Evidence of Pent-Up Demand for Total Hip and Total Knee Arthroplasty at Age 65

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BACKGROUND

Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type.

METHODS

Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities.

RESULTS

Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial).

CONCLUSIONS

Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

A Retrospective Analysis Investigating Whether Case Volume Experience of the Anesthesiologist Correlates with Intraoperative Efficiency for Joint Arthroplasty

The objective of this retrospective study was to determine if there was an association between anesthesiology experience (e.g. historic case volume) and operating room (OR) efficiency times for lower extremity joint arthroplasty cases. The primary outcome was time from patient in the OR to anesthesia ready (i.e. after spinal or general anesthesia induction was complete). The secondary outcomes included time from anesthesia ready to surgical incision, and time from incision to closing completed. Mixed effects linear regression was performed, in which the random effect was the anesthesiology attending provider. There were 4,575 patients undergoing hip or knee arthroplasty included. There were 82 unique anesthesiology providers, in which the median [quartile] frequency of cases performed was 79 [45, 165]. On multivariable mixed effects linear regression - in which the primary independent variable (anesthesiologist case volume history for joint arthroplasty anesthesia) was log-transformed - the estimate for log-transformed case volume was - 0.91 (95% confidence interval [CI] -1.62, -0.20, P = 0.01). When modeling time from incision to closure complete, the estimate for log-transformed case volume was - 2.07 (95% -3.54, -0.06, P = 0.01). Thus, when comparing anesthesiologists with median case volume (79 cases) versus those with the lowest case volume (10 cases), the predicted difference in times added up to only approximately 6 min. If the purpose of faster anesthesia workflows was to open up more OR time to increase surgical volume in a given day, this study does not support the supposition that anesthesiologists with higher joint arthroplasty case volume would improve throughput.

Patients With Cirrhosis Have Higher Costs of Care, Longer Length of Stays, and More Perioperative Complications Following Total Knee Arthroplasty: A National Inpatient Sample-Based Study

Background Cirrhosis is a growing disease affecting millions of people in the United States annually. Many cirrhosis patients undergo significant procedures and are met with increased risks such as encephalopathy, impaired immune response, ascites, variceal bleeding, renal disease, and increased malnutrition. Many cirrhosis patients need to undergo major surgical procedures such as total knee arthroplasty (TKA); however, perioperative complications following TKA in cirrhosis patients have not been studied. The purpose of this study was to analyze the demographic characteristics and perioperative complications of cirrhosis patients following TKA. Methods Using the National Inpatient Sample (NIS) database, we looked at retrospective data from the years 2016-2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing TKA who were categorized as cirrhosis patients, compared with those who are not. A propensity match was conducted to consider associated comorbidities that influence perioperative complications. Results Of the 558,256 patients analyzed who underwent TKA, 1670 (0.3%) were diagnosed with cirrhosis. After matching, cirrhosis patients had a longer LOS (4.22 vs. 3.68 days, p=0.016) and COC ($90,624 vs. 80676.87, p<0.001) than patients in the control group. Moreover, cirrhosis patients had a higher likelihood of developing acute renal failure (odds ratio (OR): 3.05, 95% CI: 2.07-4.50, p<0.001), blood loss anemia (OR: 1.60, 95% CI: 1.34-1.92, p<0.001), periprosthetic fracture (OR: 3.27, 95% CI: 1.31-8.18, p=0.007), periprosthetic infection (OR: 3.14, 95% CI: 1.99-4.95, p<0.001), and blood transfusions (OR: 1.62, 95% CI: 1.12-2.35, p=0.009) than patients in the control group. Conclusion The cirrhosis group had a significantly higher COC, longer LOS, and higher rates of perioperative complications than non-cirrhosis patients. This data will help providers make informed decisions about patient care and resource allocation for cirrhosis patients undergoing TKA.

Louisiana Medicaid Expansion and Pent-Up Demand

BACKGROUND

Nearly half a million newly eligible people enrolled in Louisiana Medicaid following its expansion.

OBJECTIVES

To evaluate postexpansion utilization trends in Louisiana Medicaid.

RESEARCH DESIGN

We plotted utilization trends for expansion and traditional Medicaid beneficiaries and conducted regression analyses to evaluate differences in monthly trends for over 2 years following expansion.

SUBJECTS

We restricted our sample to a balanced panel of beneficiaries aged 18-64. The expansion population included beneficiaries who enrolled in the first month of eligibility. The nonexpansion group enrolled at least a year pre-expansion.

MEASURES

Monthly office visits, emergency department visits, and inpatient stays per 1000 enrollees, drawn from the Louisiana Medicaid Data Warehouse claims database.

RESULTS

Compared with trends among traditional Medicaid beneficiaries, expansion beneficiaries utilized 4.59 [ P =0.08] more monthly office visits per 1000 enrollees in their first year, increasing to 6.33 [ P <0.01] more per month thereafter. Monthly emergency department visit trends were not statistically significantly different in the first year but were 0.71 [ P <0.01] monthly visits lower for expansion beneficiaries thereafter. Trends in monthly inpatient stays were 0.23 [ P =0.02] stays per 1000 enrollees higher in the first year for expansion beneficiaries but were not statistically significantly different thereafter.

CONCLUSIONS

Louisiana Medicaid expansion beneficiaries experienced lower initial rates of office visits compared with traditional Medicaid beneficiaries, but these rates consistently increased over the first 2 years after expansion. The expansion population had uniformly higher levels of emergency department and inpatient visits throughout the study period. After the first postexpansion year, emergency department visits among expansion beneficiaries fell relative to traditional beneficiaries while inpatient utilization trends leveled off after an initial increase.

Patient Out-of-Pocket Cost Burden With Elective Orthopaedic Surgery

INTRODUCTION

Out-of-pocket (OOP) costs for medical and surgical care can result in substantial financial burden for patients and families. Relatively little is known regarding OOP costs for commercially insured patients receiving orthopaedic surgery. The aim of this study is to analyze the trends in OOP costs for common, elective orthopaedic surgeries performed in the hospital inpatient setting.

METHODS

This study used an employer-sponsored insurance claims database to analyze billing data of commercially insured patients who underwent elective orthopaedic surgery between 2014 and 2019. Patients who received single-level anterior cervical diskectomy and fusion (ACDF), single-level posterior lumbar fusion (PLF), total knee arthroplasty (TKA), and total hip arthroplasty (THA) were identified. OOP costs associated with the surgical episode were calculated as the sum of deductible payments, copayments, and coinsurance. Monetary data were adjusted to 2019 dollars. General linear regression, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests were used for analysis, as appropriate.

RESULTS

In total, 10,225 ACDF, 28,841 PLF, 70,815 THA, and 108,940 TKA patients were analyzed. Most patients in our study sample had preferred provider organization insurance plans (ACDF 70.3%, PLF 66.9%, THA 66.2%, and TKA 67.0%). The mean OOP costs for patients, by procedure, were as follows: ACDF $3,180 (SD = 2,495), PLF $3,166 (SD = 2,529), THA $2,884 (SD = 2,100), and TKA $2,733 (SD = 1,994). Total OOP costs increased significantly from 2014 to 2019 for all procedures (P < 0.0001). Among the insurance plans examined, patients with high-deductible health plans had the highest episodic OOP costs. The ratio of patient contribution (OOP costs) to total insurer contribution (payments from insurers to providers) was 0.07 for ACDF, 0.04 for PLF, 0.07 for THA, and 0.07 for TKA.

CONCLUSION

Among commercially insured patients who underwent elective spinal fusion and major lower extremity joint arthroplasty surgery, OOP costs increased from 2014 to 2019. The OOP costs for elective orthopaedic surgery represent a substantial and increasing financial burden for patients.

Trends of Obesity Rates Between Patients Undergoing Primary Total Knee Arthroplasty and the General Population from 2013 to 2020

BACKGROUND

Obesity is a recognized risk factor for severe knee osteoarthritis. However, it remains unclear how obesity prevalence trends in the current population undergoing total knee arthroplasty (TKA) compare with those seen in individuals not undergoing this procedure. In this study, we assessed the yearly trends in body mass index (BMI) and obesity rates between patients who have undergone primary TKA and those in the general population.

METHODS

We retrospectively reviewed all patients ≥18 years of age from January 2013 through December 2020 who underwent primary, elective TKA and those who had an annual routine physical examination at our institution within the same period. Baseline demographic characteristics were collected. The independent samples t test was used to compare means and the chi-square test was used to compare proportions between the 2 cohorts, and a linear regression was used to determine the significance of the yearly trends.

RESULTS

A total of 11,333 patients who underwent primary TKA and 1,158,168 patients who underwent an annual physical examination were included in this study. After adjusting for age, we found the mean BMI for the TKA group to be significantly greater (p < 0.001) every year compared with the annual physicals group. The proportion of patients who were categorized into any obesity class (BMI, ≥30 kg/m2), Class-I obesity (BMI, 30 to 34.9 kg/m2), Class-II obesity (BMI, 35 to 39.9 kg/m2), and Class-III obesity (BMI, ≥40 kg/m2) was significantly higher for the TKA group each year compared with the annual physicals group. An analysis of trends over time showed a significantly increasing trend (p < 0.001) in BMI and obesity rates for the annual physicals group, but a stable trend for patients undergoing TKA.

CONCLUSIONS

Patients who underwent TKA continued to have higher BMI than the general population, which showed a steady increase over time. Physicians need to continue in their efforts to educate patients on weight management and healthy lifestyles to potentially delay the need for a surgical procedure.

LEVEL OF EVIDENCE

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

Geographic Differences in Rates of Primary Total Knee Arthroplasty in Young and Older Adults: A Comparison of 3 US States

OBJECTIVE

Rates of total knee arthroplasty (TKA) among Medicare beneficiaries (adults aged ≥ 65 yrs) vary across the United States, with higher rates in the Midwest and West than in the South. It is not known if a similar variation is present among younger patients, or if findings in Medicare reflect selective postponement of TKA in some regions.

METHODS

Data on all primary TKA performed in adults aged ≥ 20 years in 3 states (Iowa, Utah, and Florida) in 2016 were obtained from state inpatient databases. Rates of TKA were computed based on population census data. Age-, sex-, and race-standardized rates were compared between Iowa and Florida, and between Utah and Florida, among adults aged 20-64 years and adults aged ≥ 65 years.

RESULTS

There were 10,074, 8954, and 43,908 primary TKAs in Iowa, Utah, and Florida, respectively. Standardized rates were higher in Iowa and Utah than in Florida among both adults aged 20-64 years (Iowa:Florida rate ratio [RR] 1.89, 95% CI 1.79-1.99; Utah:Florida RR 2.31, 95% CI 2.18-2.45) and those aged ≥ 65 years (Iowa:Florida RR 1.41, 95% CI 1.35-1.47; Utah:Florida RR 1.77, 95% CI 1.70-1.85). Results were similar in sensitivity analyses limited to White patients, urban residents, and those with a diagnosis of knee osteoarthritis.

CONCLUSION

TKA rates were higher in Iowa and Utah than in Florida among both younger adults and those aged ≥ 65 years, indicating that geographic differences are not specific to elderly patients.

The cost-effectiveness of outpatient surgery for primary total hip arthroplasty in the United States: a computer-based cost-utility study

PURPOSE

The purpose of this study was to perform a cost-effectiveness analysis of outpatient versus inpatient total hip arthroplasty (THA) in the USA, considering complication probability and the potential cost of such complications.

METHODS

A cost-effectiveness analysis was conducted from the societal perspective to evaluate the incremental cost and effectiveness of inpatient THA compared to outpatient THA over a lifetime horizon. Effectiveness was expressed in quality-adjusted life years (QALYs). Costs, expressed in 2019 US dollars, transition probabilities, and health utilities were derived from the literature. The primary outcome was the incremental cost-effectiveness ratio (ICER), with a willingness to pay (WTP) threshold set at $50,000/QALY. 1-way and probabilistic sensitivity analyses was performed to evaluate the effect of the various variables on the model.

RESULTS

In the base case, inpatient THA was more effective in terms of total utility (10.36 vs. 10.30 QALY), but also more costly ($48,155 ± 1673 vs. $43,288 ± 1, 606 for Medicare) than outpatient THA. Even with a lifetime horizon, the ICER was $81,116 per QALY and $140,917 per QALY for Medicare and private payer insurance, respectively, which is higher than the willingness to pay threshold. 1-way sensitivity analyses indicated that the variables having the most influence on the model were the utility of inpatient and outpatient THA and cost of inpatient and outpatient THA.

CONCLUSIONS

This model determined that for a WTP threshold set at $50,000/QALY, outpatient THA is more cost-effective than inpatient THA from a societal perspective. Despite this, surgeons must weigh clinical factors first and foremost in determining if an individual patient can be safely operated on in the outpatient setting.

Perioperative Immunonutrition in Elderly Patients Undergoing Total Hip and Knee Arthroplasty: Impact on Postoperative Outcomes

BACKGROUND

Arthroplasties in elderly patients are surgeries performed to ensure their quality of life. Perioperative care with specific nutrients can improve nutrition status and metabolic response to orthopedic surgeries, such as total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

Retrospective study with elderly patients divided into 2 groups: control and immunonutrition. The immunonutrition group was instructed to start oral intake of the nutrition supplement 5 days before and to resume it 5 days after arthroplasty (200 mL, 3 times per day). The following were analyzed as primary and secondary outcomes: length of stay (LOS), infectious and noninfectious complications, need for intensive care unit (ICU), transfusion requirement, and C-reactive protein.

RESULTS

A total of 3015 elderly patients met the inclusion criteria: control group (n = 1398) and immunonutrition group (n = 1617). Overall, 81.2% were women and mean age was 72.6 ± 6.9 years. Immunonutrition group had a shorter LOS in hours (32.0 ± 19.4 vs 56.0 ± 26.4; P < .001) and lower rates of infectious complications (2.2% vs 4.6%; P < .001). Noninfectious complications and need for ICU also had lower rates in the immunonutrition group. In the logistic regression analysis, immunonutrition reduced the chance of infectious complications by 55% (odds ratio [OR], 0.45; 95% CI, 0.30-0.68; P < .001) even after adjusting for variables (OR, 0.45; 95% CI, 0.28-0.71; P < .001).

CONCLUSION

Perioperative immunonutrition in elderly patients undergoing THA or TKA may shorten postoperative LOS and reduce infectious and noninfectious complications and transfusion requirement.

Influence of Anxiety/Depression, Age, Gender and ASA on 1-Year Follow-Up Outcomes Following Total Hip and Knee Arthroplasty in 5447 Patients

Introduction: There are many factors influencing the outcome after total joint arthroplasty (TJA). In particular, patient-related factors such as age, gender, ASA (American Society of Anesthesiologists), or preoperative anxiety/depression have become increasingly important. The aim of this study was to examine the association of these parameters with 1-year postoperative outcomes after total knee and total hip arthroplasty (TKA, THA). Methods: A retrospective cohort of 5447 TJA patients was evaluated by pre- and postoperative analysis of EQ-5D, EQ-VAS and WOMAC Score. Furthermore, major focus was put on the association between age, gender, ASA, preoperative anxiety/depression and outcome parameters. Results: 53.3% (2903/5447) of all patients were identified with anxiety/depression at time of surgery. In the analysis, patients without anxiety/depression showed statistically significantly (p < 0.05) better EQ-5D, EQ-VAS and WOMAC scores. In addition, patients with ASA 2 or 3 and age over 70 years showed statistically significantly (p < 0.01) worse EQ-5D and WOMAC scores. Gender did not influence the postoperative EQ-5D and WOMAC results, but men had significantly better EQ-VAS scores than women in this study. Conclusion: Preoperative anxiety/depression symptoms show worse clinical outcomes 1 year postoperatively after TJA. Other outcome-influencing factors are higher age and ASA 2 or 3. In the future, such patients should be identified, and as far as applicable, a treatment of anxiety/depression or comorbidities should be implemented preoperatively of the surgical procedure to improve clinical outcomes.

Increased Utilization of Total Joint Arthroplasty After Medicaid Expansion

BACKGROUND

The expansion of state Medicaid programs under the U.S. Affordable Care Act has led to a dramatic increase in the number of Americans with health insurance coverage. Prior analyses of a limited number of states have suggested that greater utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) should be expected after Medicaid expansion. The purpose of our study was to examine whether increased utilization of THA and TKA occurred across a broader range of states after Medicaid expansion.

METHODS

We analyzed administrative data from the Healthcare Cost and Utilization Project from 9 states (Arkansas, Arizona, Colorado, Iowa, Massachusetts, Maryland, Nevada, New York, and Vermont) that expanded Medicaid in 2014 and 2 states that did not expand Medicaid (Florida and Missouri). We included patients who were 18 to 64 years of age and had a primary THA or TKA from 2012 to 2015 with Medicaid as the primary payer. Other payers (including dual-eligible Medicaid and Medicare beneficiaries) were excluded. We performed multivariable regression modeling with the number of Medicaid-insured THAs or TKAs as the dependent variable and the interaction between the state Medicaid expansion status and year as the main policy independent variable, with adjustment for community characteristics.

RESULTS

Among all 11 states, there were 39,452 total joint arthroplasties (42% THA and 58% TKA) funded by Medicaid from 2012 to 2015. After adjusting for community characteristics, within expansion states, compared with 2013, THA and TKA increased 15% in 2014 (p < 0.0001) and 23% in 2015 (p < 0.0001) within expansion states. Within non-expansion states, compared with 2013, there were significant utilization decreases of 18% in 2014 (p < 0.0001) and 11% in 2015 (p = 0.0002).

CONCLUSIONS

Medicaid expansion was associated with significant increases in Medicaid-funded THA and TKA utilization in 9 states. As additional states consider expanding Medicaid programs and as alternative health reforms that increase insurance eligibility are debated, surgeons, administrators, and policymakers should prepare for a surge in the utilization of THA and TKA.

Arthrofibrosis after total knee arthroplasty: patients with keloids at risk

BACKGROUND

Arthrofibrosis remains one of the leading causes for revision in primary total knee arthroplasty (TKA). Similar in nature to arthrofibrosis, hypertrophic scars and keloid formation are a result of excessive collagen formation. There is paucity in the literature on whether there is an association between keloid formation and the development of arthrofibrosis following TKA. Therefore, the purpose of this study was to utilize a large nationwide database to identify and compare the rates of postoperative complications related to arthrofibrosis after primary TKA in patients with history of hypertrophic scar and keloid disorders versus those without.

METHODS

Patient records from 2010 to the second quarter of 2016 were queried from an administrative claims database, comparing rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with chart diagnosis of keloids versus those without in patients who underwent primary TKA. Data analysis was performed using R statistical software (R Project for Statistical Computing, Vienna, Austria) utilizing multivariate logistic regression, chi square analysis, or Welch's t- test where appropriate with p values < 0.05 being considered statistically significant.

RESULTS

Of 545,875 primary TKAs, 11,461 (2.1%) had a keloid diagnosis at any time point in their record, while 534,414 (97.9%) had not. Patients in the keloid cohort had a significantly higher association with ankylosis within 30 days (OR, 1.7), 90 days (OR, 1.2), 6 months (OR, 1.2), and 1 year (OR, 1.3) following primary TKA. The keloid cohort also had a significantly greater risk of MUA (90-day OR, 1.1; 6-month OR, 1.1; 1-year OR, 1.2) and LOA (90-day OR, 2.2; 6-month OR, 2.0; 1-year OR, 1.9).

CONCLUSION

Patients with keloids have increased odds risk of arthrofibrosis following primary TKA. These patients are subsequently at a higher odds risk of undergoing the procedures necessary to treat arthrofibrosis, such as MUA and LOA. Future studies investigating confounding factors such as race, prior surgery, range of motion, and postoperative recovery are needed to confirm the association of keloid diagnosis and arthrofibrosis following primary TKA demonstrated in this study.

LEVEL OF EVIDENCE

Level III retrospective comparative study.

The projected volume of primary and revision total knee arthroplasty will place an immense burden on future health care systems over the next 30 years

PURPOSE

Total knee arthroplasty (TKA) rates have increased substantially in the recent decades worldwide, with Germany being one of the leading countries in the prevalence of TKA. The aim of this study was to provide an overview of treatment changes during the last decade and to project the expected burden of primary and revision TKA (rTKA) for the next 30 years.

METHODS

Comprehensive nationwide data from Germany was used to quantify primary and revision TKA rates as a function of age and gender. Projections were performed with use of a Poisson regression models and a combination of exponential smoothing and autoregressive integrated moving average models on historical procedure rates in relation to official population projections from 2020 to 2050.

RESULTS

The incidence rate of primary TKAs is projected to increase by around 43% to 299 per 100,000 inhabitants [95% CI 231-368], leading to a projected total number of 225,957 primary TKAs in 2050 (95% CI 178,804-276,442). This increase has been related to a growing number of TKA performed in male patients, with the highest increase modelled in patients between 50 and 65 years of age. At the same time, the annual total number of revision procedures is forecast to increase even more rapidly by almost 90%, accounting for 47,313 (95% CI 15,741-78,885; IR = 62.7 per 100,000, 95% CI 20.8-104.5) procedures by 2050. Those numbers are primarily associated with a rising number of rTKAs secondary to periprosthetic joint infection (PJI).

CONCLUSIONS

Using this country- specific forecast approach, a rising number of primary TKA and an even more rapidly growing number of rTKA, especially for PJI, has been projected until 2050, which will inevitably provide a huge challenge for the future health care system. As many other industrialized nations will face similar demographic and procedure-specific developments, these forecasts should be alarming for many health care systems worldwide and emphasize the tremendous need for an appropriate financial and human resource management in the future.

LEVEL OF EVIDENCE

Level III, prognostic study, economic and decision analysis.

Complication rates of bilateral total hip versus unilateral total hip arthroplasty are similar

Objective

Utilize a nationwide database to identify and compare the differences between patient demographics and clinical outcomes for patients undergoing simultaneous bilateral total hip arthroplasty (THA) and unilateral THA.

Methods

A nationwide administrative claims database was utilized; In-hospital, 90-day, and 1-year post-discharge rates of local and systemic complications were collected and compared with multivariate logistic regression.

Results

Incidence of prosthetic joint infection was significantly lower in the bilateral cohort. Length of stay was significantly shorter in the unilateral THA cohort.

Conclusion

Surgeons should consider simultaneous bilateral THA a safe and effective procedure for low risk patients with appropriate comorbidities.

Rapid Decline in Online Search Queries for Hip and Knee Arthroplasties Concurrent With the COVID-19 Pandemic

BACKGROUND

In response to the coronavirus disease 2019 (COVID-19) pandemic, US hospitals have canceled elective surgeries. This decline in total joint arthroplasty (TJA) revenue may place financial strain on hospitals. Our goal was to quantify the impact of COVID-19 on the public interest in elective TJA.

METHODS

The Google Search Volume Index (GSVI) identified the terms "knee replacement," "hip replacement," and "orthopedic surgeon" as the most common to describe TJA. The term "elective surgery cancellation" was also analyzed. Weekly GSVI data were extracted between 04-01-2015 and 04-04-2020. Time series analysis was conducted and state GSVI values were compared with COVID-19 prevalence and unemployment claims.

RESULTS

The relative public interest in elective TJA has sharply declined since the WHO declaration of COVID-19 as a global pandemic. Between 03-01-2020 and 03-29-2020, the popularity of searches for "knee replacement", "hip replacement," and "orthopedic surgeon" dropped by 62.1%, 52.1%, and 44.3%, respectively. A concurrent spike was observed for the term "elective surgery cancellation." California, New Hampshire, Maine, and Nevada showed a low relative rate for TJA searches, and the highest increase in unemployment claims.

CONCLUSION

The onset of COVID-19 correlates with declining relative popularity of searches related to elective TJA. Higher volume of COVID-19 cases in certain states may correspond with lower relative search popularity, although this correlation remains unclear. These results portend the possibility of a decline in elective TJA case volume, further straining hospitals. Further research is required to inform stakeholders how best to proceed and determine any sustained effects from the current diminished relative interest in TJA.

LEVEL OF EVIDENCE

Level III.

Unmet Need for Total Joint Arthroplasty in Medicaid Beneficiaries After Affordable Care Act Expansion

BACKGROUND

The utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) increased after Medicaid expansion under the U.S. Affordable Care Act (ACA), suggesting a potential unmet need for THA and TKA. We examined the timing of THA and TKA in patients after obtaining Medicaid expansion insurance coverage. We hypothesized that patients with Medicaid expansion insurance would undergo a surgical procedure sooner than patients in traditional Medicaid populations.

METHODS

We used administrative data from a Medicaid managed care company to determine the timing of primary THA and TKA in patients who were 18 to 64 years of age in 4 states with Medicaid expansion (Illinois, Ohio, Oregon, and Washington) and 4 states without Medicaid expansion (Louisiana, Mississippi, Texas, and Wisconsin) from 2008 to 2015. The insurance types were Medicaid expansion, Medicaid plans for Supplemental Security Income (SSI), or Temporary Assistance for Needy Families (TANF). Roughly, these 3 groups correspond to relatively healthy childless adults, relatively unhealthy disabled adults, and parents of children with Medicaid insurance. The main outcome measure was time from enrollment to the surgical procedure. The primary exposure of interest was insurance type. We used a generalized linear regression model to adjust for patient age, sex, social deprivation, surgeon supply and reimbursement, and state-level Medicaid enrollment.

RESULTS

In the unadjusted analysis of 4,117 patients, there was a significantly shorter time from enrollment to THA and TKA for the expansion group (median, 7.5 months) relative to the SSI group (median, 16.1 months; p < 0.0001) and the TANF group (median, 12.2 months; p < 0.0001). In the adjusted analysis, the time from enrollment to THA and TKA was significantly shorter in the expansion group (β, -1.21 [95% confidence interval (CI), -1.35 to -1.07]; p < 0.001) compared with the TANF group (β, -0.27 [95% CI, -0.38 to -0.17]; p < 0.001) and the SSI group (reference). Compared with the SSI group, these coefficients are equivalent to a 70% shorter time to the surgical procedure in the expansion group and a 24% shorter time to the surgical procedure in the TANF group.

CONCLUSIONS

Our findings suggest an unmet need for THA and TKA among newly enrolled Medicaid expansion beneficiaries. This need should be considered by surgeons, hospitals, and policymakers in ensuring access to care. Furthermore, consideration should be given to existing insurance-based disparities in access to orthopaedic care, as these may be exacerbated by an increased demand for THA and TKA from Medicaid expansion beneficiaries.

High-Risk Prescribing Increases Rates of New Persistent Opioid Use in Total Hip Arthroplasty Patients

BACKGROUND

The association between surgeon prescribing practices and new persistent postoperative opioid use is not well understood. We examined the association between surgeon prescribing and new persistent use among total hip arthroplasty (THA) patients.

METHODS

A retrospective analysis of Medicare claims in Michigan was performed. The study cohort consisted of orthopedic surgeons performing THAs from 2013 to 2016 and their opioid-naïve patients, aged >65 years. High-risk prescribing included high daily doses, overlapping benzodiazepine prescriptions, concurrent opioid prescriptions, prescriptions from multiple providers, or long-acting opioid prescriptions. The occurrence of a preoperative prescription, initial prescription size, and 30-day prescription dosage were examined as individual exposures. Surgeons were categorized into quartiles by prescribing practices, and multilevel hierarchical logistic regression was used to examine associations with postoperative new persistent opioid use.

RESULTS

Surgeons exhibited high-risk prescribing for 66% of encounters. Patients of surgeons with the highest rates of high-risk prescribing were more likely to develop persistent use compared with patients of surgeons with the lowest rates (adjusted rates: 9.7% vs 4.6%, P = .011). Patients of surgeons with initial prescription sizes in the "high" (third) quartile (adjusted odds ratio, 2.91; 95% confidence interval, 1.53-5.51), and of surgeons in the "highest" (fourth) quartile of 30-day prescription dosage (adjusted odds ratio, 1.93; 95% confidence interval, 1.03-3.61), were more likely to develop persistent opioid use compared with patients of surgeons with low initial and 30-day prescription sizes, respectively.

CONCLUSION

The development of persistent opioid use after surgery is multifactorial, and surgeon prescribing patterns play an important role. Reducing prescribing and encouraging opioid alternatives could minimize postoperative persistent opioid use.

Integrated clinical pathways with watertight, multi-layer closure to improve patient outcomes in total hip and knee joint arthroplasty

The number of primary total hip and knee replacement surgeries is increasing primarily due to an aging population. There is also a concomitant increase in the number of complications which could be attributed to high variation in arthroplasty techniques, peri-operative methods and the absence of integrated clinical pathways (ICP) to mitigate risks such as surgical site infections (SSIs). The implementation of ICPs incorporating watertight, multi-layer closure could increase the preventative effectiveness against joint prosthetic adverse events. The objective of this review is to describe the ICPs implemented by one US facility to help address ten adverse events synergistically.