Managing episodes of care: strategies for orthopaedic surgeons in the era of reform

National Decline in Knee Fusions Performed for Salvage of Chronic Periprosthetic Total Knee Infections

The primary purpose of this study was to study and compare rates of two salvage operations for patients with chronically infected total knee arthroplasties: (1) knee arthrodesis and (2) above knee amputation (AKA). An analysis was performed comparing the inpatient hospital characteristics and complications between the two procedures. Secondarily, we presented rates of all surgically treated periprosthetic total knee infections over a 6-year period. Using the Nationwide Inpatient Sample, we identified all patients with a periprosthetic infection (International Classification of Diseases, Ninth Revision [ICD-9] 996.66) from 2009 to 2014. Subsequently, we identified surgically treated total knee infections through the following ICD-9 codes: 00.80 (all component revision), 00.84 (liner exchange), 80.06 (removal of prosthesis), 84.17 (AKA), and 81.22 (knee fusion). From 2009 to 2014, the annual incidence of surgically treated total knee periprosthetic infections increased by 34.9% nationally, while the annual incidence of primary total knees increased by only 13.9%. Salvage operations (AKA and knee fusion) represented 5.8% of all surgically treated infections. The rate of knee fusions decreased from 1.9% of surgically treated infections in 2009 to 1.4% in 2014 (p < 0.05), while the rate of AKA stayed steady at 4.5% of cases over the 6-year period. Length of stay was significantly shorter in the knee fusion group (7.9 vs. 10.8 days, p < 0.05), but total hospital costs were higher (33,016 vs. 24,933, p < 0.05). In the multivariable adjusted model, patients undergoing knee fusion had significantly decreased odds of being discharged to skilled nursing facility (odds ratio: 0.42, 95% confidence interval: 0.31-0.58). The annual incidence of surgically treated periprosthetic total knee infections is increasing. The rate of knee arthrodesis for chronic periprosthetic total knee infections is decreasing. Reasons for this downward trend in knee fusions should be evaluated carefully as knee fusions have shown to have the potential advantage of improved mobility and decreased patient morbidity for chronic PJI. The level of evidence is III.

Healthcare Transformation and Changing Roles for Nursing

Factors driving healthcare transformation include fragmentation, access problems, unsustainable costs, suboptimal outcomes, and disparities. Cost and quality concerns along with changing social and disease-type demographics created the greatest urgency for the need for change. Caring for and paying for medical treatments for patients suffering from chronic health conditions are a significant concern. The Affordable Care Act includes programs now led by the Centers for Medicare & Medicaid Services aiming to improve quality and control cost. Greater coordination of care-across providers and across settings-will improve quality care, improve outcomes, and reduce spending, especially attributed to unnecessary hospitalization, unnecessary emergency department utilization, repeated diagnostic testing, repeated medical histories, multiple prescriptions, and adverse drug interactions. As a nation, we have taken incremental steps toward achieving better quality and lower costs for decades. Nurses are positioned to contribute to and lead the transformative changes that are occurring in healthcare by being a fully contributing member of the interprofessional team as we shift from episodic, provider-based, fee-for-service care to team-based, patient-centered care across the continuum that provides seamless, affordable, and quality care. These shifts require a new or an enhanced set of knowledge, skills, and attitudes around wellness and population care with a renewed focus on patient-centered care, care coordination, data analytics, and quality improvement.

A Preoperative Scale for Determining Surgical Readmission Risk After Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is one of the most common orthopaedic procedures performed in the U.S. The purpose of this study was to develop and verify a scale to preoperatively stratify a patient's risk of being readmitted to the hospital following a TKA.

METHODS

Discharge data on 433,638 patients from New York and California (derivation cohort) and 269,934 patients from Florida and Washington (validation cohort) who underwent TKA were collected from the State Inpatient Database, a part of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality (2006 to 2011). Demographic and clinical characteristics of patients were abstracted and analyzed to develop the Readmission After Total Knee Arthroplasty (RATKA) Scale.

RESULTS

Overall 30-day readmission rates in the derivation and validation cohorts were 5.11% and 4.98%, respectively. The following factors were significantly associated with increased 30-day readmission rates in the derivation cohort: age of 41 to 50 years (odds ratio [OR] = 1.13), age of 71 to 80 years (OR = 1.21), age of 81 to 90 years (OR = 1.70), male sex (OR = 1.19), African-American race (OR = 1.37), "other" race/ethnicity (OR = 1.08), Medicaid payer (OR = 1.43), Medicare payer (OR = 1.27), anemia (OR = 1.19), chronic obstructive pulmonary disease (OR = 1.29), coagulopathy (OR = 1.22), congestive heart failure (OR = 1.64), diabetes (OR = 1.19), fluid and electrolyte disorder (OR = 1.25), hypertension (OR = 1.10), liver disease (OR = 1.27), renal failure (OR = 1.33), and rheumatoid arthritis (OR = 1.14). These factors were used to create the RATKA Scale. The RATKA score was then used to define 3 levels of risk for readmission: low (RATKA score of <13; 3.7% readmission rate), moderate (RATKA score of 13 to 16; 5.4% readmission rate), and high (RATKA score of >16; 7.6% readmission rate). The relative risk of readmission was 2.06 for the high-risk group compared with the low-risk group.

CONCLUSIONS

The RATKA Scale derived from patient data from the derivation cohort was reliably able to explain readmission variability after TKA for patients in the validation cohort at a rate of >95%. Models such as the RATKA Scale will enable identification of the risk of readmission following TKA based on a patient's risk profile prior to surgery.

LEVEL OF EVIDENCE

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

The Effects of a Hospitalist Comanagement Model for Joint Arthroplasty Patients in a Teaching Facility

BACKGROUND

The goal of this study was to compare postoperative medical comanagement of total hip arthroplasty and total knee arthroplasty patients using a hospitalist (H) and nonhospitalist (NH) model at a single teaching institution to determine the clinical and economic impact of the hospitalist comanagement.

METHODS

We retrospectively reviewed the records of 1656 patients who received hospitalist comanagement with 1319 patients who did not. The NH and H cohorts were compared at baseline via chi-square test for the American Society of Anesthesiologists classification, the t test for age, and the Wilcoxon test for the unadjusted Charlson Comorbidity Index score and the age-adjusted Charlson Comorbidity Index score. Chi-square test was used to compare the postoperative length of stay, readmission rate at 30 days after surgery, diagnoses present on admission, new diagnoses during admission, tests ordered postoperatively, total direct cost, and discharge location.

RESULTS

The H cohort gained more new diagnoses (P < .001), had more studies ordered (P < .001), had a higher cost of hospitalization (P = .002), and were more likely to be discharged to a skilled nursing facility (P < .001). The H cohort also had a lower length of stay (P < .001), but we believe evolving techniques in both pain control and blood management likely influenced this. There was no significant difference in readmissions.

CONCLUSION

Any potential benefit of a hospitalist comanagement model for this patient population may be outweighed by increased cost.

Current concept review: quality and process improvement in orthopedics

Multiple health care stakeholders are increasingly scrutinizing musculoskeletal care to optimize quality and cost efficiency. This has led to greater emphasis on quality and process improvement. There is a robust set of business strategies that are increasingly being applied to health care delivery. These quality and process improvement tools (QPITs) have specific applications to segments of, or the entire episode of, patient care. In the rapidly changing health care world, it will behoove all orthopedic surgeons to have an understanding of the manner in which care delivery processes can be evaluated and improved. Many of the commonly used QPITs, including checklist initiatives, standardized clinical care pathways, lean methodology, six sigma strategies, and total quality management, embrace basic principles of quality improvement. These principles include focusing on outcomes, optimizing communication among health care team members, increasing process standardization, and decreasing process variation. This review summarizes the common QPITs, including how and when they might be employed to improve care delivery.

Decreasing spine implant costs and inter-physician cost variation

The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre.

Cite this article: 2015; 97-B:1102–5.

The economic significance of orthopaedic infections

Musculoskeletal infections are a leading cause of patient morbidity and rising healthcare expenditures. The incidence of musculoskeletal infections, including soft-tissue infections, periprosthetic joint infection, and osteomyelitis, is increasing. Cases involving both drug-resistant bacterial strains and periprosthetic joint infection in total hip and total knee arthroplasty are particularly costly and represent a growing economic burden for the American healthcare system. With the institution of the Affordable Care Act, there has been an increasing drive in the United States toward rewarding healthcare organizations for their quality of care, bundling episodes of care, and capitating approaches to managing populations. In current reimbursement models, complications following the index event, including infection, are not typically reimbursed, placing the burden of caring for infections on the physician, hospital, or accountable care organization. Without the ability to risk-stratify patient outcomes based on patient comorbidities that are associated with a higher incidence of musculoskeletal infection, healthcare organizations are disincentivized to care for moderate- to high-risk patients. Reducing the cost of treating musculoskeletal infection also depends on incentivizing innovations in infection prevention.

The effect of severity of illness on total joint arthroplasty costs across New York state hospitals: an analysis of 172,738 cases

We explored the average cost of 94,197 total knee and 78,541 total hip arthroplasties (TKA and THA) using the New York State Hospital Inpatient Cost Transparency database to evaluate the effect of beneficiary health status on hospital reported cost for the two operations. Using the 3M APR-DRG severity of illness index as a measure of patient's health status, we found a significant increase in cost for both TKA and THA for patients with higher severity of illness index. This study confirms the greater cost and variability of TKA and THA for patients with increased severity of illness and illustrates the inherent unpredictability in cost forecasting and budgeting for these same patients.

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

There is currently wide variation in the use and cost of post acute care following total joint arthroplasty. Additionally the optimum setting to which patients should be discharged after surgery is controversial. Discharge patterns following joint replacement vary widely between physicians at our institution, however, only weak correlations were found between the cost of discharge and length of stay or readmission rates. The inter-physician variance in discharge cost did not correlate to a difference in quality, as measured by length of stay and readmission rates, but does imply there is significant opportunity to modify physician discharge practices without impacting patient outcomes and the quality of care.

The effect of severity of disease on cost burden of 30-day readmissions following total joint arthroplasty (TJA)

In order to control the unsustainable rise in healthcare costs the Federal Government is experimenting with the bundled payment model for total joint arthroplasty (TJA). In this risk sharing model, providers are given one payment, which covers the costs of the TJA, as well as any additional medical costs related to the procedure for up to 90 days. The amount and severity of comorbid conditions strongly influence readmission rates and costs of readmissions in TJA patients. We identified 2026 TJA patients from our database with APR-DRG SOI data for use in this study. Both the costs of readmission and the readmission rate tended to increase as severity of illness increased. The readmission burden also increased as SOI increased, but increased most markedly in the extreme SOI patients.

Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution

BACKGROUND

Treatment of Staphylococcus aureus colonization before surgery reduces risk of surgical site infection (SSI). The regimen of nasal mupirocin ointment and topical chlorhexidine gluconate is effective, but cost and patient compliance may be a barrier. Nasal povidone-iodine solution may provide an alternative to mupirocin.

METHODS

We conducted an investigator-initiated, open-label, randomized trial comparing SSI after arthroplasty or spine fusion in patients receiving topical chlorhexidine wipes in combination with either twice daily application of nasal mupirocin ointment during the 5 days before surgery or 2 applications of povidone-iodine solution into each nostril within 2 hours of surgical incision. The primary study end point was deep SSI within the 3 months after surgery.

RESULTS

In the modified intent-to-treat analysis, a deep SSI developed after 14 of 855 surgical procedures in the mupirocin group and 6 of 842 surgical procedures in the povidone-iodine group (P = .1); S. aureus deep SSI developed after 5 surgical procedures in the mupirocin group and 1 surgical procedure in the povidone-iodine group (P = .2). In the per protocol analysis, S. aureus deep SSI developed in 5 of 763 surgical procedures in the mupirocin group and 0 of 776 surgical procedures in the povidone-iodine group (P = .03).

CONCLUSIONS

Nasal povidone-iodine may be considered as an alternative to mupirocin in a multifaceted approach to reduce SSI.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01313182.

Cost burden of 30-day readmissions following Medicare total hip and knee arthroplasty

The Centers for Medicare and Medicaid Services has proposed bundling of payments for acute care episodes for certain procedures, including total joint arthroplasty. The purpose of this study is to quantify the readmission burden of TJA as a function of readmission rate and reimbursement for the bundled payment. Using the hospital's administrative database, we identified all unplanned 30-day readmissions following index admissions for total hip and total knee arthroplasty, and revision hip and knee arthroplasty among Medicare beneficiaries from 2009 to 2012. For each group, we determined 30-day readmission rates and direct costs of each readmission. The hospital cost margins for Medicare TJAs are small and any decrease in these margins can potentially make performing these procedures economically unfeasible potentially decreasing Medicare patient access.

The effect of discharge disposition on 30-day readmission rates after total joint arthroplasty

Previous studies have demonstrated no significant difference in overall functional outcomes of patients discharged to a sub acute setting versus home with health services after total joint arthroplasty. These findings coupled with pressure to reduce health care costs and the implementation of a prospective payment system under Medicare have supported the use of home rehabilitation services and the trend towards earlier discharge after hospitalization. While the overall functional outcome of patients discharged to various settings has been studied, there is a relative dearth of investigation comparing postoperative complications and readmission rates between various discharge dispositions. Our study demonstrated patients discharged home with health services had a significantly lower 30 day readmission rate compared to those discharged to inpatient rehab facilities. Patients discharged to rehab facilities have a higher incidence of comorbidity and this association could be responsible for their higher rate of readmission.

When do readmissions for infection occur after spine and total joint procedures?

BACKGROUND

The episode-of-care concept promulgated by the federal government requires hospitals to assume the cost burden for all care rendered up to 30 days after discharge, including all readmissions occurring in that time. Although surgical site infections (SSIs) are a leading cause of readmission after total joint arthroplasties (TJA) and spine surgery, it is unclear whether these readmissions occur relative to the 30-day period.

QUESTIONS/PURPOSES

We determined whether (1) most readmissions for SSIs occurred in 30 days, (2) the type of procedure performed affected the timing of readmission, and (3) the type of infecting organism influenced the timing of readmission.

METHODS

From our hospital database we identified 91 patients treated with elective TJAs and spine surgery from 2007 through 2010 who were readmitted with SSIs. Of the 91 patients, 46 had undergone spine surgery and 45 had TJAs. For each of these readmissions, we determined the type of surgery, the length of time from initial discharge to readmission, and the type of infecting organism.

RESULTS

Readmissions after spine surgery were more likely to occur within 30 days of discharge (80.4% for spine, 58.3% for TJAs). In the TJA cohort, there was a trend toward readmissions occurring within 30 days of discharge more often in the THA subset. We identified no correlation between type of infecting organism and timing of readmission.

CONCLUSIONS

With the episode-of-care model, SSIs pose a substantial cost burden for hospitals since the majority would be included in the 30-day period included in the bundled reimbursement.