Educational Attainment Affects the Early Rehabilitation of Total Knee Arthroplasty in Southwest China

Association of Cerebral Palsy With Unanticipated Admission Following Pediatric Ambulatory Surgery

BACKGROUND

Cerebral palsy, a neurologic disorder caused by damage to the developing brain, is a leading cause of childhood disability. Due to musculoskeletal, movement, and secondary impairments, children with cerebral palsy often require surgical care. With the growing cost of surgical care, many children with cerebral palsy are scheduled for surgery in an ambulatory setting. Whether cerebral palsy increases the risk of unanticipated admission (a critical quality indicator of care) following ambulatory surgery has not been characterized. Our objective was to determine the association of cerebral palsy with unanticipated admission following pediatric ambulatory surgery.

METHODS

We used the Pediatric Health Information System (PHIS) database to evaluate a retrospective cohort of children (< 18 years) who underwent scheduled ambulatory operations between January 1, 2010 and December 31, 2022. The primary outcome was unanticipated admission. Using log-binomial regression models, we estimated the relative risk and 95% confidence intervals for unanticipated admission, comparing patients with and without cerebral palsy. To account for confounding variables, we performed a 1:1 propensity score matching without replacement.

RESULTS

A total of 1 954 108 children underwent ambulatory surgeries during the study period. Of these, 4.1% required unanticipated admission. The overall incidence of unanticipated admission was significantly higher among children with cerebral palsy than in those without (9.8% vs. 4.0%; p < 0.001). This association remained significant after multivariable adjustment (relative risk: 1.73; 95% CI: 1.59-1.87, p < 0.001).

CONCLUSION

Although cerebral palsy is not a contraindication for ambulatory surgery in children, it is significantly associated with the risk of unanticipated hospital admissions. This underscores the need for careful preoperative clinical site of care selection in this vulnerable patient population.

LEVEL OF EVIDENCE

Level II.

Assessing the costs of midfoot arthrodesis: A retrospective cohort study

This retrospective cohort study aims to determine the economic cost of midfoot arthrodesis when treating midfoot arthritis, identifying the major driving forces of cost. A retrospective analysis was conducted on midfoot arthrodesis cases in South Carolina from 2012 to 2020 using the South Carolina Revenue and Fiscal Affairs (SCRFA) database. Patient cases were identified by ICD-9, ICD-10, or CPT code, yielding a total of 1,313 cases included in our analysis. Patients undergoing midfoot arthrodesis were primarily female (71.1 %), Caucasian (74.6 %), insured through commercial insurance (40.2 %) or Medicare (37.3 %), and had a mean age of 54.27 years (range 4-86). The mean total cost per midfoot arthrodesis was $54,307.08 (range $9,433.05-$120,664.29) and the mean length of stay was 1.26 (range 1-6) days. Total charges trended upward from $42,857 in 2012 to $58,643.43 in 2020. Upon analysis, the largest contributors to this cost were supplies ($27,888.28), operating room costs ($15,876.80), and anesthesia costs ($3,866.70). Notably, surgeon fees were a comparatively minor contributor ($670.49). The mean total cost per midfoot arthrodesis was $54,307.08, with supplies and operating room costs exceeded 80 % of the mean total costs. With professional service (physician) fees accounting for only 1.2 % of costs, hospital systems, hospital administrators, and surgeons should consider improving their understanding of ways to reduce surgical costs, supply negotiation, and transitioning to more outpatient surgery as means to improve the value of midfoot arthrodesis care. LEVEL OF CLINICAL EVIDENCE: Level IV, Retrospective Cohort Study.

Ambulatory surgery center versus outpatient hospitals: a comparison of reimbursements for patients undergoing anterior cervical discectomy and fusion

BACKGROUND CONTEXT

While some studies have demonstrated that ambulatory surgery centers (ASCs) are associated with reduced costs of orthopedic procedures, there is no consensus in the current literature as to the impact of ASCs versus hospital-based outpatient departments (HOPDs) on anterior cervical discectomies and fusions (ACDFs).

PURPOSE

This study sought to (1) compare immediate procedure reimbursements, patient out-of-pocket expenditures, and surgeon reimbursements for ACDFs performed at ASCs versus HOPDs and (2) identify factors predicting facility utilization.

STUDY DESIGN

Retrospective cross-sectional study.

PATIENT SAMPLE

We identified ACDF procedures performed at an ASC or HOPD in commercially-insured patients aged 18 to 64.

OUTCOME MEASURES

Payment variables were calculated from claims within 3 days preoperatively and postoperatively.

METHODS

Multivariable regression models assessed (1) associations between the surgery setting and payment variables and (2) factors associated with the surgery setting.

RESULTS

We included 18,191 ACDFs (14.8% ASC, 85.2% HOPD). In multivariable analyses, ACDFs performed in an ASC (versus HOPD) were associated with 9.8% higher immediate procedure reimbursements (95% CI:7.5%-12.2%), 17.2% higher patient out-of-pocket expenditures (95% CI:11.8-22.8), and 11.7% higher surgeon reimbursements (95% CI:9.18-14.2; all p<.01) (all p<.001). Surgery setting utilization varied by region, insurance-related factors, comorbidities, and procedural complexity.

CONCLUSIONS

We found that ASCs had significantly higher reimbursements compared to HOPDs. Regional variations in ASC utilization imply there are opportunities for standardization of care.

LEVEL OF EVIDENCE: 3

A multi-phase approach for developing a conceptual model and preliminary content for patient-reported outcome measurement in TKA patients: from a Chinese perspective

PURPOSE

Patient-reported outcome measures (PROMs) are being used more frequently in total knee arthroplasty (TKA). By utilizing high-quality scales, surgeons can achieve a more comprehensive and accurate evaluation of the effectiveness of TKA surgery. Currently, there is no widely accepted conceptual model for TKA PROMs. The objective of this study is to fill this gap by developing a conceptual model and preliminary content for a PROM that is specifically designed for TKA patients in mainland China.

METHODS

The study design consisted of three stages: (1) a targeted literature review followed by the formation of a conceptual model pool; (2) qualitative data collection involving experts and patients, leading to the development of the preliminary Chinese TKA PROM (CTP); and (3) review of the CTP by experts using the Delphi method, along with cognitive debriefing interviews with patients.

RESULTS

64 patients and 28 experts took part in this study. The conceptual model focused on six key concepts: pain, symptom, function, quality of life, expectation, and satisfaction. To match the model, the authors developed a total of 35 items.

CONCLUSION

A conceptual model and preliminary content for CTP was developed with substantial participation from patients and a multidisciplinary group of experts. The integration of patient and clinical perspectives ensured a comprehensive representation of all relevant disease experiences and the focus of clinical practice. With further refinement through psychometric testing, the CTP is positioned to provide a standardized, comprehensive measure for research specific to Chinese TKA patients.

Optimizing Durable Medical Equipment at an Ambulatory Surgery Center

Orthopaedic outpatient surgery in the form of Ambulatory Surgical Centers (ASCs) continues to rise over the past several decades with enhancements for the patient and organization that includes ease of convenience, efficiency, and cost-effectiveness when examining the comparison to a traditional hospital with outpatient departments (Wang, K. Y., Puvanesarajah, V., Marrache, M., Ficke, J. R., Levy, J. F., & Jain, A. (2022). Ambulatory surgery centers versus hospital outpatient departments for orthopaedic surgeries. Journal of the American Academy of Orthopaedic Surgeons, 30(5), 207-214). Furthermore, the rise of ASCs also includes various ownership models such as a sole physician, ASC management company, or a health system, which also commonly results in a blend of all three elements based on the strategy of the group. The purpose of this brief is to examine the unique delivery role that durable medical equipment (DME) plays in the care for patients following an orthopaedic surgery at an ASC when providing DME by Certified Athletic Trainers. Optimizing Certified Athletic Trainers in the ASC space creates opportunities for improving patient satisfaction and surgical staff burden while adding revenue to the ASC.

Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum 2-year follow-up

BACKGROUND

Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up.

METHODS

A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, range of motion (ROM), strength, complications, readmissions, and reoperations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up.

RESULTS

A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < .0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different.

CONCLUSION

This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up.

Trends in payments for facility and surgeon professional fees for shoulder surgeries performed at ambulatory surgery centers

BACKGROUND

It has previously been demonstrated that utilization of ambulatory surgery centers (ASCs) results in cost savings and improved outcomes. Despite these benefits, Medicare reimbursement for professional fees at ASCs are decreasing over time. In this study, we sought to analyze the discrepancy between facility fee and professional fee reimbursements for ASCs by Medicare for common shoulder procedures over time. We hypothesized that professional fees for shoulder procedures would decrease over the study period while facility fees kept pace with inflation.

METHODS

Current Procedural Terminology codes were used to identify shoulder specific procedures approved for ASCs by Centers for Medicare and Medicaid Services. Procedures were grouped into arthroscopic and open categories. Publicly available data from Centers for Medicare and Medicaid Services was accessed via the Medicare Physician Fee Schedule Lookup Tool and used to determine professional fee payments from 2018 to 2024. Additionally, Medicare ASC Payment Rates files were accessed to determine facility fee reimbursements to ASCs from 2018 to 2024. Descriptive statistics were used to calculate means and percent change over time. Compound annual growth rates were calculated and discrepancies in inflation were corrected for using the Consumer Price Index. The Benjamini and Hochberg method was used to correct P values in the setting of multiple comparisons.

RESULTS

A total of 33 common shoulder procedures were included for analysis (10 arthroscopic codes and 23 open codes). Reimbursements for facility fees have remained significantly higher than corresponding professional fees for both open and arthroscopic procedures (P < .01). On average, facility fee reimbursements for common shoulder surgeries have risen on an annual basis in a manner consistent with inflation (P = .838). However, professional fees for these procedures have experienced a nearly uniform decline over the study period both nominally and in inflation-adjusted dollars (P = .064 and P = .005, respectively).

CONCLUSION

Facility fee payments for outpatient approved shoulder surgeries have matched or outpaced inflation. Over the same time period, professional fee reimbursements for surgeons are consistently decreasing, both in absolute and inflation-adjusted dollars. Reform to the physician fee schedule is necessary to ensure that Medicare patients retain access to high-quality physician care.

Education, Language, and Cultural Concordance Influence Patient-Physician Communication in Orthopaedics

BACKGROUND

Orthopaedic surgery has a diversity gap, as it is not representative of the racial or sex proportions of the U.S. population. This gap can lead to communication barriers stemming from health literacy, language proficiency, or cultural discordance that may contribute to current health inequities. This study assesses the influence of educational attainment, language, and cultural concordance on patient-physician communication.

METHODS

In this cross-sectional study, 394 patients from an urban orthopaedic clinic were administered a Likert-type survey regarding race or ethnicity, educational level, communication, patient satisfaction, language proficiency, and culture. One-way analysis of variance, chi-square tests, and Welch t tests were used to evaluate responses.

RESULTS

The majority of subjects identified as African-American/Black (50%) or Hispanic/Latino (30%). Completing high school was associated with a better ability of the subjects to communicate with their orthopaedic surgeon (p < 0.001). Hispanic subjects reported lower English proficiency (p < 0.001) and decreased ability to communicate with their physician (p < 0.001) compared with other subjects, with educational attainment influencing their ability to understand their orthopaedic surgeon in English (p < 0.001). African-American and Hispanic patients placed greater importance on orthopaedic surgeons understanding their culture than White patients (p < 0.001). Hispanic patients who saw a language and culture-concordant surgeon valued having a Spanish-speaking surgeon more than Hispanic patients who did not see a concordant surgeon (p = 0.04).

CONCLUSIONS

These results suggest that patient-physician language concordance, particularly in patients with lower education, may be essential to delivering high-quality patient care. Hispanic and African-American patients placed significantly greater importance on their orthopaedic surgeons understanding their culture. Hispanic patients frequently sought care with language-concordant surgeons and placed higher value on physicians understanding their culture. To better serve minority communities, efforts should be made to increase orthopaedic surgeons' cultural humility and to recruit a diverse multilingual surgeon workforce.

CLINICAL RELEVANCE

This research demonstrates that cultural and language concordance, specifically between Hispanic patients and Hispanic, Spanish-speaking surgeons, can significantly enhance patient preference and potentially improve patient satisfaction and outcomes in orthopaedic care. Additionally, it underscores the importance of understanding and addressing the diversity within the field and the patient population to better meet the needs of a multicultural society.

Impact of Tibetan ethnicity and residence altitude on complications during total knee arthroplasty and difficulties of measurement of perioperative blood loss

PURPOSE

Tibetan patients undergoing total knee arthroplasty (TKA) have greater fluctuations in perioperative haemoglobin levels and blood hypercoagulability. This study was to investigate whether ethnicity and altitude affect perioperative blood loss and the risk of complications after TKA.

METHODS

We retrospectively enrolled 1,116 patients undergoing TKA for knee osteoarthritis at our hospital between January 2016 and September 2021. We divided patients into four groups according to whether they were of Tibetan or Han ethnicity and whether they lived above or below 2500 m above sea level. Primary outcomes were total, intraoperative, and hidden blood losses, while secondary outcomes were complications and homologous transfusion. Factors associated with increased blood loss were analyzed by multivariate regression.

RESULTS

Total blood loss was higher among patients residing at high altitude compared with lower altitude, whether they were of Han (794.6 mL vs. 667.2 mL, P = 0.020) or Tibetan (904.4 mL vs. 663.8 mL, P < 0.001). Total blood loss was similar between the two ethnic groups at the same altitude. Altitude, but not Tibetan ethnicity, remained associated with increased blood loss after being analyzed by multivariate regression. Complications among the four groups were generally similar, although the frequency of calf muscular venous thrombosis was higher among Tibetan patients, while the frequency of blood transfusion was higher among Han subjects.

CONCLUSIONS

Our findings indicate that residence at high altitude, but not ethnicity, may contribute to increased total blood loss during TKA. Thrombotic complications were more frequent among Tibetan than Han patients.

Comparison of Intravenous, Topical, or Combined Routes of Tranexamic Acid in Primary Total Knee Arthroplasty

Introduction: The optimal route and dosing regimen of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) remains unclear. This study aims to explore if there was a synergistic effect of intravenous (IV) and topical TXA on blood loss and risk of complications. Materials and methods: From Jan 2019 to June 2021, medical records of patients aged 65 years or older who underwent primary unilateral TKA for primary osteoarthritis were retrospectively reviewed. The included patients were divided into 3 groups according to the methods of TXA application: Intravenous (IV) group, topical group, or combined group. Propensity-score match was used to reduce the bias and imbalance of confounding variables. The primary outcome was total blood loss. Results: The total blood loss, hidden blood loss, and the reduction of Hb concentration in the combined group were significantly lower than in the IV group and topical group (all P < .01). There is no significant difference in the transfusion rate, length of hospital stay, and incidence of thromboembolic events (both P > .05). Conclusions: Combined administration of IV and topical TXA is the most effective approach to decrease blood loss and postoperative Hb drop in the treatment of TKA without increasing any risk of complications.