RAPT Scores Predict Inpatient Versus Outpatient Status and Readmission Rates After IPO Changes for Total Joint Arthroplasty: An Analysis of 12,348 Cases

"Outpatient Arthroplasty Risk Assessment" (OARA) Score for Same Day Outpatient Primary Total Joint Arthroplasty: A Multi-Center Study

BACKGROUND

The Outpatient Arthroplasty Risk Assessment (OARA) Score was developed to risk-stratify patients for safe same-day discharge outpatient total joint arthroplasty (TJA). It has demonstrated predictive ability for length of stay in primary TJA. However, there is minimal external validity of the original studies. This multicenter database study evaluated the risk assessment and predictive ability for same-day discharge of the OARA score and clinical outcomes following primary TJA.

METHODS

From 2017 to 2023, across 40 locations, 12,809 primary TJAs (4,656 hips, 8,153 knees) were identified. A total of 5,552 and 4,974 cases had length of stay, complication, and readmission data, respectively. Overall, 1,864 (34%) patients were discharged on the same day after primary TJA. Machine learning and statistical models evaluated the predictive ability of the OARA score on same-day discharge, readmission rates, and complications within 90 days. P-values ≤ 0.05 were considered statistically significant.

RESULTS

Patients who had an OARA Score < 60 and < 80 were ≥ 2.6 times more likely to be discharged on the same day of surgery. A lower OARA score was associated with proportionally fewer complications and readmissions (P ≤ 0.001). Complications and readmissions were 2.9 to 3.1 and 3.1 to 3.3 times more likely with OARA scores ≥ 60 and ≥ 80, respectively.

CONCLUSION

Study results demonstrate that patients who had lower OARA scores are more likely to be discharged the same day and have lower complication or readmission rates after primary TJA. These results from multiple centers across the United States further support the original studies and provide evidence for the continued use of the OARA score to help identify medically appropriate candidates for outpatient primary TJA.

The Predictability of the Outpatient Arthroplasty Risk Assessment Score on Clinical Outcomes Following Revision Total Joint Arthroplasty: A Preliminary Registry Analysis

BACKGROUND

The Outpatient Arthroplasty Risk Assessment (OARA) Score was developed to identify surgically appropriate patients for outpatient total joint arthroplasty (TJA). In addition, it has shown excellent predictive ability for length of stay (LOS) following primary TJA compared to other medical risk stratification systems. However, it has not been studied in the revision TJA (rTJA) patient population. This study evaluated the OARA score's ability to predict LOS and postoperative outcomes following rTJA.

METHODS

From 2017 to 2023, 366 rTJAs (116 hips, 250 knees) performed across 17 locations were analyzed. Statistical models evaluated the predictive ability of the OARA Score on same-day or next-day discharge, complications, and readmissions within 90 days. P-values ≤ 0.05 were considered statistically significant.

RESULTS

Overall, 156 (51%) rTJAs were discharged postoperatively on the same or the next day. A lower OARA score was a significant predictor of same- or next-day discharge, and proportionally fewer complications and readmissions (P ≤ 0.035). There were 71% of rTJAs discharged ≥ 2 days postoperatively when the OARA score was ≥ 113. Likewise, complications (19.6 versus 4.7%, P = 0.002) and readmissions (13.0 versus 3.4%, P = 0.016) were ≥ 4.2 (95% confidence interval, 1.4 to 12.8) times more likely when the OARA score was ≥ 113. For all models related to LOS, positive predictive values were great to excellent (range, 73 to 91%), while false positive rates were higher than ideal (range, 63 to 76%).

CONCLUSIONS

The study results demonstrate that a lower OARA score was predictive of same- or next-day discharge and fewer complications and readmissions following rTJA. As the burden of rTJA rises, future studies with higher sample sizes and accounting for revision etiology and the number of components revised should be conducted to further test the OARA Score's utility in the rTJA population.

Trends in comorbidities and complications among patients undergoing elective total hip and knee arthroplasty in the USA

BACKGROUND

Demand for total hip and knee arthroplasty procedures continues to rise. Ongoing changes in surgical care and patient populations require continued monitoring of outcome trends. Using nationwide data from the USA, we aimed to describe updated trends in patient and peri-operative care characteristics as well as complications among total hip and knee arthroplasty recipients.

METHODS

We included patients who underwent elective primary total hip or knee arthroplasty between 2016 and 2021. Trends were reported for a variety of patient and peri-operative care characteristics as well as complications.

RESULTS

We identified significant trends in patient and peri-operative care characteristics as well as the incidence of complications. While patient median age increased, demographic composition remained consistent over the time period studied. There was a shift towards outpatient total hip and knee arthroplasty procedures, with one in five performed in the outpatient setting in 2021; the median duration of hospital stay decreased by 1 day over the time period for both procedures. Parallel increasing trends of total procedure numbers were found for patients without comorbidities and those with ≥ 3 comorbidities. Postoperative mortality increased significantly over the time period analysed for patients having total hip arthroplasty but not those having total knee arthroplasty (0.08 to 0.15 events per 1000 inpatient days, p = 0.037 and 0.09 to 0.33 events per 1000 inpatient days, p = 0.149, respectively).

DISCUSSION

Compared with previous trend analyses of patients having total hip or knee arthroplasty, the present study shows: an increasing rate of outpatient surgeries; increasing numbers of arthroplasty procedures in high comorbidity burden groups; and an increase incidence of certain serious postoperative complications.

Preoperative prediction of postoperative needs after spinal tumor surgery

INTRODUCTION

Spinal oncology care is challenging and resource-intensive. Unfortunately, there are few validated preoperative clinical tools to accurately predict postoperative healthcare needs. The Risk Assessment and Prediction Tool (RAPT) assesses current walking capacity, use of gait aids, home support, and reliance on community support. We aim to assess the utility of the RAPT in predicting discharge disposition for patients undergoing spinal tumor surgery.

METHODS

RAPT was administered preoperatively to consecutive patients (n = 389) undergoing spinal tumor resection from 2017 to 2024 at an academic medical center. Logistic regression analysis was used to associate the total RAPT score, and its subcomponents, with non-home discharge. Secondary outcomes included intraoperative complications, length of stay, 30- and 90-day Emergency Department (ED) visits, readmissions, reoperations, and mortality.

RESULTS

A higher RAPT score was associated with significantly increased odds of home discharge (p < 0.0001, OR=1.484) and reduced risk of 30-day ED visits (p = 0.0151, OR=0.834). There was no correlation between preoperative RAPT score and intraoperative complications, length of stay, readmission, or reoperation. Improved RAPT subscore for baseline walking ability was able to predict home discharge (p = 0.0001, OR=2.865), fewer 30-day ED visits (p = 0.0422, OR=0.622), and reduced 90-day mortality (p = 0.0008, OR= 0.456). Furthermore, preoperative ambulation without gait assistance was also correlated with increased home discharge (p = 0.0001, OR=2.778) and decreased 30-day ED visits (p = 0.0291, OR=0.622).

CONCLUSION

RAPT score and its subcomponents are highly predictive and specific tools for discharge disposition in the spinal oncology population. Implementation of this simple questionnaire can help surgeons identify high-risk patients preoperatively and design risk mitigation strategies.

Outpatient Total Joint Arthroplasty in the "Unhealthy": Staying Safe Using Institutional Protocols

BACKGROUND

Recent expansion in the indications for outpatient total joint arthroplasty has led to debates over patient selection. The purpose of this study was to compare early clinical outcomes and complications of same-day discharge (SDD) hip and knee arthroplasties from a high-volume institution based on the American Society of Anesthesiologists (ASA) physical status classification.

METHODS

Prospectively collected data were reviewed for all SDD primary joint arthroplasties between January 2013 and August 2023. There were 8 surgeons who performed 7,258 cases at hospital outpatient (n = 4,288) or ambulatory surgery centers (n = 2,970). This included 3,239 total hip arthroplasties, 1,503 total knee arthroplasties, and 2,516 unicompartmental knee arthroplasties. The ASA 1 group comprised 506 subjects, compared to 5,005 for ASA 2 and 1,736 for ASA 3. The primary outcomes included emergency department (ED) visits, readmissions, complications, and revisions within 24 hours and 90 days of surgery. The ASA 3 group was older (ASA 1 = 55 versus ASA 2 = 63 versus ASA 3 = 66 years; P < .01) and had a higher body mass index (ASA 1 = 25.4 versus ASA 2 = 28.5 versus ASA 3 = 32.7; P < .01).

RESULTS

There were no differences between ASA groups in joint-related ED visits, readmissions, and complications within 24 h and 90 days of surgery (P > .05). Subjects in the ASA 3 group experienced greater 90-day revisions compared to the other groups (ASA 1 = 1 of 506, 0.2% versus ASA 2 = 15 of 5,005, 0.3% versus ASA 3 = 15 of 1,736, 0.9%; P = .01). Regarding systemic events, ASA 1 subjects experienced significantly greater 24-hour complications (8 of 506, 1.6%) and ED visits (5 of 506, 1.0%), and the ASA 3 subjects had a higher incidence of 90-day readmissions (19 of 1,736, 1.1%) compared to the other groups (P < .05). Within 24 hours of discharge, urinary retention and syncope were the most frequent complications that required additional health care utilization.

CONCLUSIONS

Medically optimized patients categorized as ASA 3 can safely undergo SDD hip and knee arthroplasty without increased risk of 24-hour or 90-day complications. Patient preference for outpatient care, reliable social support, and independent functional status are imperative for a successful outpatient program.

Episode-of-care costs of total knee arthroplasty: Outpatient versus inpatient postoperative care protocol

BACKGROUND

Total knee arthroplasty (TKA) is the most commonly performed joint replacement procedure in North America. Few studies have successfully evaluated the episode-of-care cost (EOCC) of common elective orthopedic procedures using an activity-based costing (ABC) framework. The objective of this study is to compare the EOCC of same-day discharge versus inpatient TKA using an activity-based costing methodology.

METHODS

An observational case-control study was conducted comparing the EOCC of 25 consecutive patients who underwent same-day discharge (SDD) TKA and 25 consecutive patients who underwent same-day admission (SDA) TKA at an academic center. The EOCC was generated using an ABC framework.

RESULTS

The median total EOCC for outpatient TKA was $7,243.26 CAD (IQR=614.12), while the median EOCC in the inpatient group was $8,303.94 CAD (IQR=1,157.77). The costs incurred secondary to the hospital admission were the main driver of the increased cost for inpatients. The mean length of stay for admitted patients was 2.45 days (SD=1,52). Patients in the outpatient group were younger (p < 0.01) and had a lower mean Charlson Comorbidity Index group (p = 0.01). There was no significant difference in gender, BMI, ASA scores, and complication rates between the two groups.

CONCLUSION

Through the application of an ABC framework, this value-based healthcare study demonstrates that outpatient procedures are a cost-effective approach to knee arthroplasty. Our findings demonstrate that the total cost of outpatient TKA was on average 15% ($1,060 CAD) lower than the cost of TKA with the standard inpatient postoperative care protocol.

Evaluation of Preoperative Variables that Improve the Predictive Accuracy of the Risk Assessment and Prediction Tool in Primary Total Hip Arthroplasty

INTRODUCTION

Discharge disposition after total joint arthroplasty may be predictable. Previous literature has attempted to improve upon models such as the Risk Assessment and Prediction Tool (RAPT) in an effort to optimize postoperative planning. The purpose of this study was to determine whether preoperative laboratory values and other previously unstudied demographic factors could improve the predictive accuracy of the RAPT.

METHODS

All patients included had RAPT scores in addition to the following preoperative laboratory values: red blood cell count, albumin, and vitamin D. All values were recorded within 90 days of surgery. Demographic variables including marital status, American Society of Anesthesiologists (ASA) scores, body mass index, Charlson Comorbidity Index, and depression were also evaluated. Binary logistic regression was used to determine the significance of each factor in association with discharge disposition.

RESULTS

Univariate logistic regression found significant associations between discharge disposition and all original RAPT factors as well as nonmarried patients ( P < 0.001), ASA class 3 to 4 ( P < 0.001), body mass index >30 kg/m 2 ( P = 0.065), red blood cell count <4 million/mm 3 ( P < 0.001), albumin <3.5 g/dL ( P < 0.001), Charlson Comorbidity Index ( P < 0.001), and a history of depression ( P < 0.001). All notable univariate models were used to create a multivariate model with an overall predictive accuracy of 90.1%.

CONCLUSIONS

The addition of preoperative laboratory values and additional demographic data to the RAPT may improve its PA. Orthopaedic surgeons could benefit from incorporating these values as part of their discharge planning in THA. Machine learning may be able to identify other factors to make the model even more predictive.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data

INTRODUCTION

Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty.

METHODS

Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes.

RESULTS

A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time ( P < 0.001).

DISCUSSION

TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective cohort study.

Outpatient vs. inpatient designation in total hip arthroplasty: can we predict who will require hospitalization?

INTRODUCTION

Following removal of total hip arthroplasty (THA) from the inpatient only (IPO) list by the Center for Medicare Services (CMS), arthroplasty surgeons face increased pressure to perform procedures on an outpatient (OP) basis. The purposes of the present study were to compare patients booked for THA as OP who required conversion to IP status postoperatively, to patients who were booked as, and remained OP, and to identify factors predictive of conversion from OP to IP status.

METHODS

We retrospectively reviewed all patients who underwent a primary THA at our institution between January 1, 2020 and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions were used to determine factors predictive of status conversion.

RESULTS

Of 1,937 patients, 372 (19.2%) designated as OP preoperatively required conversion to IP status postoperatively. These patients had significantly higher facility discharge rates (P < 0.001) and 90-day readmission rates (P = 0.024). Patients aged 65 and older (P < 0.001), females (P < 0.001), patients with Black/African American race (P = 0.027), with a recovery room arrival time after 12 pm (P < 0.001), with a BMI > 30 kg/m2 (P = 0.001), and with a Charlson Comorbidity Index (CCI) ≥ 4 (P = 0.013) were Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation more likely to require conversion to IP designation. Marital status and time of procedure were also significant factors, as patients who were married (P < 0.001) and who were the first case of the day (P < 0.001) were less likely to be converted to IP.

CONCLUSION

Several factors were identified which could help determine appropriate hospital designation status at the time of surgical booking to ultimately avoid insurance claim denials. These included BMI, certain demographic factors, CCI ≥ 4, and patients 65 or older.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Use of The Risk Assessment and Prediction Tool to Predict Same-day Discharge After Primary Hip and Knee Arthroplasty

INTRODUCTION

The Risk Assessment and Prediction Tool (RAPT) is a preoperative screening tool developed to predict discharge disposition after total hip arthroplasty (THA) and total knee arthroplasty (TKA), but its predictive value for same-day discharge (SDD) has not been investigated. The aims of this study were (1) to assess RAPT's ability to predict SDD after primary THA and TKA and (2) to determine a cutoff RAPT score that may recognize patients appropriate for SDD.

METHODS

Data were retrospectively collected from patients undergoing primary THA and TKA at a single tertiary care center between February 2020 and May 2021. A receiver operating characteristic curve was generated to choose a cutoff value to screen for SDD. Logistic regression analysis was done to identify factors including age, BMI, or RAPT score that may be associated with SDD.

RESULTS

Three hundred sixty-one patients with preoperative RAPT scores were included in the analysis of whom 147 (42.6%) underwent SDD. A cutoff of ≥9 was identified for TKA and ≥11 for THA. RAPT had a predictive accuracy of only 66.7% for SDD, whereas the discharge plan documented in the preoperative note was 91.7% accurate.

DISCUSSION

Although there is a positive association between RAPT and SDD, it is not a useful screening tool given its low predictive accuracy.

The successful and safe conversion of joint arthroplasty to same-day surgery: A necessity after the COVID-19 pandemic

INTRODUCTION

A key strategy to address system pressures on hip and knee arthroplasty through the COVID-19 pandemic has been to shift procedures to the outpatient setting.

METHODS

This was a retrospective cohort and case-control study. Using the Discharge Abstract Database and the National Ambulatory Care Reporting System databases, we estimated the use of outpatient hip and knee arthroplasty in Ontario, Canada. After propensity-score matching, we estimated rates of 90-day readmission, 90-day emergency department (ED) visit, 1-year mortality, and 1-year infection or revision.

RESULTS

204,066 elective hip and 341,678 elective knee arthroplasties were performed from 2010-2022. Annual volumes of hip and knee arthroplasties increased steadily until 2020. Following the start of the COVID-19 pandemic (March 1, 2020) through December 31, 2022 there were 7,561 (95% CI 5,435 to 9,688) fewer hip and 20,777 (95% CI 17,382 to 24,172) fewer knee replacements performed than expected. Outpatient arthroplasties increased as a share of all surgeries from 1% pre-pandemic to 39% (hip) and 36% (knee) by 2022. Among inpatient arthroplasties, the tendency to discharge to home did not change since the start of the pandemic. During the COVID-19 era, patients receiving arthroplasty in the outpatient setting had a similar or lower risk of readmission than matched patients receiving inpatient arthroplasty [hip: RR 0.65 (0.56-0.76); knee: RR 0.86 (0.76-0.97)]; ED visits [hip: RR 0.78 (0.73-0.83); knee: RR 0.92 (0.88-0.96)]; and mortality, infection, or revision [hip: RR 0.65 (0.45-0.93); knee: 0.90 (0.64-1.26)].

CONCLUSION

Following the start of the COVID-19 pandemic in Ontario, the volume of outpatient hip and knee arthroplasties performed increased despite a reduction in overall arthroplasty volumes. This shift in surgical volumes from the inpatient to outpatient setting coincided with pressures on hospitals to retain inpatient bed capacity. Patients receiving arthroplasty in the outpatient setting had relatively similar outcomes to those receiving inpatient surgery after matching on known sociodemographic and clinical characteristics.

Preoperative Prediction and Risk Factor Identification of Hospital Length of Stay for Total Joint Arthroplasty Patients Using Machine Learning

Background

The aim of this study was to improve understanding of hospital length of stay (LOS) in patients undergoing total joint arthroplasty (TJA) in a high-efficiency, hospital-based pathway.

Methods

We retrospectively reviewed 1401 consecutive primary and revision TJA patients across 67 patient and preoperative care characteristics from 2016 to 2019 from the institutional electronic health records. A machine learning approach, testing multiple models, was used to assess predictors of LOS.

Results

The median LOS was 1 day; outpatients accounted for 16.5%, 1-day inpatient stays for 38.0%, 2-day stays for 26.4%, and 3-days or more for 19.1%. Patients characteristically fell into 1 of 3 broad categories that contained relatively similar characteristics: outpatient (0-day LOS), short stay (1- to 2-day LOS), and prolonged stay (3 days or greater). The random forest models suggested that a lower Risk Assessment and Prediction Tool score, unplanned admission or hospital transfer, and a medical history of cardiovascular disease were associated with an increased LOS. Documented narcotic use for surgery preparation prior to hospitalization and preoperative corticosteroid use were factors independently associated with a decreased LOS.

Conclusions

After TJA, most patients have either an outpatient or short-stay hospital episode. Patients who stay 2 days do not differ substantially from patients who stay 1 day, while there is a distinct group that requires prolonged admission. Our machine learning models support a better understanding of the patient factors associated with different hospital LOS categories for TJA, demonstrating the potential for improved health policy decisions and risk stratification for centers caring for complex patients.

Challenges with patient management of osteoarthritis during the COVID-19 pandemic: review

Osteoarthritis is a growing public health concern, affecting millions of people worldwide. With progressively worsening joint function and pain, management of osteoarthritis is important to ensure high quality of life for patients. Treatment includes a combination of pharmacologic agents and non-pharmacologic methods such as exercise and physical therapy. However, if multiple treatments fail to improve symptoms, joint replacement surgery is the final course of action. When the new coronavirus, SARS-CoV-2 (COVID-19), was declared a pandemic, all aspects of osteoarthritis treatment become affected. Due to increased public health measures, non-pharmacologic modalities and elective surgeries became limited in accessibility. Additionally, there were concerns about the interaction of current medications for osteoarthritis with the virus. As a result of limited options for treatment and quality of life of patients was negatively impacted, especially in those with severe osteoarthritis. Furthermore, a backlog of joint replacement surgeries was created which could take up to several months or years to address. In this review, we describe the impact COVID-19 had on osteoarthritis management as well as tactics to deal with the large caseload of surgeries as operative rooms begin to re-open for elective surgeries.

The Risk Assessment and Prediction Tool (RAPT) Score Predicts Discharge Destination, Length of Stay, and Postoperative Mobility after Total Joint Arthroplasty

INTRODUCTION

Predicting an arthroplasty patient's discharge disposition, length of stay, and physical function is helpful because it allows for preoperative patient optimization, expectation management, and discharge planning. The goal of this study was to evaluate the ability of the Risk Assessment and Prediction Tool (RAPT) score to predict discharge destination, length of stay, and postoperative mobility in patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

Primary unilateral TKAs (n=9,064) and THAs (n=8,649) performed for primary osteoarthritis at our institution from 2018 to 2021 (excluding March to June 2020) were identified using a prospectively maintained institutional registry. We evaluated the associations between preoperative RAPT score and (1) discharge destination, (2) length of stay, and postoperative mobility as measured by (3) successful ambulation on the day of surgery and (4) Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score.

RESULTS

On multivariable analyses adjusting for multiple covariates, every one-point increase in RAPT score among TKA patients was associated with a 1.82-fold increased odds of home discharge (P<0.001), 0.22 days shorter length of stay (P<0.001), 1.13-fold increased odds of ambulating on postoperative day 0 (P<0.001), and 0.25-point higher AM-PAC score (P<0.001). Similar findings were seen among THAs. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict home discharge.

CONCLUSION

Among nearly 18,000 TKA and THA patients, RAPT score was predictive of discharge disposition, length of stay, and postoperative mobility. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict discharge to home. In contrast to prior studies of the RAPT score which have grouped TKAs and THAs together, this study ran separate analyses for TKAs and THAs and found that THA patients seemed to perform better than TKA patients with equal RAPT scores, suggesting that RAPT may behave differently between TKAs and THAs, particularly in the intermediate risk RAPT range.

Medicare Payments to Hospitals and Physicians for Total Hip and Knee Arthroplasty Declined From 2009 to 2019

BACKGROUND

Recent research has reported hospital payments for total hip arthroplasty (THA) and knee arthroplasty (TKA) from commercial payers to be increasing, despite increasing price pressure from the increasing scale and scope of alternative reimbursement schemes. Therefore, the primary objective of this study was to analyze the recent trends in Medicare payments to hospitals and surgeons for primary THA and TKA.

METHODS

The primary data source for this study was the Medicare Provider Analysis and Review Limited Data Set (MEDPAR) for the years 2009, 2014, and 2019. A total of 331,721 patients undergoing primary elective THA and 742,476 patients undergoing primary elective TKA were included. Total Medicare payments and total hospital reimbursements, which included Medicare payments and patient copayments, were calculated. Physician fees were obtained from the Medicare physician fee schedule (MPFS) look-up tool. All financial data were inflation-adjusted. Patient comorbidities were identified as a measure of health status. The data were stratified by year and analyzed using descriptive statistics.

RESULTS

From 2009 to 2019, inflation-adjusted Medicare payments declined by 11.5% and total hospital reimbursements (Medicare payments plus copayments) declined by 6.5% for THA, while Medicare payments declined by 13.4%, and total hospital reimbursements declined by 7.7% for TKA. Over the same period, surgeons' fees declined by 13.1% for THA and 18.9% for TKA.

CONCLUSION

From 2009 to 2019, Medicare payments to hospitals and physicians declined markedly. Physician payments decreased faster than hospital payments. These results may have implications for the future viability of performing THA and TKA on Medicare patients.