1
|
Kutzner KP, Walz A, Afghanyar Y, Drees P, Schneider M. Calcar-guided short-stem total hip arthroplasty in fractures of the femoral neck: a prospective observational study of 68 hips. Arch Orthop Trauma Surg 2024; 144:1793-1802. [PMID: 38172436 DOI: 10.1007/s00402-023-05170-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION The indications for cementless short-stem total hip arthroplasty (THA) have been expanded due to encouraging results. However, no evidence in cases of femoral neck fractures (FNFs) is available. We aimed to prospectively obtain data on the safety and the clinical outcomes of a cementless calcar-guided short stem in patients with FNFs. MATERIALS AND METHODS We conducted a prospective observational study of 68 patients diagnosed with FNFs who underwent short-stem THA between 2016 and 2019 with a calcar-guided stem. Complications during follow-up leading to revision were documented, and patient reported outcome measurements recorded. Stem migration was analyzed using the Einzel-Bild-Röntgen-Analysis Femoral Component Analysis software. RESULTS The mean follow-up was 33.8 ± 14.8 months. The patient mortality at last follow-up was 10.6%. Two patients required stem revision, due to periprosthetic fracture and late aseptic loosening, respectively, corresponding to 96.2% stem survival. Survivorship for the endpoint of revision for any reason was 91.1% at 6 years. All revisions occurred in females. The mean Harris Hip Score at the last follow-up was 93.0 ± 8.9. The mean axial migration at last follow-up was 1.90 ± 1.81 mm. No significant influence on migration was found regarding gender, age, weight, and body mass index. CONCLUSIONS The clinical and radiological findings were satisfying and most patients benefited from the minimally invasive procedure. However, as for conventional THA as well, implant survivorship and mortality were markedly worse compared to results regarding osteoarthritis. Especially in elderly female patients with FNF, cementless short-stem THA is a concern and a cemented THA should be the first choice.
Collapse
Affiliation(s)
- Karl Philipp Kutzner
- Department of Orthopaedics and Traumatology, St. Josefs Hospital Wiesbaden, Beethovenstr. 20, 65189, Wiesbaden, Germany.
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Alexander Walz
- Department of Orthopaedics and Traumatology, St. Josefs Hospital Wiesbaden, Beethovenstr. 20, 65189, Wiesbaden, Germany
| | - Yama Afghanyar
- Department of Orthopaedics and Traumatology, St. Josefs Hospital Wiesbaden, Beethovenstr. 20, 65189, Wiesbaden, Germany
| | - Philipp Drees
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University of Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Michael Schneider
- Department of Orthopaedics and Traumatology, St. Josefs Hospital Wiesbaden, Beethovenstr. 20, 65189, Wiesbaden, Germany
| |
Collapse
|
2
|
Schiavi P, Pogliacomi F, Bergamaschi M, Ceccarelli F, Vaienti E. Evaluation of Outcome after Total Hip Arthroplasty for Femoral Neck Fracture: Which Factors Are Relevant for Better Results? J Clin Med 2024; 13:1849. [PMID: 38610614 PMCID: PMC11012496 DOI: 10.3390/jcm13071849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/04/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Femoral neck fractures (FNFs) are frequent orthopedic injuries in elderly patients. Despite improvements in clinical monitoring and advances in surgical procedures, 1-year mortality remains between 15% and 30%. The aim of this study is to identify variables that lead to better outcomes in patients treated with total hip arthroplasty (THA) for FNFs. Methods: All patients who underwent cementless THA for FNF from January 2018 to December 2022 were identified. Patients aged more than 80 years old and with other post-traumatic lesions were excluded. Patient data and demographic characteristics were collected. The following data were also registered: time trauma/surgery, surgical approach, operative time, intraoperative complications, surgeon arthroplasty-trained or not, and anesthesia type. In order to search for any predictive factors of better short- and long-term outcomes, we performed different logistic regression analyses. Results: A total of 92 patients were included. From multivariable logistic regression models, we derived that a direct anterior surgical approach and an American Society of Anesthesiologists (ASA) classification < 3 can predict improved short-term outcomes. Moreover, THAs performed by surgeons with specific training in arthroplasty have a lower probability of revision at 1 year. Mortality at 1 year was ultimately influenced by the ASA classification. Conclusions: A direct anterior approach and specific arthroplasty training of the surgeon appear to be able to improve the short- and long-term follow-up of THA after FNF.
Collapse
Affiliation(s)
- Paolo Schiavi
- Orthopedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy; (F.P.); (M.B.); (F.C.); (E.V.)
| | | | | | | | | |
Collapse
|
3
|
Moon TJ, Blackburn CW, Du JY, Marcus RE. What Are the Differences in Hospital Cost Associated With the Use of Cemented Versus Cementless Femoral Stems in Hemiarthroplasty and Total Hip Arthroplasty for the Treatment of Femoral Neck Fracture? J Arthroplasty 2024; 39:313-319.e1. [PMID: 37572717 DOI: 10.1016/j.arth.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 05/29/2023] [Accepted: 08/03/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine if there is a difference in hospital costs associated with the use of cemented versus cementless femoral stems in hemiarthroplasty (HA) and total hip arthroplasty (THA) for the treatment of femoral neck fracture (FNF). METHODS This retrospective cohort study utilizes the 2019 Medicare Provider Analysis and Review Limited Data Set. Patients undergoing arthroplasty for the treatment of FNF were identified. Patients were grouped by cemented or cementless femoral stem fixation. There were 16,148 patients who underwent arthroplasty for FNF available: 4,913 THAs (3,705 patients who had cementless femoral stems and 1,208 patients who had cemented femoral stems) and 11,235 HAs (6,099 patients who had cementless femoral stems and 5,136 who had cemented femoral stems). Index hospital costs were estimated by multiplying total charges by cost-to-charge ratios. Costs were analyzed using univariable and multivariable generalized linear models. RESULTS Cemented femoral stem THA generated 1.080 times (95% confidence interval, 1.06 to 1.10; P < .001), or 8.0%, greater index hospital costs than cementless femoral stem THA, and cemented femoral stem HA generated 1.042 times (95% confidence interval, 1.03 to 1.05; P < .001), or 4.2%, greater index hospital costs than cementless femoral stem HA. CONCLUSIONS Cemented femoral stems for FNF treated with either THA or HA are associated with only a small portion of increased cost compared to cementless femoral stems. Providers may choose the method of arthroplasty stem fixation for the treatment of FNF based on what they deem most appropriate for the specific patient.
Collapse
Affiliation(s)
- Tyler J Moon
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Collin W Blackburn
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jerry Y Du
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Randall E Marcus
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| |
Collapse
|
4
|
Spek RWA, Spekenbrink-Spooren A, Vanhommerig JW, Jonkman N, Doornberg JN, Jaarsma RL, Jutte PC, van der Veen HC, van Noort A, van den Bekerom MPJ. Primary reverse total shoulder arthroplasty for fractures requires more revisions than for degenerative conditions 1 year after surgery: an analysis from the Dutch Arthroplasty Register. J Shoulder Elbow Surg 2023; 32:2508-2518. [PMID: 37327989 DOI: 10.1016/j.jse.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/18/2023] [Accepted: 05/06/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Although reverse total shoulder arthroplasty (RTSA) is considered a viable treatment strategy for proximal humeral fractures, there is an ongoing discussion of how its revision rate compares with indications performed in the elective setting. First, this study evaluated whether RTSA for fractures conveyed a higher revision rate than RTSA for degenerative conditions (osteoarthritis, rotator cuff arthropathy, rotator cuff tear, or rheumatoid arthritis). Second, this study assessed whether there was a difference in patient-reported outcomes between these 2 groups following primary replacement. Finally, the results of conventional stem designs were compared with those of fracture-specific designs within the fracture group. MATERIALS AND METHODS This was a retrospective comparative cohort study with registry data from the Netherlands, generated prospectively between 2014 and 2020. Patients (aged ≥ 18 years) were included if they underwent primary RTSA for a fracture (<4 weeks after trauma), osteoarthritis, rotator cuff arthropathy, rotator cuff tear, or rheumatoid arthritis, with follow-up until first revision, death, or the end of the study period. The primary outcome was the revision rate. The secondary outcomes were the Oxford Shoulder Score, EuroQol 5 Dimensions (EQ-5D) score, numerical rating scale score (pain at rest and during activity), recommendation score, and scores assessing change in daily functioning and change in pain. RESULTS This study included 8753 patients in the degenerative condition group (mean age, 74.3 ± 7.2 years) and 2104 patients in the fracture group (mean age, 74.3 ± 7.8 years). RTSA performed for fractures showed an early steep decline in survivorship: Adjusted for time, age, sex, and arthroplasty brand, the revision risk after 1 year was significantly higher in these patients than in those with degenerative conditions (hazard ratio [HR], 2.50; 95% confidence interval, 1.66-3.77). Over time, the HR steadily decreased, with an HR of 0.98 at year 6. Apart from the recommendation score (which was slightly better within the fracture group), there were no clinically relevant differences in the patient-reported outcome measures after 12 months. Patients who received conventional stems (n = 1137) did not have a higher likelihood of undergoing a revision procedure than those who received fracture-specific stems (n = 675) (HR, 1.70; 95% confidence interval, 0.91-3.17). CONCLUSION Patients undergoing primary RTSA for fractures have a substantially higher likelihood of undergoing revision within the first year following the procedure than patients with degenerative conditions preoperatively. Although RTSA is regarded as a reliable and safe treatment option for fractures, surgeons should inform patients accordingly and incorporate this information in decision making when opting for head replacement surgery. There were no differences in patient-reported outcomes between the 2 groups and no differences in revision rates between conventional and fracture-specific stem designs.
Collapse
Affiliation(s)
- Reinier W A Spek
- Department of Orthopaedic Surgery, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia; Department of Orthopaedic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands; Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands.
| | | | | | - Nini Jonkman
- Department of Epidemiology, OLVG, Amsterdam, The Netherlands
| | - Job N Doornberg
- Department of Orthopaedic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Ruurd L Jaarsma
- Department of Orthopaedic Surgery, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Hugo C van der Veen
- Department of Orthopaedic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Arthur van Noort
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands; Department of Orthopaedic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Michel P J van den Bekerom
- Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands; Shoulder and Elbow Expertise Center, Amsterdam, The Netherlands; Faculty of Behavioral and Movement Sciences, Department of Human Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| |
Collapse
|
5
|
Szymski D, Walter N, Krull P, Melsheimer O, Schindler M, Grimberg A, Alt V, Steinbrueck A, Rupp M. Comparison of mortality rate and septic and aseptic revisions in total hip arthroplasties for osteoarthritis and femoral neck fracture: an analysis of the German Arthroplasty Registry. J Orthop Traumatol 2023; 24:29. [PMID: 37329492 DOI: 10.1186/s10195-023-00711-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/02/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Indications for total hip arthroplasties (THA) differ from primary osteoarthritis (OA), which allows elective surgery through femoral neck fractures (FNF), which require timely surgical care. The aim of this investigation was to compare mortality and revisions in THA for primary OA and FNF. METHODS Data collection for this study was performed using the German Arthroplasty Registry (EPRD) with analysis THA for the treatment of FNF and OA. Cases were matched 1:1 according to age, sex, body mass index (BMI), cementation, and the Elixhauser score using Mahalanobis distance matching. RESULTS Overall 43,436 cases of THA for the treatment of OA and FNF were analyzed in this study. Mortality was significantly increased in FNF, with 12.6% after 1 year and 36.5% after 5 years compared with 3.0% and 18.7% in OA, respectively (p < 0.0001). The proportion for septic and aseptic revisions was significantly increased in FNF (p < 0.0001). Main causes for an aseptic failure were mechanical complications (OA: 1.1%; FNF: 2.4%; p < 0.0001) and periprosthetic fractures (OA: 0.2%; FNF: 0.4%; p = 0.021). As influencing factors for male patients with septic failure (p < 0.002), increased BMI and Elixhauser comorbidity score and diagnosis of fracture (all p < 0.0001) were identified. For aseptic revision surgeries, BMI, Elixhauser score, and FNF were influencing factors (p < 0.0001), while all cemented and hybrid cemented THA were associated with a risk reduction for aseptic failure within 90 days after surgery (p < 0.0001). CONCLUSION In femoral neck fractures treated with THA, a significant higher mortality, as well as septic and aseptic failure rate, was demonstrated compared with prosthesis for the therapy of osteoarthritis. Increased Elixhauser comorbidity score and BMI are the main influencing factors for development of septic or aseptic failure and can represent a potential approach for prevention measures. LEVEL OF EVIDENCE Level III, Prognostic.
Collapse
Affiliation(s)
- Dominik Szymski
- Department for Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Nike Walter
- Department for Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Paula Krull
- Endoprothesenregister Deutschland gGmbH (EPRD), Berlin, Germany
| | | | - Melanie Schindler
- Department for Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | | | - Volker Alt
- Department for Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Arnd Steinbrueck
- Endoprothesenregister Deutschland gGmbH (EPRD), Berlin, Germany
- Orthopädisch Chirurgisches Kompetenzzentrum Augsburg (OCKA), Augsburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| |
Collapse
|
6
|
Innocenti M, Cozzi Lepri A, Civinini A, Mondanelli N, Matassi F, Stimolo D, Cerciello S, Civinini R. Functional Outcomes of Anterior-Based Muscle Sparing Approach Compared to Direct Lateral Approach for Total HIP Arthroplasty Following Acute Femoral Neck Fractures. Geriatr Orthop Surg Rehabil 2023; 14:21514593231170844. [PMID: 37162810 PMCID: PMC10164248 DOI: 10.1177/21514593231170844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/03/2023] [Accepted: 03/31/2023] [Indexed: 05/11/2023] Open
Abstract
Introduction Total hip arthroplasty (THA) performed for femoral neck fractures (FNFs) is becoming a more frequent treatment in the active elderly population. Since there is limited research available presenting clinical outcomes after THA using the anterior-based muscle sparing (ABMS) approach, the aim of this study was to compare this surgical approach to the direct lateral (DL) approach in patients treated by THA for FNFs. Materials and Methods We retrospectively reviewed the data prospectively collected as a part of our "Hip Fracture Unit" and included 163 patients who underwent THA from January 2016 to January 2019 for acute displaced FNFs. Results A total of 132 patients who completed a minimum 2-years follow up (69 in the ABMS group and 63 in DL group) were included. The ABMS group demonstrated significantly shorter time to reach milestone for hospital discharge (1.5 Days vs 2.1 days, P = .018), while no statistically significant differences were detected in peri-operative complications. At 3 months, the timed up and go test, the Harris Hip Score (HHS) and the Oxford ip Score (OHS) were significantly better (P = .024, .032 and .034, respectively) in the ABMS group compared to the DL group. No differences were found in functional outcomes (HHS and OHS) nor in complication rate at 6, 12 and 24 months. Discussion This is one of the first studies to analyze functional results of THA performed for FNFs through an ABMS approach. Results are in line with those already present in the Literature. Conclusion ABMS approach allows earlier mobilization and better early functional outcomes, compared to DL approach, in patients undergoing THA for acute displaced FNF. No differences are found after 6 months in functional results and complications rate.
Collapse
Affiliation(s)
- Matteo Innocenti
- Department of Health Sciences, Orthopedic Unit, University of Florence, Florence, Italy
| | - Andrea Cozzi Lepri
- Department of Health Sciences, Orthopedic Unit, University of Florence, Florence, Italy
| | - Alessandro Civinini
- Department of Health Sciences, Orthopedic Unit, University of Florence, Florence, Italy
| | - Nicola Mondanelli
- Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Fabrizio Matassi
- Department of Health Sciences, Orthopedic Unit, University of Florence, Florence, Italy
| | - Davide Stimolo
- Department of Health Sciences, Orthopedic Unit, University of Florence, Florence, Italy
| | | | - Roberto Civinini
- Department of Health Sciences, Orthopedic Unit, University of Florence, Florence, Italy
| |
Collapse
|
7
|
Verhaegen JCF, Bourget-Murray J, Morris J, Horton I, Arthroplasty Group O, Papp S, Grammatopoulos G. Is outcome of total hip arthroplasty for hip fracture inferior to that of arthritis in a contemporary arthroplasty practice? J Arthroplasty 2023:S0883-5403(23)00201-2. [PMID: 36889530 DOI: 10.1016/j.arth.2023.02.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/22/2023] [Accepted: 02/25/2023] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Outcome of total hip arthroplasty (THA) for femoral neck fractures (FNF) has been associated with higher complication rates. However, THA for FNF is not always performed by arthroplasty-surgeons. This study aimed to compare THA outcomes for FNF to osteoarthritis (OA). In doing so, we described contemporary THA failure modes for FNF performed by arthroplasty surgeons. METHODS This was a retrospective, multi-surgeon study from an academic center. Of FNF treated between 2010 and 2020, 177 received THA by an arthroplasty-surgeon [mean age 67 years (range, 42 to 97), sex: 64.4% women]. These were matched (1:2) for age and sex with 354 THAs performed for hip OA, by the same surgeons. No dual-mobilities were used. Outcomes included radiologic measurements (inclination/anteversion and leg-length), mortality, complications, reoperation rates and patient-reported outcomes including Oxford Hip Score (OHS). RESULTS Post-operative mean leg-length difference was 0 millimeters (mm) (range, -10 to -10 mm), with a mean cup inclination and anteversion of 41 and 26° respectively. There was no difference in radiological measurements between FNF and OA patients (p=0.3). At 5 years follow-up, mortality rate was significantly higher in the FNF-THA compared to the OA-THA group (15.3 vs. 1.1%; p<0.001). There was no difference in complications (7.3 vs. 4.2%; p=0.098) or reoperation rates (5.1 vs. 2.9%; p=0.142) between groups. Dislocation rate was 1.7%. OHS at final follow-up was similar [43.7 points (range, 10 to 48) vs. 43.6 points (range, 10 to 48); p=0.030]. CONCLUSION Total hip arthroplasty for the treatment of FNF is a reliable option and is associated with satisfactory outcomes. Instability was not a common reason of failure, despite not using dual-mobility articulations in this at-risk population. This is likely due to THAs being performed by the arthroplasty staff. When patients live beyond 2-years, similar clinical and radiographic outcomes with low rates of revision can be expected, comparable to elective THA for OA.
Collapse
|
8
|
Malik AT, Yu E, Kim J, Khan SN. Posterior Cervical Fusion for Fracture Is Not the Same as Fusion for Degenerative Cervical Spine Disease: Implications for a Bundled Payment Model. Clin Spine Surg 2023; 36:70-74. [PMID: 36191181 DOI: 10.1097/bsd.0000000000001400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 08/17/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN/SETTING Retrospective. OBJECTIVE To understand differences in 30-day outcomes between patients undergoing posterior cervical fusion (PCF) for fracture versus degenerative cervical spine disease. SUMMARY OF BACKGROUND DATA Current bundled payment models for cervical fusions, such as the Bundled Payments for Care Improvement revolve around the use of diagnosis-related groups to categorize patients for reimbursement purposes. Though a PCF performed for a fracture may have a different postoperative course of care as compared with a fusion being done for degenerative cervical spine pathology, the current DRG system does not differentiate payments based on the indication/cause of surgery. METHODS The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program was queried using Current Procedural Terminology code 22600 to identify patients receiving elective PCFs. Multivariate analyses were used to compare rates of 30-day severe adverse events, minor adverse events, readmissions, length of stay, and nonhome discharges between the 2 groups. RESULTS A total 2546 (91.4%) PCFs were performed for degenerative cervical spine pathology and 240 (8.6%) for fracture. After adjustment for differences in baseline clinical characteristics, patients undergoing a PCF for a fracture versus degenerative pathology had higher odds of severe adverse events [18.8% vs. 10.6%, odds ratio (OR): 1.65 (95% CI, 1.10-2.46); P =0.015], prolonged length of stay >3 days [54.2% vs. 40.5%, OR: 1.93 (95% CI, 1.44-2.59); P <0.001], and nonhome discharges [34.2% vs. 27.6%, OR: 1.54 (95% CI, 1.10-2.17); P =0.012]. CONCLUSIONS Patients undergoing PCFs for fracture have significant higher rates of postoperative adverse events and greater resource utilization as compared with individuals undergoing elective PCF for degenerative spine pathology. The study calls into question the need of risk adjustment of bundled prices based on indication/cause of the surgery to prevent the creation of a financial disincentive when taking care/performing surgery in spinal trauma patients.
Collapse
Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | | |
Collapse
|
9
|
Singh S, Morshed S, Motamedi D, Kidane J, Paul A, Hsiao EC, Wentworth KL. Identification of Risk Factors in the Development of Heterotopic Ossification After Primary Total Hip Arthroplasty. J Clin Endocrinol Metab 2022; 107:e3944-e3952. [PMID: 35451005 PMCID: PMC9387692 DOI: 10.1210/clinem/dgac249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Heterotopic ossification (HO) is a process by which bone forms abnormally in soft tissues. Known risk factors for developing HO include male sex, spinal cord injury, trauma, and surgery. We investigated additional risk factors in the development of HO after hip arthroplasty. METHODS We performed a retrospective review of electronic medical records of 4070 individuals who underwent hip arthroplasty from September 2010 to October 2019 at the University of California, San Francisco Hospital. Demographics, anthropometrics, medications, and comorbid conditions were used in logistic regression analysis to identify factors associated with the development of HO. RESULTS A total of 2541 patients underwent primary hip arthroplasty in the analyzed timeframe (46.04% men, mean age at procedure: 62.13 ± 13.29 years). The incidence of postsurgical HO was 3% (n = 80). A larger proportion of individuals who developed HO had underlying osteoporosis (P < 0.001), vitamin D deficiency (P < 0.001), spine disease (P < 0.001), type 1 or 2 diabetes (P < 0.001), amenorrhea (P = 0.037), postmenopausal status (P < 0.001), parathyroid disorders (P = 0.011), and history of pathologic fracture (P = 0.005). Significant predictors for HO development were Black/African American race [odds ratio (OR) 2.97, P = 0.005], preexisting osteoporosis (OR 2.72, P = 0.001), spine disease (OR 2.04, P = 0.036), and low estrogen states (OR 1.99, P = 0.025). In the overall group, 75.64% received perioperative nonsteroidal anti-inflammatory drugs (NSAIDs), which negatively correlated with HO formation (OR 0.39, P = 0.001). CONCLUSIONS We identified new factors potentially associated with an increased risk of developing HO after primary hip arthroplasty, including African American race, osteoporosis, and low estrogen states. These patients may benefit from HO prophylaxis, such as perioperative NSAIDs.
Collapse
Affiliation(s)
- Sukhmani Singh
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Saam Morshed
- Departments of Orthopedic Surgery, Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Daria Motamedi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Joseph Kidane
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Alexandra Paul
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- The Institute for Human Genetics, The Program in Craniofacial Biology, and the Robert L. Kroc Chair in Rheumatic and Connective Tissue Diseases III, University of California-San Francisco, San Francisco, CA, USA
| | - Kelly L Wentworth
- Correspondence: Kelly Wentworth, MD, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Room 3501A, UCSF Box 0874, San Francisco, CA 94110, USA.
| |
Collapse
|
10
|
Cooper KB, Mears SC, Siegel ER, Stambough JB, Bumpass DB, Cherney SM. The Hip and Femur Fracture Bundle: Preliminary Findings From a Tertiary Hospital. J Arthroplasty 2022; 37:S761-S765. [PMID: 35314286 DOI: 10.1016/j.arth.2022.03.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The voluntary hip and femur fracture Bundled Payments for Care Improvement Advanced (BCPI-A) includes Diagnosis Related Groups (DRG) 480, 481, and 482, which include diverse and medically complex patients undergoing urgent inpatient surgery without optimization. Concern exists that this bundle is financially unfavorable for hospitals, and this study aimed to identify the costliest services. METHODS We retrospectively reviewed a 12-month cohort of 32 consecutive patients in the DRG 480-482 bundle at our academic tertiary referral center. Cost of discharge disposition, readmission, and other variables were analyzed for all patients in the 90-day bundle. RESULTS Overall, a net financial gain averaging $2,028 per patient (range -$52,128 to +$30,199) was seen. Discharge to facilities (n = 19) resulted in higher costs than discharge to home (n = 11, P < .0001). Use of inpatient rehabilitation (n = 6) averaged a loss of $11,028 per patient and use of skilled nursing facilities (n = 15) averaged a loss of $7,250 per patient, compared to a gain of $15,011 for patients discharged home (n = 11). Episodes with readmission (n = 6) averaged a loss of only $1,390. Total index admission costs averaged $12,489 ± $2,235 per patient (range $9,329-$18,884) while post-inpatient cost averaged $30,150 per patient (range $4,803 - $77,768). CONCLUSION The BPCI-A hip and femur fracture bundle has a wide variability in costs, with the largest component in the post-acute care phase. Discharge home is favorable in the bundle while discharge to post-acute facilities leads to net losses. Institutions in this bundle need to develop multi-disciplinary teams to promote safe discharge home.
Collapse
Affiliation(s)
- Kasa B Cooper
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - David B Bumpass
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Steven M Cherney
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| |
Collapse
|
11
|
Wang WL, Lutsky KF, McEntee RM, Banner L, Katt BM, Nakashian MN, Sodha SC, Rivlin M, Beredjiklian PK. Does Undergoing Outpatient Hand Surgery Lead to Prolonged Opioid Use? A Comparison of Surgical and Nonsurgical Patients. Hand (N Y) 2022; 17:701-705. [PMID: 33073584 PMCID: PMC9274888 DOI: 10.1177/1558944720964967] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Orthopedic surgical patients in general have been found to be at higher risk for developing opioid dependence in the postoperative period. However, there is conflicting evidence in the literature whether opioid exposure after hand surgery leads to prolonged use. In the absence of a nonoperative control group, it is not clear whether prolonged opioid use in hand surgical patients is related to undergoing a surgical intervention. The purpose of our study to compare opioid prescription fulfillment patterns in surgical and nonoperative patients in a hand surgery practice. METHODS We retrospectively compared 320 patients that underwent elbow, wrist, and hand surgery procedures with 741 nonoperative patients treated by 2 hand surgeons. The Pennsylvania Drug Monitoring Program (PDMP), a mandatory statewide database, was used to evaluate the primary outcomes of filling more than one opioid prescription and filling opioid prescriptions beyond 6 months of the index surgery or clinic visit. Bivariate and multivariable logistic regression analysis was performed using the following variables: surgery, prior benzodiazepine use, and prior opioid use. RESULTS There was no difference in prior opioid use (15.2% vs 16.9%, P = .51) or prior benzodiazepine (10.4% vs 8.4%, P = .33) use between the nonoperative and operative groups. Patients that underwent surgery had a higher incidence of filling more than one opioid prescription (20.9% vs 8.8%, P < .001). However, continued opioid use was not statistically different between nonoperative and operative patients (2.8% vs 5%, P = .08). Bivariate analysis demonstrated that prior opioids (odds ratio [OR] = 12.94, P < .001) and prior benzodiazepines (OR = 1.95, P < .001) were significant independent risk factors for prolonged opioid use. Multivariable analysis demonstrated prior opioid use to be the only independent risk factor for prolonged opioid use (OR = 12.58, P < .001). CONCLUSION Undergoing outpatient hand surgery do not appear to be an independent risk factor for filling opioid prescriptions beyond 6 months. Significant risk factors for prolonged opioid use include prior use of controlled substances, particularly prior opioid use.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Pedro K. Beredjiklian
- Thomas Jefferson University, Philadelphia, PA, USA,Pedro K. Beredjiklian, Rothman Orthopaedics Institute, Thomas Jefferson University, 925 Chestnut Street, 5 Floor, Philadelphia, PA 19107, USA.
| |
Collapse
|
12
|
DeMik DE, Carender CN, Glass NA, Brown TS, Elkins JM, Bedard NA. Not all Total Hip and Knee Arthroplasties Are the Same: What Are the Implications in Large Database Studies? J Arthroplasty 2022; 37:1247-1252.e2. [PMID: 35271975 DOI: 10.1016/j.arth.2022.02.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/26/2022] [Accepted: 02/28/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The use of claims databases for research after total hip and knee arthroplasty (THA, TKA) has increased exponentially. These studies rely on accurate coding, and inadvertent inclusion of patients with nonroutine indications may influence results. The purpose of this study was to evaluate the complexity of THA and TKA captured by CPT code and determine if complication rates vary based on the indication. METHODS The NSQIP database was queried using CPT codes 21730 and 27447 to identify patients undergoing THA and TKA from 2018 to 2019. The surgical indication was classified based on the ICD-10 diagnosis code as routine primary, complex primary, inflammatory, fracture, oncologic, revision, infection, or indeterminant. Patient factors and 30-day complications, readmission, reoperation, and wound complications were compared. RESULTS A total of 86,009 THA patients had 703 ICD-10 diagnosis codes and 91.4% were routine primary indications. Complication rates were: routine primary 7.4%, complex primary 11.3%, inflammatory 12.5%, fracture 23.9%, oncologic 32.4%, revision 26.9%, infection 38.7%, and indeterminant 10.3% (P < .0001). 137,500 TKA patients had 552 ICD-10 diagnosis codes and 96.1% were routine primary cases. Complication rates were: routine primary 5.9%, complex primary 8.0%, inflammatory 7.2%, fracture 38.9%, oncologic 32.7%, revision 13.3%, infection 37.7%, and indeterminant 9.6% (P < .0001). Routine primary arthroplasty had significantly lower rates of reoperation, readmission, and wound complications. CONCLUSION Using CPT code alone captures 10% of THA and 4% of TKA patients with procedures for nonroutine primary indications. It is essential to recognize identification of patients simply by CPT code has the potential to inadvertently introduce bias, and surgeons should critically assess methods used to define the study populations.
Collapse
Affiliation(s)
- David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | | | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Timothy S Brown
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, Texas
| | - Jacob M Elkins
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | | |
Collapse
|
13
|
Moore HG, Kahan JB, Sherman JJZ, Burroughs PJ, Donohue KW, Grauer JN. Total shoulder arthroplasty for osteoarthritis in patients with Parkinson's disease: a matched comparison of 90-day adverse events and 5-year implant survival. J Shoulder Elbow Surg 2022; 31:1436-1441. [PMID: 35176495 DOI: 10.1016/j.jse.2022.01.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/01/2022] [Accepted: 01/03/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with Parkinson's disease and shoulder osteoarthritis may be indicated for total shoulder arthroplasty. However, short- and long-term outcomes after total shoulder arthroplasty in this population remain poorly characterized. METHODS A retrospective matched case-control study was performed using data abstracted from the 2010-2018 PearlDiver Mariner administrative database. Patients undergoing total shoulder arthroplasty were identified, and those with and without the diagnosis of Parkinson's disease were matched (1:10) based on age, gender, Elixhauser comorbidity index, diabetes, chronic kidney disease, obesity, coronary artery disease, and congestive heart failure. Ninety-day incidence of adverse events were compared with multivariate regressions. Implant survival was also assessed for up to 5 years, based on the occurrence of revision surgery. Kaplan-Meier implant survival curves were compared using a log-rank test. RESULTS In total, 478 patients with Parkinson's disease were matched to 4715 patients without Parkinson's disease. After adjusting for demographic and comorbid factors, patients with Parkinson's disease had significantly higher odds of prosthetic dislocation (odds ratio = 3.07, P = .001), but did not experience increased odds of other 90-day adverse events. Five-year follow-up was available for 428 (89.5%) of those with Parkinson's disease and 3794 (80.5%) of those without Parkinson's disease. There was 97.2% implant survival in the Parkinson's disease cohort and 97.7% implant survival in the matched control cohort (not significantly different, P = .463). CONCLUSIONS Patients with Parkinson's disease undergoing total shoulder arthroplasty, compared with patients without Parkinson's disease, have 3-fold higher odds of periprosthetic dislocation in the 90-day postoperative period, but equivalent rates of other short-term adverse events as well as implant survival at 5 years. Accordingly, surgeons should be mindful of the short-term risk of implant instability but should have confidence in long-term total shoulder implant success in the Parkinson's disease population.
Collapse
Affiliation(s)
| | - Joseph B Kahan
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | | | | | - Kenneth W Donohue
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
14
|
DeKeyser GJ, Martin BI, Ko H, Kahn TL, Haller JM, Anderson LA, Gililland JM. Increased Complications and Cost Associated With Hip Arthroplasty for Femoral Neck Fracture: Evaluation of 576,119 Medicare Patients Treated With Hip Arthroplasty. J Arthroplasty 2022; 37:742-747.e2. [PMID: 34968650 DOI: 10.1016/j.arth.2021.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The benefit of total hip arthroplasty (THA) for treatment of osteoarthritis (OA) and femoral neck fractures (FNFs) in the geriatric population is well established. We compare perioperative complications and cost of THA for treatment of OA to hemiarthroplasty (HA) and THA for treatment of FNF. METHODS Data from the Centers for Medicare & Medicaid Services were used to identify all patients 65 years and older undergoing primary hip arthroplasty between 2013 and 2017. Patients were divided into 3 cohorts: THA for OA (n = 326,313), HA for FNF (n = 223,811), and THA for FNF (n = 25,995). Generalized regressions were used to compare group mortality, 90-day readmission, thromboembolic events, and 90-day episode costs, controlling for age, gender, race, and comorbidities. RESULTS Compared to patients treated for OA, FNF patients were older and had significantly more comorbidities (all P < .001). Even among the youngest age group (65-69 years) without comorbidities, FNF was associated with a greater risk of mortality at 90 days (THA-FNF odds ratio [OR] 9.3, HA-FNF OR 27.0, P < .001), 1 year (THA-FNF OR 7.8, HA-FNF OR 19.0, P < .001) and 5 years (THA-FNF hazard ratio 4.5, HA-FNF hazard ratio 10.0, P < .001). The average 90-day direct cost was $12,479 and $14,036 greater among THA and HA for FNF respectively compared to THA for OA (all P < .001). CONCLUSION Among Centers for Medicare & Medicaid Services hip arthroplasty patients, those with an FNF had significantly higher rates of mortality, thromboembolic events, readmission, and greater direct cost. Reimbursement models for arthroplasty should account for the distinctly different perioperative complication and resource utilization for FNF patients.
Collapse
Affiliation(s)
| | - Brook I Martin
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Hyunkyu Ko
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Timothy L Kahn
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Justin M Haller
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Lucas A Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | | |
Collapse
|
15
|
Pollard TG, Wang KY, Fassihi SC, Gu A, Farley B, Ramamurti P, DeBritz JN, Golladay G, Thakkar SC. Does Prior Lumbar Fusion Influence Dislocation Risk in Hip Arthroplasty Performed for Femoral Neck Fracture? J Arthroplasty 2022; 37:62-68. [PMID: 34592357 DOI: 10.1016/j.arth.2021.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/08/2021] [Accepted: 09/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Immobility of the lumbar spine predicts instability following elective total hip arthroplasty (THA). The purpose of this study is to determine how prior lumbar fusion (LF) influenced dislocation rates and revision rates for patients undergoing THA or hemiarthroplasty (HA) for femoral neck fracture (FNF). METHODS A retrospective cohort analysis was conducted utilizing the PearlDiver database from 2010 to 2018. Patients who underwent arthroplasty for FNF were identified based on history of LF and whether they underwent THA or HA. Univariate and multivariate analyses were performed. RESULTS A total of 328 patients with prior LF and FNF who underwent THA were at increased risk for 1-year dislocation (odds ratio [OR] 2.19, P < .001) and 2-year revision (OR 2.22, P < .001) compared to 14,217 patients without LF. The 461 patients with prior LF and FNF who underwent HA were at increased risk for dislocation (OR 2.22, P < .001) compared to 42,327 patients without LF. Patients with prior LF and FNF who underwent THA had higher rates of revision than patients with prior LF who underwent HA for FNF (OR 2.11, P < .001). In patients with prior LF and FNF, THA was associated with significantly increased risk for dislocation (OR 3.07, P < .001) and revision (OR 2.53, P < .001) compared to THA performed for osteoarthritis. CONCLUSION Patients with prior LF who sustained an FNF and underwent THA or HA were at increased risk for early dislocation and revision compared to those without prior LF. This risk of dislocation and revision is even greater than that observed in patients with prior LF who underwent THA for osteoarthritis. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Tom G Pollard
- Department of Orthopedic Surgery, George Washington University, Washington, DC
| | - Kevin Y Wang
- Johns Hopkins, Department of Orthopaedic Surgery, Adult Reconstruction Division, Columbia, MD
| | - Safa C Fassihi
- Department of Orthopedic Surgery, George Washington University, Washington, DC
| | - Alex Gu
- Department of Orthopedic Surgery, George Washington University, Washington, DC
| | - Benjamin Farley
- Department of Orthopedic Surgery, George Washington University, Washington, DC
| | - Pradip Ramamurti
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville VA, USA
| | - James N DeBritz
- Department of Orthopedic Surgery, George Washington University, Washington, DC
| | - Gregory Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Savyasachi C Thakkar
- Johns Hopkins, Department of Orthopaedic Surgery, Adult Reconstruction Division, Columbia, MD
| |
Collapse
|
16
|
Ledford CK, VanWagner MJ, Spaulding AC, Spencer-Gardner LS, Wilke BK, Porter SB. Outcomes of Femoral Neck Fracture Treated With Hip Arthroplasty in Solid Organ Transplant Patients. Arthroplast Today 2021; 11:212-216. [PMID: 34660866 PMCID: PMC8503575 DOI: 10.1016/j.artd.2021.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/31/2021] [Accepted: 09/08/2021] [Indexed: 11/29/2022] Open
Abstract
Background Solid organ transplant (SOT) patients have increased risk of complications, infection, and mortality after elective total hip arthroplasty (THA). The study aims to compare SOT recipients' clinical outcomes to a matched group of nontransplant patients after nonelective THA and hemiarthroplasty for acute femoral neck fracture (FNF). Methods A retrospective review identified 31 SOT patients undergoing hip arthroplasty (24 hemiarthroplasty and 7 THA) for FNF and were matched 1:1 to non-SOT patients based on age, sex, body mass index, surgical procedure, and year of surgery. Patient survivorship, perioperative outcomes, complications, and reoperations were compared. The mean follow-up was 3 years. Results The estimated survivorship free from mortality for SOT and non-SOT patients at 1- year was not different (77% and 84%, respectively, P = .52). The 90-day readmission rate was significantly higher with 8 (26%) in the SOT cohort and none in the non-SOT group (P < .01). Major medical complications occurred in 16% of SOT patients compared to 5% in controls (P = .21). Three (10%) reoperations/revisions were required for SOT patients and none in non-SOT group (P = .24). Conclusion SOT recipients undergoing nonelective hip arthroplasty for FNF demonstrated increased readmission rates compared to matched controls. For this rare clinical scenario, diligent perioperative care by surgeons and multidisciplinary transplant specialists is necessary to mitigate increased risk of SOT patients.
Collapse
Affiliation(s)
- Cameron K Ledford
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Aaron C Spaulding
- Division of Health Delivery Research, Mayo Clinic, Jacksonville, FL, USA
| | | | - Benjamin K Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
17
|
Moore HG, Justen MA, Kirwin DS, Burroughs PJ, Rubin LE, Grauer JN. Does dehydration prior to primary total joint arthroplasty increase risk of perioperative complications? Arthroplasty 2021; 3:34. [PMID: 35236481 PMCID: PMC8796573 DOI: 10.1186/s42836-021-00090-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prior studies have suggested that preoperative dehydration increases odds of perioperative complications in several areas of orthopedic surgery. This study aimed to evaluate whether preoperative hydration status is associated with the incidence of short-term complications after primary total joint arthroplasty. METHODS The 2012-2019 National Surgical Quality Improvement Program (NSQIP) database was used to explore the relationship between preoperative dehydration (ratio of preoperative BUN divided by preoperative Creatinine (BUN/Creatinine) > 20) and perioperative outcomes of total hip (THA) and total knee arthroplasty (TKA) patients. Univariate comparisons and multivariate regression analyses were conducted to identify specific complications that occurred more often in patients with preoperative dehydration. RESULTS Of 188,629 THA and 332,485 TKA patients, 46.3 and 47.0% had preoperative dehydration, respectively. After controlling for demographics and comorbidities, dehydrated THA patients were no more likely to experience a complication compared to their non-dehydrated counterparts (relative risk [RR] = 0.97, 99.7% Confidence Interval [CI]: 0.92-1.03, P = 0.138) nor increased risk of blood transfusion (RR = 1.02, CI = 0.96-1.08, P = 0.408). Similar to THA patients, dehydrated TKA patients were not more likely to have a complication after surgery (RR = 0.97, CI = 0.92-1.03, P = 0.138) and were at no greater risk of transfusion (RR = 1.02, CI = 0.96-1.07, P = 0.408). A sub-analysis covering only patients with BUN and Cr values determined within 24 h after surgery was performed and similarly found no significant increase in perioperative complications or transfusion. CONCLUSION Overall, preoperative dehydration in patients undergoing THA/TKA did not appear to increase risk of transfusion or other perioperative complications. Further research is needed to characterize the role of hydration prior to elective total joint arthroplasty.
Collapse
Affiliation(s)
| | | | | | | | - Lee E Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06511, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06511, USA.
| |
Collapse
|
18
|
Szczesiul J, Bielecki M. A Review of Total Hip Arthroplasty Comparison in FNF and OA Patients. Adv Orthop 2021; 2021:5563500. [PMID: 34567807 PMCID: PMC8463253 DOI: 10.1155/2021/5563500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/09/2021] [Accepted: 08/07/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Worldwide, total hip arthroplasty (THA) has become one of the most commonly performed surgical procedures. Femoral neck fracture (FNF) and osteoarthritis (OA) are two of the medical conditions necessitating a hip replacement, most frequently carried out. The preoperative and postoperative pathways for patients suffering from these two diseases differ, yet worldwide, many national healthcare systems underestimate or misinterpret the (more than nuanced) care plan differences of the two. Factors and Criteria. Analyzed material was gathered from studies published between 2013 and 2019. Various strands of data demographics, comorbidities, and complications, as well as treatment outcomes, were tabulated to compare and contrast THA patients suffering from FNF and OA to collate their findings. Outcomes were cross-checked and validated for reliability and then were presented in a table format. RESULTS All five retrospective cohort studies fitted the required criteria for inclusion in this work, four US-based study groups and one European-based study group. Data were gathered from three separate databases. The "average" FNF patient is 76.8 years old. There was a 68.96% female probability. The "average" OA patient is 69.15 years old. There was a 5.24% female probability. 59.57% operated for athrosis, and only 34.63% operated for fracture which received grade lower than the third in the American Society of Anaesthesiologist (ASA) classification. There was more than 3 times higher prevalence of complications in the trauma group. FNF patients' hospitalization was approximately 3 days longer. On average, 3.7% of patients operated for trauma and 1.5% of patients with elective THA required a second surgery. 6.57% FNF and 2.93% OA patients had unplanned readmission. CONCLUSIONS In general, patients who suffer a femoral neck fracture are an extremely fragile group. They require additional perioperative and postoperative care. To meet these desired expectations, more FNF cost-comprehensive systems need to be initiated.
Collapse
Affiliation(s)
- Jakub Szczesiul
- Department of Orthopedic, Traumatology and Hand Surgery, Medical University of Białystok, Białystok, Poland
- Department of Orthopedic, Traumatology and Hand Surgery, Uniwersytecki Szpital Kliniczny w Białymstoku, Białystok, Poland
| | - Marek Bielecki
- Department of Orthopedic, Traumatology and Hand Surgery, Medical University of Białystok, Białystok, Poland
- Department of Orthopedic, Traumatology and Hand Surgery, Uniwersytecki Szpital Kliniczny w Białymstoku, Białystok, Poland
| |
Collapse
|
19
|
Gausden EB, Cross WW 3rd, Mabry TM, Pagnano MW, Berry DJ, Abdel MP. Total Hip Arthroplasty for Femoral Neck Fracture: What Are the Contemporary Reasons for Failure? J Arthroplasty 2021; 36:S272-6. [PMID: 33736895 DOI: 10.1016/j.arth.2021.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) for femoral neck fracture (FNF) appears to provide superior functional outcomes compared to hemiarthroplasty in selected active, elderly patients; however, the historical tradeoff has been higher risk of complications including dislocation. We aimed to describe implant survivorship and reasons for failure after THA for FNFs. METHODS We identified 217 FNFs treated with THA from 2000 to 2017 from our institutional total joint registry (during the same time period 2039 FNFs were treated with hemiarthroplasty). Mean age was 70 years, and 65% were female. Cemented femoral components were utilized in 41%. Approach was anterolateral in 71%, posterior in 21%, and direct anterior in 8%. Dual-mobility constructs were utilized in 3%. A competing risk model accounting for death was used to analyze revisions and complications. Mean follow-up was 6 years. RESULTS The 5-year cumulative incidence of any revision was 8%. Nineteen hips were revised for the following indications: postoperative periprosthetic femur fracture (6: 3 uncemented stems and 3 cemented), infection (5), aseptic loosening of the femoral component (3: 2 cemented and 1 uncemented), dislocation (3), iliopsoas impingement (1), and liner dissociation (1). The 5-year cumulative incidence of periprosthetic femur fractures was 7%, including 7 intraoperative fractures and 11 postoperative fractures. The 5-year cumulative incidence of dislocation was 1.4%. CONCLUSION The 5-year cumulative incidence of any revision after THA for FNFs was 8%, mostly attributed to periprosthetic fracture and infection. Hip instability was not as common after FNF with contemporary patient selection, techniques, and implants compared to previous series. LEVEL OF EVIDENCE Prognostic, level III.
Collapse
|
20
|
Uriarte I, Moreta J, Jimenez I, Legarreta MJ, Martínez de Los Mozos JL. Dual-mobility cups in total hip arthroplasty after femoral neck fractures: A retrospective study comparing outcomes between cemented and cementless fixation. Injury 2021; 52:1467-72. [PMID: 33454062 DOI: 10.1016/j.injury.2020.12.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/06/2020] [Accepted: 12/27/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Total hip arthroplasty (THA) after femoral neck fracture (FNF) is associated with an increased risk of dislocation. The goals of our study were (1) to determine dislocation and revision rates when dual-mobility cups (DMCs) are used in these patients, (2) to analyze clinical and radiographic outcomes, survivorship, complications and mortality rate, and (3) to compare results between cemented and cementless cups. PATIENTS AND METHODS We retrospectively reviewed patients with FNF treated using DMC-THA between 2011 and 2018. A minimum 2-year follow-up was required for clinical and radiographic assessment. The clinical outcome was assessed using the Harris Hip Score (HHS) and Merlé D´Aubigné-Postel score (MDP). Radiolucent lines, osteolysis and cup loosening were analyzed. RESULTS We included 105 patients (105 hips) with a mean age of 75.5 years. There were no dislocations. One patient (1.0%) underwent cup revision at 39 months for aseptic cup loosening. The mean HHS and MDP were 80.5 and 14.2 respectively at a mean follow-up of 4.1 years. A higher MDP was found in patients with cementless rather than cemented cups (15.0 vs. 13.1; p = 0.006). Four patients had radiolucent lines > 1 mm, around cemented cups. At 6.8 years, estimated cup survival was 98.2% for revision for aseptic loosening and 97.3% for revision for any reason. The mortality rates were 6.7% at 1 year and 23.8% at last follow-up. CONCLUSION Our findings suggest that using DMC in THA for FNF may prevent dislocation with a low revision rate. Cementless cups had a higher MDP than cemented cups.
Collapse
|
21
|
Affiliation(s)
- Martyn Parker
- Department of Orthopaedics, Peterborough City Hospital, Peterborough, UK
| |
Collapse
|
22
|
Crespo AM, Luthringer TA, Frost A, Khabie L, Roche C, Zuckerman JD, Egol KA. Does reverse total shoulder arthroplasty for proximal humeral fracture portend poorer outcomes than for elective indications? J Shoulder Elbow Surg 2021; 30:40-50. [PMID: 33317704 DOI: 10.1016/j.jse.2020.03.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The number of reverse total shoulder arthroplasties (RTSAs) performed annually has increased, and the indications for RTSA have expanded beyond rotator cuff arthropathy to include treatment of complex proximal humeral fractures. No studies exist comparing clinical, functional, and radiographic outcomes in patients receiving RTSA for the treatment of acute fracture vs. those undergoing the procedure for degenerative conditions. This study was designed to fill the void in this knowledge gap. We hypothesized that patients undergoing RTSA for fracture treatment would experience worse clinical outcomes than those undergoing elective RTSA. METHODS A prospectively collected database was queried for patients undergoing RTSA between 2007 and 2016. Patients were sorted based on the indication for RTSA: treatment of acute proximal humeral fracture vs. "elective" treatment of degenerative conditions of the shoulder. Baseline demographic characteristics, intraoperative and perioperative complications, and clinical, functional, and radiographic outcomes were collected. Only patients with ≥2 years' follow-up were included. Final outcomes were compared between the fracture and elective groups. RESULTS In total, 1984 patients met the inclusion criteria, with 1876 in the elective group and 108 in the fracture group. Compared with the elective RTSA group, the group undergoing RTSA for fracture treatment was older, was female dominant, and was less likely to have undergone a previous operation on the ipsilateral shoulder. RTSA for fracture was associated with a longer hospital length of stay and greater intraoperative blood loss. The incidence of postoperative adverse events was 7.1% in the elective group vs. 4.6% in the fracture group. Functional outcomes did not differ beyond 1 year or at mean final follow-up > 40 months. CONCLUSION Despite differences in patient demographic characteristics, the outcome and complication profiles are similar between patients undergoing RTSA for acute fracture and those indicated for the treatment of degenerative conditions of the shoulder.
Collapse
Affiliation(s)
- Alexander M Crespo
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Tyler A Luthringer
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA.
| | - Alexander Frost
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Lily Khabie
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | | | - Joseph D Zuckerman
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| |
Collapse
|
23
|
Cichos KH, Mabry SE, Spitler CA, McGwin G, Quade JH, Ghanem ES. Comparison Between the Direct Anterior and Posterior Approaches for Total Hip Arthroplasty Performed for Femoral Neck Fracture. J Orthop Trauma 2021; 35:41-48. [PMID: 32618813 DOI: 10.1097/bot.0000000000001883] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare 90-day and 1-year outcomes, including mortality, of femoral neck fracture patients undergoing total hip arthroplasty (THA) by direct anterior approach (DAA) versus posterior approach (PA). DESIGN Retrospective cohort. SETTING Level I Trauma Center. PATIENTS One hundred forty-three consecutive intracapsular femoral neck fractures treated with THA from 2010 to 2018. The minimum follow-up was 12 months, and the average follow-up was 14.6 months (12-72 months). MAIN OUTCOME MEASURES Postoperative outcomes, including discharge ambulation, dislocation, periprosthetic joint infection, revision THA, and mortality at 90 days and 1 year after THA. RESULTS Of the 143 THA included, 44 (30.7%) were performed by DAA while 99 (69.3%) were performed by PA. In-hospital outcomes were similar between the cohorts. Compared with DAA patients, PA patients were more likely to ambulate without assistance preinjury (88.9% vs. 72.7%, P = 0.025) and be nonambulatory at the time of discharge (27.3% vs. 11.4%, P = 0.049). There were no significant differences in 90-day and 1-year postoperative outcomes between the DAA and PA groups, including dislocation, periprosthetic joint infection, periprosthetic fracture, mechanical complications, and revision surgery. Although there was no difference in mortality rate at 90 days, at 1-year follow-up the mortality rate was lower in the DAA group (0% vs. 11.1%, P = 0.018). CONCLUSIONS Performing THA by DAA provides similar benefits in regards to medical and surgical outcomes compared with the PA for displaced femoral neck fracture. However, the DAA may lead to decreased 1-year mortality rates, possibly, because of improved early ambulation capacity that is an important predictor of long-term mortality. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Kyle H Cichos
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Scott E Mabry
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Gerald McGwin
- Department of Epidemiology, UAB School of Public Health, Birmingham, AL
| | - Jonathan H Quade
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Elie S Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| |
Collapse
|
24
|
Henstenburg JM, Lieber AM, Boniello AJ, Kerbel YE, Shah M. Higher complication rates after management of lower extremity fractures in lower socioeconomic classes: Are risk adjustment models necessary? Trauma. [DOI: 10.1177/1460408620975693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
IntroductionAlternative payment models, such as bundled payments, have been proposed to control rising costs in orthopaedic trauma surgery. Without risk adjustment models, concerns exist about the financial burden incurred by so called “safety-net hospitals” that serve patients of lower socioeconomic status. The purpose of this study was to determine whether lower socioeconomic status was associated with increased complications and subsequently higher resource utilization following surgical treatment of high-energy lower extremity fractures.MethodsThe National Inpatient Sample database was queried for patients who underwent surgical fixation of the femur and tibia between 2005–2014. The top and bottom income quartiles were compared. Demographics, medical comorbidities, length of stay (LOS), complications, in-hospital mortality were compared between patients of top and bottom income quartiles. Multivariate logistic regression analysis was then performed to identify factors independently associated with complications, mortality, and increased resource utilization.ResultsPatients with femur fracture in the bottom income quartile had longer length of stay (6.9 days vs 6.5 days, p < 0.001) and a higher mortality rate (1.9% vs 1.7%, p = 0.034). Patients with tibia fracture in the bottom income quartile had greater complication rates (7.3% vs 6.1%, p < 0.001), longer length of stay (5.3 days vs. 4.5 days, p < 0.001), and higher mortality (0.3% vs. 0.2%, p < 0.001).ConclusionsLower income status is associated with increased in-hospital mortality and longer length of stay in patients following lower extremity fractures. Risk adjustment models should consider the role of socioeconomic status in patient resource utilization to ensure continued access to orthopedic trauma care for all patients.
Collapse
|
25
|
Wang Y, Wang C, Hu C, Chen B, Li J, Xi Y. Incidence, Risk Factors, and Nomogram of Transfusion and Associated Complications in Nonfracture Patients following Total Hip Arthroplasty. Biomed Res Int 2020; 2020:2928945. [PMID: 33123567 DOI: 10.1155/2020/2928945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/13/2020] [Accepted: 10/03/2020] [Indexed: 11/17/2022]
Abstract
The incidence, risk factors, and associated complications of perioperative transfusion in nonfracture patients following total hip arthroplasty (THA) are unclear. The aim of the present research was to study the predictors of transfusion risk in nonfracture patients following THA and develop a nomogram. One thousand six hundred and thirty-five patients who underwent THA due to nonfracture disease in our institution between September 2013 and July 2017 were included. Independent predictors of transfusion were identified by univariate, LASSO, and multivariate analyses. A nomogram was established based on independent predictors. In addition, a prospective cohort was used to validate the nomogram. The area under the receiver operating characteristic curve was utilized to evaluate the discrimination of the nomogram. Calibration and decision curve analyses were established to evaluate the nomogram. In addition, the association between perioperative transfusion and 30- and 90-day complications was studied. The incidence of transfusion was 15.78%, and 10 independent predictors were confirmed. The areas under the curve of the nomogram were 0.834 and 0.867 in the training and validation cohorts, respectively. Moreover, the area under the curve of the nomogram was significantly higher than that of any single predictor in both the training and validation cohorts. Calibration curve and decision curve analyses in both the training and validation cohorts showed good performance of the nomogram. In addition, perioperative transfusion was identified as an independent risk factor for both 30- and 90-day complications. Generally, ten transfusion-related factors for nonfracture patients following THA were identified. A validated nomogram was established, and several adverse events were confirmed to be associated with transfusion.
Collapse
|
26
|
Wu VJ, Ross BJ, Sanchez FL, Billings CR, Sherman WF. Complications Following Total Hip Arthroplasty: A Nationwide Database Study Comparing Elective vs Hip Fracture Cases. J Arthroplasty 2020; 35:2144-2148.e3. [PMID: 32229152 DOI: 10.1016/j.arth.2020.03.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/21/2020] [Accepted: 03/01/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The changing evaluation of provider metrics and payments in total hip arthroplasty (THA) necessitates current information for leaders in advocacy and policy. This study aims to use a contemporary nationwide cohort to compare and quantify the differences between the preoperative profile and clinical outcomes of THA performed for elective indications and for femoral neck fractures. METHODS Patient records from 2007 to 2017 were queried from an administrative claims database of privately insured patients comparing THA performed for femoral neck fractures vs elective indications. Ninety-day readmission rates as well as in-hospital and 90-day postdischarge rates of local and systemic complications were collected and compared with multivariate logistic regression. RESULTS Of 83,319 primary THAs, 6895 (8.3%) were fracture cases and 76,424 (91.7%) were elective. A greater proportion of fracture patients were older, female, not obese, and had a higher burden of comorbidities (all P < .001). Fracture patients had significantly higher average lengths of stay and complication rates for all perioperative and postoperative joint and systemic complications measured (all P < .001) as well as 90-day cost (32,228 vs 22,917 USD, P < .001). CONCLUSION Fracture patients are inherently more difficult cases to manage as surgeons. The results of these data may have significance in improving care coordination and provide evidence for further risk adjustment in payment models. Leaders in advocacy and policy should consider patient-level risk adjustments within alternative payment models to account for the increased association of complications, length of stay, readmission rate, and comorbidities in fracture patients receiving THA compared to elective patients.
Collapse
Affiliation(s)
- Victor J Wu
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Bailey J Ross
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Fernando L Sanchez
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Charles R Billings
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| | - William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
| |
Collapse
|
27
|
Malik AT, Sridharan M, Bishop JY, Neviaser AS, Khan SN, Cvetanovich GL. Current diagnosis-related group-based bundling for upper-extremity arthroplasty: a case of insufficient risk adjustment and misaligned incentives. J Shoulder Elbow Surg 2020; 29:e297-e305. [PMID: 32217062 DOI: 10.1016/j.jse.2019.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/10/2019] [Accepted: 12/21/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The current Centers for Medicare & Medicaid Services diagnosis-related group (DRG) bundled-payment model for upper-extremity arthroplasty does not differentiate between the type of arthroplasty (anatomic total shoulder arthroplasty [ATSA] vs. reverse total shoulder arthroplasty vs. total elbow arthroplasty [TEA] vs. total wrist arthroplasty) or the diagnosis and indication for surgery (fracture vs. degenerative osteoarthritis vs. inflammatory arthritis). METHODS The 2011-2014 Medicare 5% Standard Analytical Files (SAF5) database was queried to identify patients undergoing upper-extremity arthroplasty under DRG-483 and -484. Multivariate linear regression modeling was used to assess the marginal cost impact of patient-, procedure-, diagnosis-, and state-level factors on 90-day reimbursements. RESULTS Of 6101 patients undergoing upper-extremity arthroplasty, 3851 (63.1%) fell under DRG-484 and 2250 (36.9%) were classified under DRG-483. The 90-day risk-adjusted cost of an ATSA for degenerative osteoarthritis was $14,704 ± $655. Patient-level factors associated with higher 90-day reimbursements were male sex (+$777), age 75-79 years (+$740), age 80-84 years (+$1140), and age 85 years or older (+$984). Undergoing a TEA (+$2175) was associated with higher reimbursements, whereas undergoing a shoulder hemiarthroplasty (-$1000) was associated with lower reimbursements. Surgery for a fracture (+$2354) had higher 90-day reimbursements. Malnutrition (+$10,673), alcohol use or dependence (+$6273), Parkinson disease (+$4892), cerebrovascular accident or stroke (+$4637), and hyper-coagulopathy (+$4463) had the highest reimbursements. In general, states in the South and Midwest had lower 90-day reimbursements associated with upper-extremity arthroplasty. CONCLUSIONS Under the DRG-based model piloted by the Centers for Medicare & Medicaid Services, providers and hospitals would be reimbursed the same amount regardless of the type of surgery (ATSA vs. hemiarthroplasty vs. TEA), patient comorbidity burden, and diagnosis and indication for surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Lack of risk adjustment for fracture indications leads to strong financial disincentives within this model.
Collapse
Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mathangi Sridharan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julie Y Bishop
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Andrew S Neviaser
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gregory L Cvetanovich
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| |
Collapse
|
28
|
Padilla JA, Gabor JA, Ryan SP, Long WJ, Seyler TM, Schwarzkopf RM. Total Hip Arthroplasty for Femoral Neck Fracture: The Economic Implications of Orthopedic Subspecialty Training. J Arthroplasty 2020; 35:S101-S106. [PMID: 32067895 DOI: 10.1016/j.arth.2020.01.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Hip fractures have significant economic implications as a result of their associated direct and indirect medical costs. Under alternative payment models, it has become increasingly important for institutions to find avenues by which costs could be reduced while maintaining outcomes in these cases. METHODS A multi-institutional retrospective analysis of Medicare patients who underwent total hip arthroplasty (THA) for femoral neck fracture was conducted to assess the impact of fellowship training in adult reconstruction (AR) on the total costs of the 90-day episode of care. Patients were divided into 2 cohorts according to fellowship training status of the operating surgeon: (1) AR-trained and (2) other fellowship training (non-AR). The primary outcome was the total cost of the 90-day episode of care converted to a percentage of the bundled payment target price. RESULTS A total of 291 patients who underwent THA for the treatment of a femoral neck fracture were included. The average total cost percentage of the 90-day episode of care was significantly lower for the AR cohort 70.9% (±36.6%) than the non-AR cohort 82.6% (±36.1%) (P < .01). After controlling for baseline demographics in the multivariable logistic regression, the care episodes in which the operating surgeons were AR fellowship-trained were still found to be significantly lower, at a rate of 0.87 times the costs of the non-AR surgeons (95% confidence interval 0.78-0.97, P = .011). In addition, the non-AR cohort exceeded the bundle target price more frequently than the AR cohort, 49 (28.7%) vs 16 (13.3%) (P = .02). CONCLUSION In an era of bundled payments, ascertaining factors that may increase the value of care while decreasing the cost is paramount for institutions and policymakers alike. The results presented in this study suggest that in the femoral neck fracture population, surgeons trained in AR achieve lower total costs for the THA episode of care. Furthermore, non-AR fellowship-trained surgeons exceeded the bundled payment target more frequently than the AR surgeons.
Collapse
Affiliation(s)
- Jorge A Padilla
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York
| | - Jonathan A Gabor
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - William J Long
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ran M Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| |
Collapse
|
29
|
Trivedi NN, Abola MV, Kim CY, Sivasundaram L, Smith EJ, Ochenjele G. The Incremental Cost of Inpatient Venous Thromboembolism After Hip Fracture Surgery. J Orthop Trauma 2020; 34:169-73. [PMID: 31977669 DOI: 10.1097/BOT.0000000000001675] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To (1) identify trends in the rates of deep venous thrombosis (DVT) and pulmonary embolism (PE) and (2) calculate the additional incremental inpatient cost and length of stay associated with venous thromboembolism (VTE) after hip fracture surgery. DESIGN Retrospective database analysis. SETTING Hospital discharge data. PATIENTS/PARTICIPANTS A total of 838,054 patients undergoing operative treatment of hip fractures in the National Inpatient Sample from 2003 to 2014. INTERVENTION Internal fixation or partial/total hip replacement. MAIN OUTCOME MEASURES The length of stay and cost of hospitalization were compared between patients with VTE and those without using a Student t-test. A logistic regression model was performed to evaluate the trends in VTE rates, and a multivariable linear regression model was performed to evaluate inpatient hospital costs. RESULTS The overall rates of DVT and PE were 0.3% and 0.53%, respectively. VTE was associated with an increased length of stay (9 days vs. 5 days) and increased inpatient cost ($103,860.83 vs. $51,576.00). The rate of DVT over the study period decreased, whereas the rate of PE increased. CONCLUSIONS Each episode of VTE after hip fracture is a significant source of additional inpatient cost. Patients who sustain a VTE have approximately twice the length of stay and total inpatient cost compared with those who do not. The rates of DVT after hip fracture surgery are decreasing, whereas the rates of PE are increasing. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
30
|
Malik AT, Khan SN, Ly TV, Phieffer L, Quatman CE. The "Hip Fracture" Bundle-Experiences, Challenges, and Opportunities. Geriatr Orthop Surg Rehabil 2020; 11:2151459320910846. [PMID: 32181049 PMCID: PMC7059231 DOI: 10.1177/2151459320910846] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 02/10/2020] [Indexed: 12/19/2022] Open
Abstract
Introduction: With growing popularity and success of alternative-payment models (APMs) in elective
total joint arthroplasties, there has been recent discussion on the probability of
implementing APMs for geriatric hip fractures as well. Significance: Despite the growing interest, little is known about the drawbacks and challenges that
will be faced in a stipulated “hip fracture” bundle. Results: Given the varying intricacies and complexities of hip fractures, a “one-size-fits-all”
bundled payment may not be an amenable way of ensuring equitable reimbursement for
participating physicians and hospitals. Conclusions: Health-policy makers need to advocate for better risk-adjustment methods to prevent the
creation of financial disincentives for hospitals taking care of complex, sicker
patients. Hospitals participating in bundled care also need to voice concerns regarding
the grouping of hip fractures undergoing total hip arthroplasty to ensure that trauma
centers are not unfairly penalized due to higher readmission rates associated with hip
fractures skewing quality metrics. Physicians also need to consider the launch of better
risk-stratification protocols and promote geriatric comanagement of these patients to
prevent occurrences of costly adverse events.
Collapse
Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thuan V Ly
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Laura Phieffer
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carmen E Quatman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
31
|
Agarwalla A, Liu JN, Gowd AK, Amin NH, Werner BC. Differential Use of Narcotics in Total Hip Arthroplasty: A Comparative Matched Analysis Between Osteoarthritis and Femoral Neck Fracture. J Arthroplasty 2020; 35:471-476. [PMID: 31564525 DOI: 10.1016/j.arth.2019.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/21/2019] [Accepted: 09/05/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The United States is currently in an opioid epidemic as it consumes the majority of narcotic medications. The purpose of this investigation is to identify the incidence and risk factors for prolonged opioid usage following total hip arthroplasty (THA) due to hip fracture (Fx) or osteoarthritis (OA). METHODS The PearlDiver database was reviewed for patients undergoing THA from 2007 through the first quarter of 2017. Following a 3:1 match based on comorbidities and demographics, patients were divided into THA due to Fx (n = 1801) or OA (n = 5403). Preoperative and prolonged postoperative narcotic users were identified. Multivariate logistic regression analysis was performed to identify demographics, comorbidities, or diagnoses as risk factors for prolonged opioid use and preoperative and postoperative opioid use as risk factors for complications. RESULTS One thousand seven hundred ninety-four OA patients (33.2%) were prescribed narcotics preoperatively and 1655 patients (30.6%) were using narcotics postoperatively, while 418 Fx patients (23.2%) were prescribed narcotics preoperatively and 499 patients (27.7%) were using narcotics postoperatively. Diagnosis of Fx (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.28-1.72, P < .001) and preoperative narcotic use (OR 6.12, 95% CI 5.27-6.82, P < .001) were the most significant risk factors for prolonged postoperative narcotic use. Prolonged postoperative narcotic use was associated with increased infection, dislocation, and revision THA in both Fx and OA groups. CONCLUSION Diagnosis of femoral neck fracture and overall preoperative narcotic use were significant predictors of chronic postoperative opioid use. Patients with significant risk factors for opioid dependence should receive additional consultation and more prudent follow-up with regards to pain management. LEVEL OF EVIDENCE Therapeutic, Level III.
Collapse
Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC
| | - Nirav H Amin
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA
| |
Collapse
|
32
|
Campbell A, Lott A, Gonzalez L, Kester B, Egol KA. Patient-Centered Care: Total Hip Arthroplasty for Displaced Femoral Neck Fracture Does Not Increase Infection Risk. J Healthc Qual 2020; 42:27-36. [PMID: 31895079 DOI: 10.1097/JHQ.0000000000000213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Total hip arthroplasty (THA) is often used for displaced femoral neck fracture. In this study, institutional hip arthroplasty data were compared with the National American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data for any differences in outcomes between our hospital, with an integrated hip fracture care pathway, and those of the country as a whole. METHODS Elective THA was compared with arthroplasty performed for acute fracture. Outcomes for both groups included thromboembolic event (VTE), death, and deep prosthetic infection. RESULTS Institutional data revealed no increased rate of infection after THA for fracture compared with elective. National Surgical Quality Improvement Program analysis revealed higher infection rates in fracture arthroplasty. There was an increased VTE rate in fracture performed for arthroplasty compared with elective in both institutional and NSQIP data. CONCLUSIONS When performed at an academic medical center with an integrated care program, THA for fracture can have similar infection rates to elective THA. By contrast, national data showed significantly higher rates of infection and VTE for arthroplasty for fracture compared with elective. The contrast in complication rates may be related to well-functioning comprehensive interdisciplinary pathways. Patient-centered care pathways may be optimal for hip fracture patients.
Collapse
|
33
|
Malik AT, Phillips FM, Yu E, Khan SN. Are current DRG-based bundled payment models for lumbar fusions risk-adjusting adequately? An analysis of Medicare beneficiaries. Spine J 2020; 20:32-40. [PMID: 31125696 DOI: 10.1016/j.spinee.2019.04.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/05/2019] [Accepted: 04/17/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Current bundled payment programs in spine surgery, such as the bundled payment for care improvement rely on the use of diagnosis-related groups (DRG) to define payments. However, these DRGs may not be adequate enough to appropriately capture the large amount of variation seen in spine procedures. For example, DRG 459 (spinal fusion except cervical with major comorbidity or complication) and DRG 460 (spinal fusion except cervical without major comorbidity or complication) do not differentiate between the type of fusion (anterior or posterior), the levels/extent of fusion, the use of interbody/graft/BMP, indication of surgery (primary vs. revision) or even if the surgery was being performed for a vertebral fracture. PURPOSE We carried out a comprehensive analysis to report the factors responsible for cost-variation in a bundled payment model for spinal fusions. STUDY DESIGN Retrospective review of a 5% national sample of Medicare claims from 2008 to 2014 (SAF5). OUTCOME MEASURES To understand the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day costs for patients undergoing spinal fusions under DRG 459 and 460. METHODS The 2008 to 2014 Medicare 5% standard analytical files (SAF) were used to retrieve patients undergoing spinal fusions under DRG 459 and DRG 460 only. Patients with missing gender, age, and/or state-level data were excluded. Only those patients who had complete data, with regard to payments/costs/reimbursements, starting from day 0 of surgery up to 90 days postoperatively were included to prevent erroneous collection. Multivariate linear regression models were built to assess the independent marginal cost impact (decrease/increase) of each patient-level, state-level, and procedure-level characteristics on the average 90-day cost while controlling for other covariates. RESULTS A total of 21,367 patients (DRG-460=20,154; DRG-459=1,213) were included in the study. The average 90-day cost for all lumbar fusions was $31,716±$18,124, with the individual 90-day payments being $54,607±$30,643 (DRG-459) and $30,338±$16,074 (DRG-460). Increasing age was associated with significant marginal increases in 90-day payments (70-74 years: +$2,387, 75-79 years: +$3,389, 80-84 years: +$2,872, ≥85: +$1,627). With regards to procedure-level factors-undergoing an anterior fusion (+$3,118), >3 level fusion (+$5,648) vs. 1 to 3 level fusion, use of interbody device (+$581), intraoperative neuromonitoring (+$1,413), concurrent decompression (+$768) and undergoing surgery for thoracolumbar fracture (+$6,169) were associated with higher 90-day costs. Most individual comorbidities were associated with higher 90-day costs, with malnutrition (+$12,264), CVA/stroke (+$5,886), Alzheimer's (+$4,968), Parkinson's disease (+$4,415), and coagulopathy (+$3,810) having the highest marginal 90-day cost-increases. The top five states with the highest marginal cost-increase, in comparison to Michigan (reference), were Maryland (+$12,657), Alaska (+$11,292), California (+$10,040), Massachusetts (+$8,800), and the District of Columbia (+$8,315). CONCLUSIONS Under the proposed DRG-based bundled payment model, providers would be reimbursed the same amount for lumbar fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion (1-3 level vs. >3 level), use of adjunct procedures (decompressions) and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated costs. When defining and developing future bundled payments for spinal fusions, health-policy makers should strive to account for the individual patient-level, state-level, and procedure-level variation seen within DRGs to prevent the creation of a financial dis-incentive in taking care of sicker patients and/or performing more extensive complex spinal fusions.
Collapse
Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH 43210, USA.
| | - Frank M Phillips
- Midwest Orthopaedics at Rush, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612, USA
| | - Elizabeth Yu
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH 43210, USA
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH 43210, USA
| |
Collapse
|
34
|
Malik AT, Bishop JY, Neviaser AS, Beals CT, Jain N, Khan SN. Shoulder Arthroplasty for a Fracture Is Not the Same as Shoulder Arthroplasty for Osteoarthritis: Implications for a Bundled Payment Model. J Am Acad Orthop Surg 2019; 27:927-32. [PMID: 30985478 DOI: 10.5435/JAAOS-D-18-00268] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The Center for Medicare Services currently bundles all shoulder arthroplasties, total shoulder arthroplasty and reverse total shoulder arthroplasty, into one Diagnosis-Related Group on which bundled reimbursements are then further characterized. An arthroplasty performed for traumatic indications, such as fractures, may have a different postoperative course of care compared with the one being done for degenerative arthritis/osteoarthritis (OA), despite having the same Current Procedural Terminology (CPT) and Diagnosis-related Group code. METHODS The 2012 to 2016 American College of Surgeons-National Surgical Quality Improvement Program databases were queried using CPT-23472 to retrieve records of patients undergoing total shoulder arthroplasty/reverse total shoulder arthroplasty for degenerative arthritis/OA or proximal humerus fracture. RESULTS A total of 8,283 (92.5%) and 667 (7.5%) patients underwent a shoulder arthroplasty for OA and proximal humeral fracture, respectively. After adjustment, the fracture group was associated with a higher risk for a longer length of stay of >2 days (P < 0.001), 30-day surgical complications (P = 0.005), revision surgeries within 30 days (P = 0.008), 30-day medical complications (P < 0.001), pulmonary embolism (P = 0.013), postoperative transfusions (P < 0.001), non-home discharge (P < 0.001), and 30-day readmissions (P < 0.001). DISCUSSION Shoulder arthroplasty is associated with higher resource utilization when this procedure is performed for a fracture. As we move toward the era of bundled payment models, an appropriate risk adjustment based on the indication of surgery should be promoted to maintain the quality of care for all patients.
Collapse
|
35
|
Abstract
Objective: Ambulatory surgical centers (ASC's) have emerged as an alternative to the traditional hospital- based outpatient department (HOPD). We aim to determine the effect of surgical setting on adverse events following anterior cruciate ligament reconstruction (ACLR).Methods: The Humana Claims Database was queried for all patients undergoing ACLR in the HOPD or ASC setting, using the PearlDiver supercomputer. To eliminate selection bias in our study, the HOPD and ASC cohorts were propensity score matched on baseline demographics, comorbidities, and operative factors. Comparisons between the matched cohorts were made using chi-square tests. Logistic regression models were created to determine the effect of surgical setting on adverse events.Results: A total of 13,647 patients were queried in our study, 5,298 of whom underwent surgery in an ASC and 8,349 of whom underwent surgery in an HOPD. Analysis of the post-matched cohort revealed no differences between cohorts for mechanical failure, nerve injury, pulmonary embolism, septic joint, wound infection, revision surgery and readmission. Rates of deep vein thrombosis (1.18% vs 1.84%; p = .03) were significantly lower in the ASC group. On logistic regression, ASC was associated with decreased risk for deep vein thrombosis (.87, .83-.93) and pulmonary embolism (.85, .78-.95).Conclusion: ACLR performed in ASC is associated with reduced risk of venous thromboembolism and no difference in surgical morbidity and readmissions versus ACLR performed in HOPD. Development of a standardized algorithm for patient selection in the ASC setting is needed to preserve acceptability of ASC-based ACLR in cost-savings and patient safety models.
Collapse
Affiliation(s)
- Charles Qin
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, IL, USA
| | - Mia M Helfrich
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Daniel M Curtis
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, IL, USA
| | - Sherwin Ho
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, IL, USA
| | - Aravind Athiviraham
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, IL, USA
| |
Collapse
|
36
|
Liu JN, Agarwalla A, Gowd AK, Romeo AA, Forsythe B, Verma NN, Nicholson GP. Reverse shoulder arthroplasty for proximal humerus fracture: a more complex episode of care than for cuff tear arthropathy. J Shoulder Elbow Surg 2019; 28:2139-2146. [PMID: 31300365 DOI: 10.1016/j.jse.2019.03.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/27/2019] [Accepted: 03/27/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND The purpose of this investigation is to identify the in-hospital and 30-day postoperative complications for reverse total shoulder arthroplasty (RTSA) performed because of proximal humerus fracture (PHFx) vs. cuff tear arthropathy (CTA), and determine whether acute fracture is associated with differences in complications after RTSA. METHODS The National Surgical Quality Improvement Program database was queried for RTSA performed for PHFx and CTA. This database contains surgical outcomes within 30 days after the index procedure. Patients underwent a 1:1 propensity matched based on preoperative demographics and comorbidities. Outcomes included operative time, length of stay (LOS), complications, transfusion, readmission, and discharge destination. RESULTS A total of 1006 patients (503 per group) were included. With a PHFx, operative time was longer (129.5 ± 54.2 vs. 96.0 ± 40.0 minutes, P < .001), and the patients were more likely to have an adverse event (19.0% vs. 8.2%, P < .001), require transfusion (15.71% vs. 3.98%, P < .001), have longer LOS (3.8 ± 3.6 vs. 2.2 ± 1.7 days, P < .001), and were more likely to be discharged to an extended care facility (27.2% vs. 10.3%, P < .001). PHFx was an independent risk factor for an adverse event after an RTSA. CONCLUSIONS RTSA to treat PHFx is associated with longer LOS, increased complications, and discharge to an extended care facility compared with RTSA for CTA. Patients with PHFx require more health care resources than patients with CTA. It is imperative for surgeons, patients, families, governments, hospital systems, and insurance payers to recognize the differences in resource utilization for RTSA in treating PHFx compared with CTA.
Collapse
Affiliation(s)
- Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University, Baptist Medical Center, Winston-Salem, NC, USA
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, The Rothman Institute, New York, NY, USA
| | - Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
| | - Gregory P Nicholson
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
37
|
Charpentier PM, Srivastava AK, Zheng H, Ostrander JD, Hughes RE. Readmission Rates for One Versus Two-Midnight Length of Stay for Primary Total Knee Arthroplasty: Analysis of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Database. J Bone Joint Surg Am 2019; 100:1757-1764. [PMID: 30334886 DOI: 10.2106/jbjs.18.00166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The length of stay (LOS) in the hospital for total knee arthroplasty (TKA) has been declining over recent decades. The purpose of this study was to determine if patients with an LOS for TKA that includes only 1 midnight have an increased odds of 90-day readmission compared with those with a 2-midnight LOS. We also sought to identify any predictors of 90-day hospital readmission among those readmitted during our period of analysis. METHODS A retrospective review of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was performed to identify patients with a 1-midnight or 2-midnight LOS for TKA during a 5-year period. The primary end point of this study was inpatient readmission within the 90-day postoperative period. A multiple logistic regression model and propensity score matching were used to compare the odds of 90-day readmission between 1-midnight and 2-midnight LOS. The secondary end points of this study were 90-day complications. RESULTS There were 96,250 TKA procedures identified in the database, and 46,709 met our inclusion criteria for LOS. No difference in 90-day-readmission odds between patients with a 1-midnight LOS and those with a 2-midnight LOS for primary TKA was identified. Male sex, single marital status, age of ≥80 years, type-I diabetes, previous smoking, narcotic use prior to surgery, and a higher American Society of Anesthesiologists (ASA) scores increased the odds of 90-day readmission. Patients in the age group of ≥50 to <65 years, those with a higher preoperative hemoglobin level, and those with a positive social history of alcohol use were found to have decreased odds of readmission. CONCLUSIONS We found no association between the LOS for primary TKA (1 midnight compared with 2 midnights) and the 90-day readmission risk. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- P M Charpentier
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia.,Department of Orthopedic Surgery, McLaren Flint Hospital, Flint, Michigan
| | - A K Srivastava
- Department of Orthopedic Surgery, McLaren Flint Hospital, Flint, Michigan.,OrthoMichigan, Flint, Michigan
| | - H Zheng
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - J D Ostrander
- Department of Orthopedic Surgery, McLaren Flint Hospital, Flint, Michigan.,OrthoMichigan, Flint, Michigan
| | - R E Hughes
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
38
|
Malik AT, Phillips FM, Retchin S, Xu W, Yu E, Kim J, Khan SN. Refining risk adjustment for bundled payment models in cervical fusions-an analysis of Medicare beneficiaries. Spine J 2019; 19:1706-1713. [PMID: 31226386 DOI: 10.1016/j.spinee.2019.06.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/05/2019] [Accepted: 06/05/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The current Bundled Payment for Care Improvement model relies on the use of "Diagnosis Related Groups" (DRGs) to risk-adjust reimbursements associated with a 90-day episode of care. Three distinct DRG groups exist for defining payments associated with cervical fusions: (1) DRG-471 (cervical fusions with major comorbidity/complications), (2) DRG-472 (with comorbidity/complications), and (3) DRG-473 (without major comorbidity/complications). However, this DRG system may not be entirely suitable in controlling the large amounts of cost variation seen among cervical fusions. For instance, these DRGs do not account for area/location of surgery (upper cervical vs. lower cervical), type of surgery (primary vs. revision), surgical approach (anterior vs. posterior), extent of fusion (1-3 level vs. >3 level), and cause/indication of surgery (fracture vs. degenerative pathology). PURPOSE To understand factors responsible for cost variation in a 90-day episode of care following cervical fusions. STUDY DESIGN Retrospective study of a 5% national sample of Medicare claims from 2008 to 2014 5% Standard Analytical Files (SAF5). OUTCOME MEASURES To calculate the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day reimbursements for patients undergoing cervical fusions under DRG-471, DRG-472, and DRG-473. METHODS The 2008 to 2014 Medicare SAF5 was queried using DRG codes 471, 472, and 473 to identify patients receiving a cervical fusion. Patients undergoing noncervical fusions (thoracolumbar), surgery for deformity/malignancy, and/or combined anterior-posterior fusions were excluded. Patients with missing data and/or those who died within 90 days of the postoperative follow-up period were excluded. Multivariate linear regression modeling was performed to assess the independent marginal cost impact of DRG, gender, age, state, procedure-level factors (including cause/indication of surgery), and comorbidities on total 90-day reimbursement. RESULTS Following application of inclusion/exclusion criteria, a total of 12,419 cervical fusions were included. The average 90-day reimbursement for each DRG group was as follows: (1) DRG-471=$54,314±$32,643, (2) DRG-472=$28,535±$17,271, and (3) DRG-473=$18,492±$10,706. The risk-adjusted 90-day reimbursement of a nongeriatric (age <65) female, with no major comorbidities, undergoing a primary 1- to 3-level anterior cervical fusion for degenerative cervical spine disease was $14,924±$753. Male gender (+$922) and age 70 to 84 (+$1,007 to +$2,431) was associated with significant marginal increases in 90-day reimbursements. Undergoing upper cervical surgery (-$1,678) had a negative marginal cost impact. Among other procedure-level factors, posterior approach (+$3,164), >3 level fusion (+$2,561), interbody (+$667), use of intra-operative neuromonitoring (+$1,018), concurrent decompression/laminectomy (+$1,657), and undergoing fusion for cervical fracture (+$3,530) were associated higher 90-day reimbursements. Severe individual comorbidities were associated with higher 90-day reimbursements, with malnutrition (+$15,536), CVA/stroke (+$6,982), drug abuse/dependence (+$5,059), hypercoagulopathy (+$5,436), and chronic kidney disease (+$4,925) having the highest marginal cost impacts. Significant state-level variation was noted, with Maryland (+$8,790), Alaska (+$6,410), Massachusetts (+$6,389), California (+$5,603), and New Mexico (+$5,530) having the highest reimbursements and Puerto Rico (-$7,492) and Iowa (-$3,393) having the lowest reimbursements, as compared with Michigan. CONCLUSIONS The current cervical fusion bundled payment model fails to employ a robust risk adjustment of prices resulting in the large amount of cost variation seen within 90-day reimbursements. Under the proposed DRG-based risk adjustment model, providers would be reimbursed the same amount for cervical fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion, use of adjunct procedures (decompressions), and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Our findings suggest that defining payments based on DRG codes only is an imperfect way of employing bundled payments for spinal fusions and will only end up creating major financial disincentives and barriers to access of care in the healthcare system.
Collapse
Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Ave, Columbus, OH 43210, USA.
| | - Frank M Phillips
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Sheldon Retchin
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Wendy Xu
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Elizabeth Yu
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Ave, Columbus, OH 43210, USA
| | - Jeffery Kim
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Ave, Columbus, OH 43210, USA
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 725 Prior Hall, 376 W 10th Ave, Columbus, OH 43210, USA
| |
Collapse
|
39
|
Cantrell WA, Samuel LT, Sultan AA, Acuña AJ, Kamath AF. Operative Times Have Remained Stable for Total Hip Arthroplasty for >15 Years: Systematic Review of 630,675 Procedures. JB JS Open Access 2019; 4:e0047. [PMID: 32043063 PMCID: PMC6959906 DOI: 10.2106/jbjs.oa.19.00047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Understanding trends in operative times has become increasingly important in light of total hip arthroplasty (THA) being added to the Centers for Medicare & Medicaid Services (CMS) 2019 Potentially Misvalued Codes List. The purpose of this review was to explore the mean THA operative times reported in the literature in order (1) to determine if they have increased, decreased, or remained the same for patients reported on between 2000 and 2019 and (2) to determine what factors might have contributed to the difference (or lack thereof) in THA operative time over a contemporary study period. METHODS The PubMed and EBSCOhost databases were queried to identify all articles, published between 2000 and 2019, that reported on THA operative times. The keywords used were "operative," "time," and "total hip arthroplasty." An article was included if the full text was available, it was written in English, and it reported operative times of THAs. An article was excluded if it did not discuss operative time; it reported only comparative, rather than absolute, operative times; or the cohort consisted of total knee arthroplasties (TKAs) and THAs, exclusively of revision THAs, or exclusively of robotic THAs. Data on manual or primary THAs were extracted from studies including robotic or revision THAs. Thirty-five articles reporting on 630,675 hips that underwent THA between 1996 and 2016 met our criteria. RESULTS The overall weighted average operative time was 93.20 minutes (range, 55.65 to 149.00 minutes). When the study cohorts were stratified according to average operative time, the highest number fell into the 90 to 99-minute range. Operative time was stable throughout the years reported. Factors that led to increased operative times included increased body mass index (BMI), less surgical experience, and the presence of a trainee. CONCLUSIONS The average operative time across the included articles was approximately 95 minutes and has been relatively stable over the past 2 decades. On the basis of our findings, we cannot support CMS lowering the procedural valuation of THA given the stability of its operative times and the relationship between operative time and cost.
Collapse
Affiliation(s)
- William A Cantrell
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alexander J Acuña
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| |
Collapse
|
40
|
Qin C, Curtis DM, Reider B, Shi LL, Lee MJ, Athiviraham A. Orthopaedic Shoulder Surgery in the Ambulatory Surgical Center: Safety and Outcomes. Arthroscopy 2019; 35:2545-2550.e1. [PMID: 31421959 DOI: 10.1016/j.arthro.2019.03.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the risk of adverse events and readmission after non-arthroplasty shoulder surgery is influenced by the outpatient setting of surgical care and to identify risk factors associated with these adverse events. METHODS The Humana Claims Database was queried for all patients undergoing arthroscopic shoulder surgery and related open procedures in the hospital-based outpatient department (HOPD) or ambulatory surgical center (ASC) setting, using the PearlDiver supercomputer. Arthroplasty procedures were excluded because they carry a risk profile different from that of other outpatient surgical procedures. Outcome variables included unanticipated admission after surgery, readmission, deep vein thrombosis, pulmonary embolism, and wound infection within 90 days of surgery. The ASC and HOPD cohorts were propensity score matched, and outcomes were compared between them. Finally, logistic regression models were created to identify risk factors associated with unplanned admission after surgery. RESULTS A total of 84,658 patients met the inclusion criteria for the study: 28,730 in the ASC cohort and 56,819 in the HOPD cohort. The rates of all queried outcomes were greater in the HOPD cohort and achieved statistical significance. Sex, region, race, insurance status, comorbidity burden, anesthesia type, and procedural type were included in the regression analysis of unplanned admission. Factors associated with unplanned admission included increasing Charlson Comorbidity Index (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.12-1.17; P < .001); HOPD service location (OR, 2.37; 95% CI, 2.18-2.58; P < .001); general anesthesia (OR, 1.34; 95% CI, 1.08-1.59; P = .008); male sex (OR, 2.58; 95% CI, 2.17-3.15; P = .007); and open surgery (OR, 2.35; 95% CI, 1.90-2.61; P < .001). CONCLUSIONS The lower rates of perioperative morbidity in the ASC cohort suggest that proper patient selection is taking place and lends reassurance to surgeons who are practicing or are considering practicing in an ASC. Patients to whom some or all the risk factors for unplanned admission apply (male sex, higher comorbidity burden, open surgery) may be more suitable for HOPDs because admission from an ASC can be difficult and potentially unsafe. LEVEL OF EVIDENCE Level III, comparative study.
Collapse
Affiliation(s)
- Charles Qin
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, Illinois, U.S.A..
| | - Daniel M Curtis
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, Illinois, U.S.A
| | - Bruce Reider
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, Illinois, U.S.A
| | - Lewis L Shi
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, Illinois, U.S.A
| | - Michael J Lee
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, Illinois, U.S.A
| | - Aravind Athiviraham
- Department of Orthopaedic Surgery and Rehabilitation, University of Chicago, Chicago, Illinois, U.S.A
| |
Collapse
|
41
|
Malik AT, Quatman CE, Strassels S. Outcomes Associated With Overlapping Surgery. JAMA 2019; 322:274-275. [PMID: 31310292 DOI: 10.1001/jama.2019.6463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
42
|
Abstract
Aims The Bundled Payments for Care Improvement (BPCI) initiative has identified pathways for improving the value of care. However, patient-specific modifiable and non-modifiable risk factors may increase costs beyond the target payment. We sought to identify risk factors for exceeding our institution’s target payment, the so-called ‘bundle busters’. Patients and Methods Using our data warehouse and Centers for Medicare and Medicaid Services (CMS) data we identified all 412 patients who underwent total joint arthroplasty and qualified for our institution’s BPCI model, between July 2015 and May 2017. Episodes where CMS payments exceeded the target payment were considered ‘busters’ (n = 123). Risk ratios (RRs) were calculated using a modified Poisson regression analysis. Results An increased risk of exceeding the target payment was significantly associated with increasing age (adjusted RR 1.04, 95% confidence interval (CI) 1.01 to 1.06) and body mass index (adjusted RR 1.03, 95% CI 1.003 to 1.06). Eight comorbid risk factors were also identified (all p < 0.05), only two of which were considered to be potentially modifiable (diabetes with complications and preoperative anaemia). An American Society of Anesthesiologist physical status classification system (ASA) score ≥ 3 (adjusted RR 2.3, 95% CI 1.67 to 3.18) and Charlson Comorbidity Index (CCI) ≥ 3 (adjusted RR 1.94, 95% CI 1.45 to 2.60) were risk factors for bundle busting. Conclusion Non-modifiable preoperative risk factors can increase costs and exceed the target payment. Future bundled payment models should incorporate the stratification of risk. Cite this article: Bone Joint J 2019;101-B(7 Supple C):64–69
Collapse
Affiliation(s)
- A. J. Wodowski
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - C. E. Pelt
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - J. A. Erickson
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - M. B. Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - J. M. Gililland
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - C. L. Peters
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
43
|
Yee P, Tanenbaum JE, Pelle DW, Moore D, Benzel EC, Steinmetz MP, Mroz TE. DRG-based bundled reimbursement for lumbar fusion: implications for patient selection. J Neurosurg Spine 2019; 31:542-547. [PMID: 31252386 DOI: 10.3171/2019.3.spine18875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 03/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Under the Bundled Payments for Care Improvement (BPCI) initiative, Medicare reimburses for lumbar fusion without adjusting for underlying pathology. However, lumbar fusion is a widely used technique that can treat both degenerative and traumatic pathologies. In other surgical cohorts, significant heterogeneity exists in resource use when comparing procedures for traumatic versus degenerative pathologies. If the same were true for lumbar fusion, BPCI would create a financial disincentive to treat specific patient populations. The goal of this study was to compare hospital resource use for lumbar fusion between 2 patient populations: patients with spondylolisthesis and patients with lumbar vertebral fracture. METHODS The authors compared the hospital resource use of two lumbar fusion cohorts that BPCI groups into the same payment bundle for lumbar fusion: patients with spondylolisthesis and patients with lumbar vertebral fracture. National Inpatient Sample data from 2013 were queried for patients who underwent lumbar fusion for lumbar vertebral fracture or spondylolisthesis. Hospital resource use was measured using length of stay (LOS), direct hospital costs, and odds of discharge to a post-acute care facility and compared using multivariable linear and logistic regression. All models adjusted for patient demographics, 29 comorbidities, and hospital characteristics. RESULTS After adjusting for patient demographics, insurance status, hospital characteristics, and 29 comorbidities, spondylolisthesis patients had a mean LOS that was 36% shorter (95% CI 26%-44%, p < 0.0001), a mean cost that was 13% less (95% CI 3.7%-21%, p < 0.0001), and 3.2 times greater odds of being discharged home (95% CI 2.5-5.4, p < 0.0001) than lumbar vertebral fracture patients. CONCLUSIONS Under the proposed DRG (diagnosis-related group)-based BPCI, hospitals would be reimbursed the same amount for lumbar fusion regardless of the diagnosis. However, compared with fusion for spondylolisthesis, fusion for lumbar vertebral fracture was associated with longer LOS, greater direct hospital costs, and increased likelihood of being discharged to a post-acute care facility. These findings suggest that the BPCI episode of care for lumbar fusion dis-incentivizes treatment of trauma patients.
Collapse
Affiliation(s)
- Philina Yee
- 1Center for Spine Health
- 2Case Western Reserve University School of Medicine and
- 3Department of Neurosurgery
| | - Joseph E Tanenbaum
- 1Center for Spine Health
- 2Case Western Reserve University School of Medicine and
- 6Department of Population and Quantitative Health Science, Case Western Reserve University, Cleveland, Ohio
| | | | - Don Moore
- 1Center for Spine Health
- 3Department of Neurosurgery
| | - Edward C Benzel
- 1Center for Spine Health
- 3Department of Neurosurgery
- 4Cleveland Clinic Lerner College of Medicine, Cleveland Clinic; and
| | - Michael P Steinmetz
- 1Center for Spine Health
- 3Department of Neurosurgery
- 4Cleveland Clinic Lerner College of Medicine, Cleveland Clinic; and
| | - Thomas E Mroz
- 1Center for Spine Health
- 3Department of Neurosurgery
- 4Cleveland Clinic Lerner College of Medicine, Cleveland Clinic; and
- 5Department of Orthopaedic Surgery, and
| |
Collapse
|
44
|
Sundaram K, Warren J, Anis H, George J, Murray T, Higuera CA, Piuzzi NS. An increased body mass index was not associated with higher rates of 30-day postoperative complications after unicompartmental knee arthroplasty. Knee 2019; 26:720-728. [PMID: 30902511 DOI: 10.1016/j.knee.2019.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/04/2019] [Accepted: 02/17/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The association of postoperative complications and obesity after total knee arthroplasty (TKA) has been well described. However, the effect of an increased body-mass index (BMI) on postoperative complications after unicompartmental knee arthroplasty (UKA) is controversial. Therefore, our aim was to assess the influence of BMI on 30-day postoperative complications after UKA when analyzed as both a categorical and continuous variable. METHODS The American College of Surgeons National Quality Improvement Program (NSQIP) database was used to identify a total of 8029 patients who underwent UKA from January 1, 2008, to December 31, 2016. The database was queried for over 30 unique complications occurring within 30 days. The impact of BMI on short-term outcomes was assessed as a categorical variable using univariate and multivariate regression. Additionally, BMI was assessed as a continuous variable using spline regressions. RESULTS Univariate regression analysis revealed that compared to normal weight patients, overweight patients had a lower risk of major complication (odds ratio [OR], 0.506; 95% confidence interval [CI], 0.279-0.918; p = 0.025), and any complication ([OR] 0.632; 95% CI, 0.423-0.944; p = 0.025) Multivariate regression analysis found no statistically significant relationship between categorical BMI and complications or outcomes, except for morbidly obese patients who had a greater risk of superficial SSI (p = 0.026). Spline regression found no statistically significant non-linear relationships between BMI and any complication (p = 0.4687), major complications (p = 0.1567), or minor complications (p = 0.4071). CONCLUSION Overweight and obese individuals who undergo UKA may not have an increased risk of 30-day postoperative complications compared to normal weight individuals.
Collapse
Affiliation(s)
- Kavin Sundaram
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave/A41, Cleveland, OH 44195, United States of America.
| | - Jared Warren
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave/A41, Cleveland, OH 44195, United States of America.
| | - Hiba Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave/A41, Cleveland, OH 44195, United States of America.
| | - Jaiben George
- All-Indian Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Trevor Murray
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave/A41, Cleveland, OH 44195, United States of America.
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave/A41, Cleveland, OH 44195, United States of America.
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave/A41, Cleveland, OH 44195, United States of America; Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| |
Collapse
|
45
|
Hevesi M, Wyles CC, Yao JJ, Maradit-Kremers H, Habermann EB, Glasgow AE, Bews KA, Ransom JE, Visscher SL, Lewallen DG, Berry DJ. Revision Total Hip Arthroplasty for the Treatment of Fracture: More Expensive, More Complications, Same Diagnosis-Related Groups: A Local and National Cohort Study. J Bone Joint Surg Am 2019; 101:912-919. [PMID: 31094983 DOI: 10.2106/jbjs.18.00523] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Revision total hip arthroplasty (revision THA) occurs for a wide variety of indications and in the United States it is coded under Diagnosis-Related Groups (DRGs) 466, 467, and 468, which do not account for revision etiology, a potentially substantial driver of cost. This study investigates revision THA costs and 30-day complications by indication, both locally and nationally. METHODS Hospitalization costs and complication rates for 1,422 aseptic revision THAs performed at a high-volume center between 2009 and 2014 were retrospectively reviewed. Additionally, charges for 28,133 revision THAs in the National Inpatient Sample (NIS) were converted to costs using the Healthcare Cost and Utilization Project cost-to-charge ratios, and 30-day complication rates for 3,224 revision THAs were obtained with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Costs and complications were compared between revision THAs performed for fracture, wear/loosening, and dislocation/instability with use of simultaneous and pairwise comparisons and a multivariable model accounting for American Society of Anesthesiologists (ASA) score, age, and sex. RESULTS Local hospitalization costs for fracture (median, $25,672) were significantly higher than those for wear/loosening ($20,228; p < 0.001) or dislocation/instability ($17,911; p < 0.001), with differences remaining significant even after adjusting for patient comorbidities (p < 0.001). NIS costs for fracture (median, $27,596) were higher than those for other aseptic indications (wear/loosening: $21,176, p < 0.001; dislocation/instability: $16,891, p< 0.001). Local 30-day orthopaedic complication rates for fracture (20.7%) were higher those than for dislocation/instability (9.0%; p = 0.007) and similar to those for wear/loosening (17.6%; p = 0.434). Nationally, combined medical and surgical complication rates for fracture (71.3% of patients with ≥1 complication) were significantly higher than those for wear/loosening (35.2%; p < 0.001) or dislocation/instability (35.1%; p < 0.001). CONCLUSIONS Hospitalization costs for revision THA for fracture were 33% to 48% higher than for all other aseptic revision THAs, both locally and nationally. This increased cost persisted even after multivariable comorbidity adjustment, the current DRG basis for stratifying revision THA reimbursement. Additionally, 30-day complication rates suggest that increased resource utilization for fracture patients continues even after discharge. Indication-specific coding and reimbursement systems are necessary to maintain sustainable access to revision THA for all patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Mario Hevesi
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - Cody C Wyles
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - Jie J Yao
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - Hilal Maradit-Kremers
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - Amy E Glasgow
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - Katherine A Bews
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - Jeanine E Ransom
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - Sue L Visscher
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - David G Lewallen
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
46
|
Tan TL, Courtney PM, Brown SA, Shohat N, Sobol K, Swanson KE, Abraham J. Risk Adjustment Is Necessary in Value-Based Payment Models for Arthroplasty for Oncology Patients. J Arthroplasty 2019; 34:626-631.e1. [PMID: 30612832 DOI: 10.1016/j.arth.2018.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Value-based payment models such as bundled payments have been introduced to reduce costs following total hip arthroplasty (THA). Concerns exist, however, about access to care for patients who utilize more resources. The purpose of this study is thus to compare resource utilization and outcomes of patients undergoing THA for malignancy with those undergoing THA for fracture or osteoarthritis. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program database to identify all hip arthroplasties performed from 2013 to 2016 for a primary diagnosis of malignancy (n = 296), osteoarthritis (n = 96,480), and fracture (n = 13,406). The rates of readmissions, reoperations, comorbidities, mortality, and surgical characteristics were compared between the 3 cohorts. To control for confounding variables, a multivariate analysis was performed to identify independent risk factors for resource utilization and outcomes following THA. RESULTS Patients undergoing THA for malignancy had a longer mean operative time (155.7 vs 82.9 vs 91.0 minutes, P < .001), longer length of stay (9.0 vs 7.2 vs 2.6 days, P < .001), and were more likely to be discharged to a rehabilitation facility (42.1% vs 61.8% vs 20.2%, P < .001) than patients with fracture or osteoarthritis. When controlling for demographics and comorbidities, patients undergoing THA for malignancy had a higher rate of readmission (adjusted odds ratio 3.39, P < .001) and reoperation (adjusted odds ratio 3.71, P < .001). CONCLUSION Patients undergoing THA for malignancy utilize more resources in an episode-of-care and have worse outcomes. Risk adjustment is necessary for oncology patients in order to prevent access to care problems for these high-risk patients.
Collapse
Affiliation(s)
- Timothy L Tan
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Paul Maxwell Courtney
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Scot A Brown
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Noam Shohat
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keenan Sobol
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Karl E Swanson
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - John Abraham
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| |
Collapse
|
47
|
Surace P, Sultan AA, George J, Samuel LT, Khlopas A, Molloy RM, Stearns KL, Mont MA. The Association Between Operative Time and Short-Term Complications in Total Hip Arthroplasty: An Analysis of 89,802 Surgeries. J Arthroplasty 2019; 34:426-432. [PMID: 30528133 DOI: 10.1016/j.arth.2018.11.015] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It has been established by previous studies that longer operative times can lead to higher rates of complications and poorer outcomes after total hip arthroplasty (THA). However, these studies were heterogeneous, examined limited complications, and have not provided a clear time after which complications increase. The aims of this study were to (1) assess whether longer operative time increases risk of complications within 30 days of THA, (2) investigate the relationship between operative time and various complications after THA, and (3) identify possible operative times beyond which complication rates increase. METHODS The National Surgical Quality Improvement Project database was queried to identify 89,802 procedures that were included in the final analysis. The effect of operative time on complications within 30 days was evaluated using multivariate logistic regression models. Spline regression models were created to investigate the relationship between operative time and complications. RESULTS Longer operative times were associated with higher risk of readmissions (P < .001), reoperations (P < .001), surgical site infection (P < .001), wound dehiscence (P < .001), renal or systemic complications (P < .001), and blood transfusion (P < .001). A linear relationship was observed between operative time and readmission, reoperation, surgical site infection, and transfusions with increased rate of these complications when the operative time exceeded 75 to 80 minutes. Venous thromboembolic complications had a U-shaped relationship with operative time with the trough around 90 to 100 minutes. CONCLUSION While our findings cannot establish a clear cause and effect relation, they do suggest strong correlation between increased operative time and perioperative complications. Additionally, this study suggests an optimal time of approximately 80 minutes, as a goal for surgeons, that may be associated with less risk of complications following THA.
Collapse
Affiliation(s)
- Peter Surace
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Jaiben George
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Kim L Stearns
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH; Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
| |
Collapse
|
48
|
Abstract
The optimal treatment of recent femoral neck fractures remains debated. The available options are internal fixation, hemiarthroplasty (HA) and total hip arthroplasty (THA). There is a consensus in favour of internal fixation in younger patients. In elderly individuals who are institutionalised and have limited physical activity, HA is usually performed when the joint line is intact. Whether HA or THA deserves preference in patients aged 60 years or over is unclear. In addition, there are two types of HA, unipolar and bipolar, and two types of THA, conventional and dual-mobility. Both HA types provide similar outcomes with satisfactory stability but a risk of acetabular wear that may eventually require conversion to THA. THA is associated with better functional outcomes and a lower risk of revision surgery in self-sufficient, physically active patients. Instability is the leading complication of conventional THA and occurs with a higher incidence compared to HA. With all implant types, preoperative factors associated with mortality and complications include walking ability and level of self-sufficiency, nutritional status, and haematocrit. An evaluation of these factors before surgery is of paramount importance. Factors amenable to treatment should be corrected by working jointly with geriatricians to develop a preoperative management strategy. In patients who are self-sufficient, physically active, and free of risk factors, THA remains the option of choice, as it provides better functional outcomes. A dual-mobility implant deserves preference to prevent instability. HA is indicated in patients whose self-sufficiency and physical activity are limited. A unipolar implant should be used, as no evidence exists that bipolar implants provide additional benefits. When performing HA, the posterior approach should be avoided given the risk of instability. For THA, in contrast, the posterior approach is a reliable option in the hands of an experienced surgeon using a dual-mobility cup. Cement fixation of the stem is recommended to minimise the risk of peri-prosthetic fracture.
Collapse
Affiliation(s)
- Olivier Guyen
- Service d'orthopédie-traumatologie, hôpital Orthopédique - CHUV, avenue Pierre-Decker 4, 1011 Lausanne, Switzerland.
| |
Collapse
|
49
|
Dimitriou D, Helmy N, Hasler J, Flury A, Finsterwald M, Antoniadis A. The Role of Total Hip Arthroplasty Through the Direct Anterior Approach in Femoral Neck Fracture and Factors Affecting the Outcome. J Arthroplasty 2019; 34:82-87. [PMID: 30262445 DOI: 10.1016/j.arth.2018.08.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/26/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Femoral neck fractures (FNFs) are a significant cause of mortality and disability among the elderly population. Total hip arthroplasty (THA) is the preferred treating method in active, cognitively intact patients. The direct anterior approach (DAA) has suggested a lower dislocation risk and a significant reduction in postoperative pain and recovery time in elective THA. This study aimed to compare clinical outcomes, perioperative complications, and mortality of THA through the DAA between FNF and elective cases. METHODS Patients with displaced FNF (n = 150) who received THA through the DAA were matched for gender, age, body mass index, and American Society for Anesthesiologists score with electively treated patients (n = 150). The perioperative complications, clinical and radiologic outcomes, as well as mortality were compared between groups, retrospectively. RESULTS FNF patients had an increased blood loss, operation duration, hospital stay, and mortality but similar surgery-related complication rates compared to their elective counterparts. The mortality was, however, lower than that reported in the literature. Age, American Society for Anesthesiologists score, and time-to-operation affected the duration of hospital stay and mortality. Less experienced surgeons did not have increased surgery-related complications, but longer operation time and higher blood loss compared to experienced surgeons. CONCLUSION THA through the DAA might be a credible and safe option for patients presenting an FNF, with excellent functional outcomes, less surgery-related complications, and lower short-term and long-term mortality than those reported in the literature. Early intervention and perioperative stabilization of the patients with FNF could potentially increase the survival rate.
Collapse
Affiliation(s)
- Dimitris Dimitriou
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Naeder Helmy
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Julian Hasler
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Andreas Flury
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Michael Finsterwald
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Alexander Antoniadis
- Department of Orthopaedics and Traumatology, Bürgerspital Solothurn, Solothurn, Switzerland
| |
Collapse
|
50
|
Cairns MA, Moskal PT, Eskildsen SM, Ostrum RF, Clement RC. Are Medicare's "Comprehensive Care for Joint Replacement" Bundled Payments Stratifying Risk Adequately? J Arthroplasty 2018; 33:2722-2727. [PMID: 29807786 DOI: 10.1016/j.arth.2018.04.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/28/2018] [Accepted: 04/02/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Bundled payments are meant to reduce costs and improve quality of care. Without adequate risk adjustment, bundling may be inequitable to providers and restrict access for certain patients. This study examines patient factors that could improve risk stratification for the Comprehensive Care for Joint Replacement (CJR) bundled-payment program. METHODS Ninety-five thousand twenty-four patients meeting the CJR criteria were retrospectively reviewed using administrative Medicare data. Multivariable regression was used to identify associations between patient factors and traditional (fee-for-service) Medicare reimbursement over the bundle period. RESULTS Average reimbursement was $18,786 ± $12,386. Older age, male gender, cases performed for hip fractures, and most comorbidities were associated with higher reimbursement (P < .05), except dementia (lower reimbursement; P < .01). Stratification incorporating these factors displayed greater accuracy than the current CJR risk adjustment methods (R2 = 0.23 vs 0.17). CONCLUSION More robust risk stratification could provide more equitable reimbursement in the CJR program. LEVEL OF EVIDENCE Large database analysis; Level III.
Collapse
Affiliation(s)
- Mark A Cairns
- Department of Orthopaedics, University of North Carolina Health Care, Durham, North Carolina
| | - Peter T Moskal
- Department of Orthopaedics, University of North Carolina Health Care, Durham, North Carolina
| | - Scott M Eskildsen
- Department of Orthopaedics, University of North Carolina Health Care, Durham, North Carolina
| | - Robert F Ostrum
- Department of Orthopaedics, University of North Carolina Health Care, Durham, North Carolina
| | - R Carter Clement
- Department of Orthopaedics, University of North Carolina Health Care, Durham, North Carolina
| |
Collapse
|