 1.664 [95% confidence interval (CI), 1.266 to 2.188]; p < 0.001) and 2 times greater risk for PJI at a minimum 1-year follow-up (OR, 1.984 [95% CI, 1.270 to 3.100]; p = 0.003). The risk of 90-day complications increased by 2.2% (OR, 1.022 [95% CI, 1.012 to 1.032]; p < 0.001) and the risk of PJI increased by 1.8% (OR, 1.018 [95% CI, 1.003 to 1.034]; p = 0.013) for every percentage-point increase in COV. Patients with higher glucose variability also had a longer length of stay (beta, 1.028 days [95% CI, 0.590 to 1.466 days]; p < 0.001). These associations were independent of age, sex, body mass index, Charlson Comorbidity Index, involved joint, operative time, history of diabetes, and mean glucose levels.

CONCLUSIONS

Higher glucose variability was associated with an increased risk of medical complications and PJI following aseptic revision TJA. Patients undergoing these complex procedures should have glucose levels monitored closely in the perioperative period. Future studies should evaluate the utility of continuous glucose monitoring in this high-risk population.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Total Joint Arthroplasty at a Novel "Hyperspecialty" Ambulatory Surgical Center With Extended Care Suites is as Safe as Inpatient Arthroplasty

Background

New "hyperspecialty" ambulatory surgical centers (HASCs) have been introduced to deliver safe and cost-efficient care, allowing patients to spend additional nights in an extended care suite before discharge. This study compared the 90-day complications and readmissions of total joint arthroplasty (TJA) at an HASC and inpatient TJA at a tertiary hospital.

Methods

We retrospectively reviewed 1365 primary, unilateral, TJAs (658 total hip arthroplasty, 707 total knee arthroplasty) performed at 4 HASCs in 2017-2021. Following their outpatient procedure, patients were discharged to an extended care suite staffed full-time by nurses and physical therapists. These patients were matched 1:1 with 1365 inpatient TJAs (628 total hip arthroplasty, 737 total knee arthroplasty) based on demographics, joint, and American Society of Anesthesiologists (ASA) score. Ninety-day complications and readmissions were compared.

Results

The mean age was 60.0 ± 9.8 years and 59.4 ± 8.1 years in the inpatient and outpatient groups, respectively (P = .106). There was no difference in ASA≥3 patients (16.4% vs 17.7%; P = .387) and operative time (86.9 ± 31.8 vs 88.7 ± 27.9 minutes; P = .118). Five patients (0.4%) in the outpatient group were transferred to an acute hospital. When comparing 90-day outcomes between the inpatient and outpatient groups, there was no difference in pulmonary embolism (0.1% vs 0.0%; P = .317), mechanical complications (0.3% vs 0.7%; P = .165), periprosthetic joint infections (0.5% vs 1.1%; P = .092), or readmissions (1.2% vs 1.5%; P = .513). A subgroup analysis of ASA≥3 patients yielded similar findings.

Conclusions

Patients undergoing outpatient TJA at a novel HASC had similar complication and readmission rates as those undergoing TJA at a tertiary hospital. Based on these data, such facilities seem appropriate for the care of outpatient TJA patients with ASA<4.

Intraoperative Imaging in Total Hip Arthroplasty Is Cost-Effective Regardless of Surgical Approach

BACKGROUND

Component positioning in total hip arthroplasty (THA) may be improved with utilization of intraoperative imaging. The purpose of this study is to determine if intraoperative imaging during THA is cost-effective.

METHODS

A break-even analysis was used as a model for cost-effectiveness, which incorporates cost of imaging (including direct charges and the additional time required for imaging), rate of revision surgery, and cost of revision surgery, yielding a final revision rate that needs to be achieved with use of intraoperative imaging in order for its use to be cost-effective. Absolute risk reduction (ARR) is determined by the difference between the initial revision rate and final revision rate.

RESULTS

At an anticipated institutional cost of $120 and requiring 4 additional minutes, intraoperative fluoroscopy would be cost-effective if the baseline rate of revision due to component mispositioning (0.62%) is reduced to 0.46%. Intraoperative flat plate radiographs ($127) are cost-effective at an ARR of 0.16%. Cost-effectiveness is achieved with lower ARR in the setting of lower imaging costs ($15, ARR 0.02%), and higher ARR with higher imaging costs ($225, ARR 0.29%). ARR for cost-effectiveness is independent of baseline revision rate, but varies with the cost of revision procedures.

CONCLUSION

At current revision rates for component malpositioning, only 1 revision among 400 THAs needs to be prevented for the utilization of fluoroscopy (or 1 in 385 THAs with flat plate imaging), to achieve cost-effectiveness.

Modular Metal-Backed Tibial Components Provide Minimal Mid-Term Survivorship Benefits Despite Increased Cost and Frequency of Use: A Retrospective Review of the American Joint Replacement Registry Database

BACKGROUND

Previous studies have demonstrated equivalent survivorship of modular metal-backed tibial (MBT) and all-polyethylene tibial (APT) components. The purpose of this study is to compare the utilization and outcomes of APT and MBT components in a large US database.

METHODS

The American Joint Replacement Registry was queried to identify all patients undergoing primary total knee arthroplasty (TKA) during the study period from 2012 to 2019. These patients were divided into cohorts based on tibial component (APT or MBT). Cohort demographics including gender, hospital size, hospital teaching status, region, age, and Charlson Comorbidity Index were reported with descriptive statistics. Overall reoperation rates and revisions for infection, aseptic loosening, periprosthetic fracture, manipulation under anesthesia, and revision for other reasons were identified using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes and compared across APT and MBT cohorts. Kaplan-Meir survival analysis was performed based on reason for reoperation for APT and MBT.

RESULTS

During the study period, 703,007 TKAs were reported with 97.8% utilizing MBT and 2.2% utilizing APT components. Despite the introduction of alternative payment models during the study period, the utilization of APT decreased from 5.8% in 2012 to 1.7% in 2019. The survival of APT and MBT TKAs were similar across the study period: 98.1% vs 98.6% at 8 years. The rate of reoperation for all-causes was higher for APT compared to MBT (1.36% vs 1.00%; odds ratio 1.52).

CONCLUSION

Despite their paucity of use and lower cost APT remained within a 0.4% margin of survivorship when compared to MBT implants for up to 8 years.

LEVEL OF EVIDENCE

Level III, retrospective.

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.].