Scoping Review: Anesthesiologist Involvement in Alternative Payment Models, Value Measurement, and Nonclinical Capabilities for Success in the United States of America.

The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.

Frameworks for value-based care in the nonoperating room setting.

PURPOSE OF REVIEW: Nonoperating room anesthesia (NORA) presents a unique opportunity for the application of value-based care (VBC) principles to procedures performed in the office-based and nonoperating room inpatient settings. The purpose of this article is to review how value is defined in NORA and enabling principles by which anesthesiologists can maximize value in NORA. RECENT FINDINGS: In order to drive value, NORA providers can target improvements in clinical outcomes where NORA lags behind operating room-based anesthesia (death, over-sedation, nerve injury), implement protocols focusing on intermediate outcomes/quality (postoperative nausea and vomiting, pain control, hypothermia, delirium), incorporate patient-reported outcomes (PROs) to assess the trajectory of a patient's perioperative care, and reduce costs (direct and indirect) through operational and supply-based efficiencies. Establishing a culture of patient and provider safety first, appropriate patient selection with targeted, perioperative optimization of comorbidities, and efficient deployment of staff, space, and resources are critical enablers for success. SUMMARY: Value in NORA can be defined as clinical outcomes, quality, patient-reported outcomes, and efficiency divided by the direct and indirect costs for achieving those outcomes. We present a novel framework adapting current VBC practices in operating room anesthesia to the NORA environment.

Surgical Scheduling Impacts Hospital Length of Stay and Associated Healthcare Costs for Patients Undergoing Total Hip and Knee Arthroplasty.

Background: Surgical scheduling, specifically the day of the week on which surgery is performed, has been associated with various postoperative outcomes in patients undergoing lower extremity joint arthroplasty. Purpose: We sought to investigate surgical scheduling as a potential modifiable factor for patient quality metrics and related costs. Methods: In a retrospective prognostic study, all total knee and total hip arthroplasty (TKA/THA) cases that took place in 2017 to 2018 at a multihospital academic health system were queried. Patients were separated by the day of the week the surgery was performed, with Monday/Tuesday compared to Thursday/Friday. Outcomes included length of stay (LOS) (extended LOS defined as 3 days or longer), cost, and complications. Multivariable regression models measured associations between scheduling of surgery and outcomes; odds ratios (OR) and 95% confidence intervals (CIs) are reported. Results: Overall, 1,571 TKA and 992 THA patients were included (65% and 35%, respectively, performed on Monday/Tuesday and 70% and 30%, respectively, performed on Thursday/Friday). Patients undergoing TKA on Monday/Tuesday versus Thursday/Friday had higher American Society of Anesthesiologists scores (42% vs 33% with score of 3 or higher) but less often an extended LOS (31% vs 54%; adjusted OR: 2.76, 95% CI: 2.22-3.46), lower skilled nursing facility costs (unadjusted mean, $12,515 vs $14,154) and lower home health aide costs (unadjusted mean, $3,793 vs $4,192). Similar patterns were observed in THA patients. Conclusion: These results from institutional data suggest that surgical scheduling is a modifiable factor possibly associated with postoperative outcomes. Furthermore, more rigorous study is warranted.

Barriers to Collection and Use of Patient-Reported Outcomes A Multi-Institutional Survey of Surgeons and Care Teams.

BACKGROUND: Currently there is a lack of insight into what total joint replacement (TJR) surgeons and care teams perceive to be the greatest barriers to collection and use of patient reported outcomes (PROs). The goal of this study was to provide insight on this topic using a multi-institutional survey. METHODS: A thorough literature review on PROs adoption and utilization was conducted to generate a 26-question survey. This survey was disseminated to joint replacement surgeons, associate providers (e.g., nurse practitioners and physician assistants), and other non-clinical health care staff involved in PRO collection at three institutions. Data from all respondents were analyzed qualitatively and using chi-square tests. RESULTS: Of 37 responses, 24 (65%) were from orthopedic surgeons and 13 (35%) from other clinical and administrative staff. Seventy-one percent of surgeons thought that integration into clinical workflow was the greatest barrier to initial implementation of PROs, while the greatest long-term limitations were accessibility (50%), patient engagement and compliance (50%), ability to represent their health in PROs (54%), and consistency across providers (50%). For PROs to be clinically useful, surgeons required that they should be linked to the EMR interface (65%), immediately available (59%), and are trended over time (59%). Fifty-four percent of surgeons across institutions believed administrative leadership was ultimately responsible for successful PROs implementation, while 46% of other staff believed that responsibility fell to surgeons and clinical staff. CONCLUSION: Surgeons perceive that the greatest barriers to PRO collection are workflow integration initially, and patient engagement, compliance, and ability to represent their health in PROs over the long term. Stakeholders inconsistently report which group is responsible for successful implementation.

Orthopedic Surgeon and Care Team Perceptions and Use of Patient-Reported Outcomes in Total Joint Replacement Patients.

BACKGROUND: The recent shift toward value-based health care and bundled payments in orthopedic surgery has increased the use patient-reported outcomes (PROs) in standard clinical care. Such assessments of patient function and satisfaction are particularly important among total joint arthroplasty (TJA) patients to monitor postoperative health. PURPOSE: The purpose of this study was to assess orthopedic care team perceptions of current and future PRO usage and compare current rates and modes of PRO collection between three urban, academic health care systems. METHODS: A literature search was conducted on current PRO uses and barriers to their adoption to generate a 26-question survey. The survey was disseminated to orthopedic surgeons and care team members at three academic health care institutions (institutions A, B, and C). Responses were analyzed for qualitative and quantitative insights. RESULTS: Among institutions A, B, and C, PRO collection generally declined from baseline (60%, 90%, 89%) to 6 weeks (67%, 82%, 71%) and 3 months postoperatively (44%, 36%, 47%). However, there were large variations in reported PRO collection intervals among institutions. Respondents reported assessing patient baseline functional status as the most useful current application of PROs and cited the prediction of patient benefit from TJA as the most useful future application for PROs. Though respondents were largely optimistic about PRO utility in clinical care, a small minority remained skeptical. CONCLUSIONS: Perceptions of PRO utilization and collection intervals varied considerably among respondents. For PROs to be an accurate and useful clinical tool, standardization and thorough understanding of PRO collection among orthopedic care team members is essential.

Trends in Periprosthetic Knee Infection and Associated Costs: A Population-Based Study Using National Data.

Given increasing demand for primary knee arthroplasties, revision surgery is also expected to increase, with periprosthetic joint infection (PJI) a main driver of costs. Recent data on national trends is lacking. We aimed to assess trends in PJI in total knee arthroplasty revisions and hospitalization costs. From the National Inpatient Sample (2003-2016), we extracted data on total knee arthroplasty revisions (n = 782,449). We assessed trends in PJI prevalence and (inflation-adjusted) hospitalization costs (total as well as per-day costs) for all revisions and stratified by hospital teaching status (rural/urban by teaching status), hospital bed size (≤299, 300-499, and ≥500 beds), and hospital region (Northeast, Midwest, South, and West). The Cochran-Armitage trend test (PJI prevalence) and linear regression determined significance of trends. PJI prevalence overall was 25.5% (n = 199,818) with a minor increasing trend: 25.3% (n = 7,828) in 2003 to 28.9% (n = 19,275) in 2016; p < 0.0001. Median total hospitalization costs for PJI decreased slightly ($23,247 in 2003-$20,273 in 2016; p < 0.0001) while median per-day costs slightly increased ($3,452 in 2003-$3,727 in 2016; p < 0.0001), likely as a function of decreasing length of stay. With small differences between hospitals, the lowest and highest PJI prevalences were seen in small (≤299 beds; 22.9%) and urban teaching hospitals (27.3%), respectively. In stratification analyses, an increasing trend in PJI prevalence was particularly seen in larger (≥500 beds) hospitals (24.4% in 2003-30.7% in 2016; p < 0.0001), while a decreasing trend was seen in small-sized hospitals. Overall, PJI in knee arthroplasty revisions appears to be slightly increasing. Moreover, increasing trends in large hospitals and decreasing trends in small-sized hospitals suggest a shift in patients from small to large volume hospitals. Decreasing trends in total costs, alongside increasing trends in per-day costs, suggest a strong impact of length of stay trends and a more efficient approach to PJI over the years (in terms of shorter length of stay).

Comparison of machine learning techniques to predict unplanned readmission following total shoulder arthroplasty.

BACKGROUND: Machine learning (ML) techniques have been shown to successfully predict postoperative complications for high-volume orthopedic procedures such as hip and knee arthroplasty and to stratify patients for risk-adjusted bundled payments. The latter has not been done for more heterogeneous, lower-volume procedures such as total shoulder arthroplasty (TSA) with equally limited discussion around strategies to optimize the predictive ability of ML algorithms. The purpose of this study was to (1) assess which of 5 ML algorithms best predicts 30-day readmission, (2) test select ML strategies to optimize the algorithms, and (3) report on which patient variables contribute most to risk prediction in TSA across algorithms. METHODS: We identified 9043 patients in the American College of Surgeons National Surgical Quality Improvement Database who underwent primary TSA between 2011 and 2015. Predictors included demographics, comorbidities, laboratory data, and intraoperative variables. The outcome of interest was 30-day unplanned readmission. Five ML algorithms-support-vector machine (SVM), logistic regression, random forest (RF), an adaptive boosting algorithm, and neural network-were trained on the derivation cohort (2011-2014 TSA patients) to predict 30-day unplanned readmission rates. After training, weights for each respective model were fixed and the classifiers were evaluated on the 2015 TSA cohort to simulate a prospective evaluation. C-statistic and f1 scores were used to assess the performance of each classifier. After evaluation, features were removed independently to assess which features most affected classifier performance. RESULTS: The derivation and validation cohorts comprised 5857 and 3186 primary TSA patients, respectively, with similar demographics, comorbidities, and 30-day unplanned readmission rates (2.9% vs. 2.7%). Of the ML algorithms, SVM performed the worst with a c-statistic of 0.54 and an f1-score of 0.07, whereas the random-forest classifier performed the best with the highest c-statistic of 0.74 and an f1-score of 0.18. In addition, SVM was most sensitive to loss of single features, whereas the performance of RF did not dramatically decrease after loss of single features. Within the trained RF classifier, 5 variables achieved weights >0.5 in descending order: high bilirubin (>1.9 mg/dL), age >65, race, chronic obstructive pulmonary disease, and American Society of Anesthesiologists' scores ≥3. In our validation cohort, we observed a 2.7% readmission rate. From this cohort, using the RF classifier we were then able to identify 436 high-risk patients with a predicted risk score >0.6, of whom 36 were readmitted (readmission rate of 8.2%). CONCLUSION: Predictive analytics algorithms can achieve acceptable prediction of unplanned readmission for TSA with the RF classifier outperforming other common algorithms.

Metric Selection, Metric Targets, and Risk Adjustment Should be Considered in the Design of Gainsharing Models for Bundled Payment Programs in Total Joint Arthroplasty.

BACKGROUND: Under bundled payment models, gainsharing presents an important mechanism to ensure engagement and reward innovation. We hypothesized that metric selection, metric targets, and risk adjustment would impact surgeons' performance in gainsharing models. METHODS: Patients undergoing total joint arthroplasty at an urban health system from 2017 to September 2018 were included. Gainsharing metrics included the following: length of stay, % discharge-to-home, 90-day readmission rate, % of patients with episode spend under target price, and % of patients with patient-reported outcomes (PROs) collected. Four scenarios were created to evaluate how metric selection/adjustment impacted surgeons' performance designation: scenario 1 used "aspirational targets" (>60th percentile), scenario 2 used "acceptable targets" (>50th percentile), scenario 3 risk-adjusted surgeon performance prior to comparing aspirational targets, and scenario 4 included a PRO collection metric. Number of metrics achieved determined performance tier, with higher tiers getting a greater share of the gainsharing pool. RESULTS: In total, 2776 patients treated by 12 surgeons met inclusion criteria (mean length of stay 3.0 days, readmission rate 4.0%, discharge-to-home 74%, episode spend under target price 85%, PRO collection 56%). Lowering of metric targets (scenario 1 vs. 2) resulted in a 75% increase in the number of high performers and 98% of the gainsharing pool being eligible for distribution. Risk adjustment (scenario 3) caused 50% of providers to move to higher performance tiers and potential payments to increase by 28%. Adding the PRO metric did not change performance. CONCLUSION: Quality metric/target selection and risk adjustment profoundly impact surgeons' performance in gainsharing contracts. This impacts how successful these contracts can be in driving innovation and dis-incentivizing the "cherry picking" of patients. LEVEL OF EVIDENCE: Level III.

Does Productivity-Based Physician Compensation Affect Surgical Rates for Elective Arthroplasty Surgery?

BACKGROUND: Surgeon compensation models could potentially influence the utilization of elective procedures. We assessed whether transitioning from salaried to a relative value unit (RVU) productivity-based physician compensation model changed the surgical rate and patient selection in elective total hip and knee arthroplasty (THA and TKA) procedures. METHODS: Our institution transitioned from salaried to RVU productivity-based reimbursement in July 2016. We performed a retrospective analysis on patients undergoing primary THA and TKA from July 2014 to July 2018 before and after the transition (salary period n = 820; RVU period n = 1188). Beta regression was used to determine the reimbursement structure as a predictor of surgery. The surgical rate was defined as the number of primary THA and TKA procedures per reimbursement period divided by all arthroplasty and osteoarthritis outpatient clinic encounters. RESULTS: There was a surgical rate of 15.8% (95% confidence interval [CI] 13.8%-17.8%) THA and 16.7% (95% CI 15.1%-18.1%) TKA procedures during RVU reimbursement compared to 11.1% (95% CI 9.8%-12.8%) THA and 11.7% (95% CI 10.5%-12.8%) TKA procedures during the salaried period (P < .001). The adjusted odds of undergoing a THA or TKA procedure increased in the RVU compared to the salaried model (THA odds ratio 1.48, 95% CI 1.43-1.53; TKA odds ratio 1.50, 95% CI 1.46-1.55; P < .001). There were no significant differences in patient age, gender, race, body mass index, or Charlson Comorbidity Index in salaried vs RVU productivity periods (P > .05 for all covariates). CONCLUSIONS: Productivity-based physician compensation may encourage higher rates of elective arthroplasty procedures without broadening patient selection.

The Cost of Poor Mental Health in Total Joint Arthroplasty.

BACKGROUND: The purpose of this analysis was to evaluate (1) the impact of depression on resource utilization and financial outcomes in bundled total joint arthroplasty (TJA) and (2) whether similar effects are seen using baseline patient-reported outcome scores. METHODS: All elective bundled TJA cases from 2017 to 2018 at an academic system in the New York City area were included. We analyzed variables associated with cost differences seen between patients with and without depression, and between patients with low (<40th percentile) and high baseline (>60th percentile) Veterans RAND 12-Item Health Survey mental component scores (MCSs). We also analyzed whether depression or low MCS could predict worse financial outcomes. RESULTS: Our population included 825 patients, 418 with patient-reported outcome scores data. Depression was associated with higher rates of skilled nursing facility (SNF) discharge (42.7% vs 36.5%, P = .04), SNF payments ($16,200 vs $12,100, P = .0002), and average total episode costs ($31,000 vs $27,000, P = .04). Depression predicted bundle cost to be greater than target price (OR 1.82, 95% CI: 1.04-.16; P = .04) and SNF payment greater than 75th percentile (OR: 1.91; 95% CI: 1.00-3.65; P < .05). Similar effects were not seen using MCS. CONCLUSION: This is the first study to determine that depression predicts bundle cost greater than target price and SNF payment greater than 75th percentile. Our results emphasize the importance of accurate preoperative assessment of mental health in optimization of care, focusing on attenuating the increased SNF payments associated with depression. As similar effects were not seen using MCS, future studies should analyze the use of validated screening tools for depression, such as the PHQ-9, for more accurate assessments of patient mental health in TJA.

Betadine-Soaked Alcohol Pad and Rigid Immobilization: An Inexpensive and Effective Method to Diminish Infections With Exposed Kirschner Wires in Hand Fractures.

This study describes a novel method of pin care with a Betadine-soaked alcohol pad in conjunction with immobilization to reduce pin site complications in hand fractures treated with exposed Kirschner wires (K-wires). We conducted a retrospective review of all phalangeal and metacarpal fractures from 2010 to 2016 treated with K-wire fixation, a Betadine-soaked alcohol pad, and immobilization in a well-moulded plaster cast. A total of 155 patients with metacarpal or phalangeal fractures were identified, of which 149 were included with 164 fractures treated with 217 exposed K-wires. Overall complication rate was 6.1% (10/164), of which 3 fractures (1.8%) developed infections. Two infections occurred in patients with a history of organ transplantation. The most common complication was stiffness requiring closed manipulation under anesthesia (2.4%, 4/164), resulting in full range of motion in 3 of 4 patients. Exposed K-wires remain an effective method of hand fracture fixation associated with a low complication rate.

La présente étude décrit une nouvelle méthode de soins des broches avec un tampon d'alcool imprégné de bétadine conjointement avec l'immobilisation pour réduire les complications au foyer des broches en cas de fractures de la main traitées par des broches K exposées. Les chercheurs ont effectué une analyse rétrospective de toutes les fractures phalangiennes et métacarpiennes traitées par des broches K entre 2010 et 2016, un tampon d'alcool imprégné de bétadine et une immobilisation dans un plâtre bien moulé. Ils ont repéré 155 patients victimes de fractures métacarpiennes ou phalangiennes et en ont inclus 149 qui ont été traités par 217 broches K exposées. Le taux de complication globale s'élevait à 6,1 % (dix sur 164) et trois fractures (1,8 %) se sont infectées. Deux infections se sont produites chez des patients ayant subi une transplantation d'organe. La complication la plus courante était une rigidité exigeant une manipulation fermée sous anesthésie (2,4 %, quatre sur 164), qui a favorisé une pleine amplitude de mouvement chez trois des quatre patients. Les broches K exposées demeurent une méthode efficace de fixation des fractures de la main, associées à un faible taux de complication.

Hospital-Specific Total Joint Arthroplasty Casemix and Patient Flows in the Era of Payment Reform: Impact on Resource Utilization Among New York State Hospitals.

BACKGROUND: Bundled payment models may lead to selection of healthier total joint arthroplasty (TJA) candidates resulting in comorbid patients being taken care of in fewer hospitals. We aimed to (1) evaluate hospital-specific TJA comorbidity burden ("casemix") over time and (2) associations with resource utilization. METHODS: This retrospective cohort study used 2011 and 2016 New York State data (n = 36,078 hip/knee arthroplasties). Comorbidity burden was estimated by the Charlson-Deyo Index; main outcomes were hospitalization cost and nonhome discharge. Hospitals were categorized into those with a decreased, stable (with a 5% buffer), or increased percentage of comorbidity-free patients (Charlson-Deyo = 0) between 2011 and 2016. Mixed-effects models measured the association between Charlson-Deyo Index category and outcomes, by hospital casemix categorization. Odds ratios and 95% confidence intervals (CIs) are reported. RESULTS: Overall, 29 (n = 8810), 37 (n = 16,297), and 46 (n = 10,971) hospitals were categorized into the decreased, stable, and increased Charlson-Deyo = 0 categories, respectively, with median annual TJA volumes of 499, 814, and 393 (P < .0001). Multivariable models demonstrated that-in hospitals with a stable patient casemix-increased patient comorbidity was associated with increased hospitalization costs (maximum 21.8%, CI 18.9-24.9, P < .0001). However, this effect was moderated (maximum 11.1%, CI 8.0-14.2) in hospitals that took on a more comorbid patient casemix. Similar patterns were observed for nonhome discharge. CONCLUSION: Most studied hospitals show an increase in comorbidity-free TJA patients, suggestive of patient selection. This redistribution of comorbid patients to select hospitals may not necessarily be a negative development as our results suggest more efficient resource utilization for comorbid patients in such hospitals.

Current Trends in Orthopaedic Surgery Residency Applications and Match Rates.

BACKGROUND: The current U.S. orthopaedic residency application process is becoming increasingly impersonal in the wake of an increasing number of applications. Through an analysis of orthopaedic surgery residency application statistics, we have highlighted the effect that the number of orthopaedic applications has on match rate, and we have suggested methods for a more personalized application process. METHODS: Data from the Association of American Medical Colleges (AAMC) and the National Resident Matching Program (NRMP) for United States orthopaedic residency applicants from 2008 to 2018 were collected. These data included the average number of applications submitted per applicant, the average number of applications received per program, the total number of residency positions offered in the U.S., the total number of U.S. applicants, and the total number of U.S. applicants who matched to a U.S. orthopaedic surgery residency program. U.S. applicant match rates and the average number of applications received per residency position offered were calculated. Linear regression models were used to determine the rate at which these variables changed over time. RESULTS: The average number of applications submitted by an applicant increased from 46.5 in 2008 to 74.9 in 2018. The average number of applications received per residency position offered increased from 54.1 in 2008 to 85.7 in 2018. The number of U.S. applicants was 740 in 2008 and 849 in 2018. The number of U.S. orthopaedic residency programs only slightly increased from 160 in 2008 to 171 in 2018. The match rate for U.S. medical school applicants has remained stable from 2008 to 2018 at a mean of 76.9% and a standard deviation of 2.3%. CONCLUSIONS: The match rate has remained stable from 2008 to 2018 despite an increase in the number of applications per position. This discrepancy suggests that increasing the number of submitted applications may not correlate with applicant success. We address this discrepancy and suggest methods that can potentially allow for a more targeted orthopaedic application experience.

Do Medicare's Patient-Reported Outcome Measures Collection Windows Accurately Reflect Academic Clinical Practice?

BACKGROUND: The Comprehensive Care for Joint Replacement (CJR) mandates collection of patient-reported outcome measures (PROMs) for eligible total hip and total knee arthroplasty (THA and TKA) procedures during specific time periods that may not be attainable within routine academic practice. METHODS: We performed a retrospective analysis of prospectively collected PROM data from a 2017 cohort of primary THA and TKA patients who completed the Patient-Reported Outcomes Measurement Information System-10 global health survey in preoperative or postoperative time periods. The primary outcome was completion rates of Patient-Reported Outcomes Measurement Information System-10 per the CJR collection periods (90-0 days preoperative and 270-365 days postoperative) compared to an extended postoperative collection period of 270-396 days. Bivariate analysis and logistic regression were used to analyze the association between survey completion rates and patient characteristics. RESULTS: Of the 860 primary THAs and TKAs in 2017, 725 (84.3%) had preoperative surveys completed 90-0 days before surgery. Among the 725 patients, 215 (29.7%) completed postoperative surveys within the CJR timeline of 270-365 days. Completion increased by 120 additional surveys (+16.5%) in the additional postoperative time period of 270-396 days (P < .001). No patient or procedural factors significantly correlated with a higher likelihood of postoperative PROM completion (P > .05 for all covariates). CONCLUSION: In an academic clinical practice, completion rates of postoperative PROMs as part of routine clinical practice within the CJR mandated period was low for THA and TKA patients. CJR may consider additional time beyond 365 days to improve PROM completion rates.

Risk factors for and timing of adverse events after revision total shoulder arthroplasty.

BACKGROUND: Despite increasing rates of revision total shoulder arthroplasty (RTSA), there is a paucity of literature on optimizing perioperative outcomes. The purposes of this study were to identify risk factors for unplanned readmission and perioperative complications following RTSA, risk-stratify patients based on these risk factors, and assess timing of complications. METHODS: Bivariate and multivariate analyses of risk factors were assessed on RTSA patients from the ACS-NSQIP database from 2011 to 2015. Patients were risk-stratified and timing of severe adverse events and cause of readmission were evaluated. RESULTS: Of 809 RTSA patients, 61 suffered a perioperative complication or readmission within 30 days of discharge. Multivariate analysis identified operative time, BMI > 40, infection etiology, high white blood cell count, and low hematocrit as significant independent risk factors for 30-day complications or readmission after RTSA (p ≤ 0.05). Having at least one significant risk factor was associated with 2.71 times risk of complication or readmission within 15 days compared to having no risk factors (p < 0.001). The majority of unplanned readmission, return to the operating room, open/deep wound infection, and sepsis/septic shock occurred within two weeks of RTSA. DISCUSSION: Patients at high risk of complications and readmission after RTSA should be identified and optimized preoperatively to improve outcomes and lower costs.

Defining and Optimizing Value in Total Joint Arthroplasty From the Patient, Payer, and Provider Perspectives.

BACKGROUND: The purpose of this study is to define value in bundled total joint arthroplasty (TJA) from the differing perspectives of the patient, payer/employer, and hospital/provider. METHODS: Demographic, psychosocial, clinical, financial, and patient-reported outcomes (PROs) data from 2017 to 2018 elective TJA cases at a multihospital academic health system were queried. Value was defined as improvement in PROs (preoperatively to 1 year postoperatively) for patients, improvement in PROs per $1000 of bundle cost for payers, and the normalized sum of improvement in PROs and hospital bundle margin for providers. Bivariate analysis was used to compare high value vs low value (>50th percentile vs <50th percentile). Multivariate analysis was performed to identify predictors. RESULTS: A total of 280 patients had PRO data, of which 71 had Medicare claims data. Diabetes (odds ratio [OR], 0.45; P = .02) predicted low value for patients; female gender (OR, 0.25), hypertension (OR, 0.17), pulmonary disease (OR, 0.12), and skilled nursing facility discharge (OR, 0.17) for payers (P ≤ .03 for all); and pulmonary disease (OR, 0.16) and skilled nursing facility discharge (OR, 0.19) for providers (P ≤ .04 for all). CONCLUSION: This is the first article to define value in TJA under a bundle payment model from multiple perspectives, providing a foundation for future studies analyzing value-based TJA.

What Are the Uses and Limitations of Time-driven Activity-based Costing in Total Joint Replacement?

BACKGROUND: With increasing emphasis on value-based payment models for primary total joint arthroplasty (TJA), there is greater need for orthopaedic surgeons and hospitals to better understand the actual costs and resource use of TJA. Time-driven activity-based costing (TDABC) is a methodology for accurate cost estimation, but its application in the TJA care pathway across institutions/regions has not yet been analyzed. QUESTIONS/PURPOSES: In this systematic review of studies applying TDABC to primary TJA, we investigated the following: (1) Is there variation in TDABC methodology and cost estimates across institutions? (2) Is a standard set of direct and indirect costs included across studies? (3) Is there a difference in cost estimates derived from TDABC and traditional hospital cost-accounting approaches? and (4) How are institutions using TDABC (process and outputs) with respect to the TJA care pathway? METHODS: A comprehensive search strategy was developed that included the keywords "TDABC," "time-driven activity-based cost," "THA," "TKA," "THR," "TKR," and "TJR" in the PubMed/MEDLINE, EMBASE, Web of Science, Ovid SP, Scopus, and ScienceDirect databases for articles published between 2004 and 2018 as well as extensive hand searching and citation mining. Relevant studies (n = 15) were screened to include THA or TKA as the focus of the TDABC model, full-text articles, TDABC-based cost estimates for TJA, and studies written in English (n = 8). Due to the heterogeneity of outcomes/methodology in TDABC studies involving TJA, quality assessment was based on each study's adherence to the seven steps delineated by Kaplan et al. in their original publication introducing TDABC in health care. RESULTS: There was substantial variation in TDABC methodology (especially in scope), adherence to the seven steps of TDABC, and data collection. Only five of eight studies incorporated indirect costs into their TDABC calculation, with notable differences in which direct and indirect expenses were included. TDABC-based cost estimates for TJA ranged from USD 7081 to USD 29,557, with variation driven by the TJA timeframe and whether implant costs were included in the costing calculation. TDABC was most frequently used to compare against traditional hospital accounting methods (n = 4), to increase operational efficiency (n = 4), to reduce wasted resources (n = 3), and to mitigate risk (n = 3). CONCLUSIONS: TDABC-based cost estimates are more granular and useful in practice than those calculated via traditional hospital accounting; however, there is a lack of standardized principles to guide TDABC implementation (especially for indirect costs) due to institutional and regional differences in TDABC application. Although TDABC methodology will likely continue to vary somewhat between studies, standardized principles are needed to guide the definition, estimation, and reporting of costs to enable detailed examination of study methodology and inputs by readers. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Skilled Nursing Facility Placement Process After Total Hip and Total Knee Arthroplasty: Revised Rating System and Opportunities for Intervention.

BACKGROUND: With the advent of bundled payment models, identifying high-performing skilled nursing facilities (SNFs) has become increasingly important. The goal of this study is to develop a rating system to rank SNFs within our health system and to use this system to improve the SNF discharge process at our institution. METHODS: All SNF-discharged primary total joint arthroplasty cases in 2017 at a multi-hospital academic health system were queried. Discharge patterns were assessed using heat map analysis. Regression analyses in conjunction with structured discussions with subject matter experts were used to identify measures of SNF efficiency and care quality. A revised rating system was developed and used to identify high-performing facilities within our health system. Opportunities to re-direct patients to higher performing facilities were identified. RESULTS: A revised rating system for SNFs was constructed based on risk-adjusted SNF length of stay, 30-day re-admission rate, and 30-day emergency department visit rate. As 82% of patients were discharged to SNFs in close proximity to their home, high-performing SNFs (according to the revised rating system) were identified by geographic region. Mapping of the discharge process revealed multiple opportunities where patients could be re-directed to a higher performing SNF in their area. Using conservative estimates (25% of discharges re-directed), this is expected to achieve a cost saving of $2,600,000 over a 5-year period, mainly through reductions in SNF length of stay. CONCLUSION: This study describes the development of a revised rating system for SNFs which, when implemented, is expected to achieve substantial cost savings over a 5-year period.

Development and validation of risk-adjustment models for elective, single-level posterior lumbar spinal fusions.

BACKGROUND: There is a paucity of literature examining the development and subsequent validation of risk-adjustment models that inform the trade-off between adequate risk-adjustment and data collection burden. We aimed to evaluate patient risk stratification by surgeons with the development and validation of risk-adjustment models for elective, single-level, posterior lumbar spinal fusions (PLSFs). METHODS: Patients undergoing PLSF from 2011-2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). The derivation cohort included patients from 2011-2013, while the validation cohort included patients from 2014. Outcomes of interest were severe adverse events (SAEs) and unplanned readmission. Bivariate analysis of risk factors followed by a stepwise logistic regression model was used. Limited risk-adjustment models were created and analyzed by sequentially adding variables until the full model was reached. RESULTS: A total of 7,192 and 4,182 patients were included in our derivation and validation cohorts, respectively. Full model performance was similar for the derivation and validation cohorts in both 30-day SAEs (C-statistic =0.66 vs. 0.69) and 30-day unplanned readmission (C-statistic =0.62 vs. 0.65). All models demonstrated good calibration and fit (P≥0.58). Intraoperative variables, laboratory values, and comorbid conditions explained >75% of the variation in 30-day SAEs; ASA class, laboratory values, and comorbid conditions accounted for >80% of model risk prediction for 30-day unplanned readmission. Four variables for the 30-day SAE models (age, gender, ASA ≥3, operative time) and 3 variables for the 30-day unplanned readmission models (age, ASA ≥3, operative time) were sufficient to achieve a C-statistic within four percentage points of the full model. CONCLUSIONS: Risk-adjustment models for PLSF demonstrated acceptable calibration and discrimination using variables commonly found in health records and demonstrated only a limited set of variables were required to achieve an appropriate level of risk prediction.

Preoperative Patient-Reported Outcomes and Clinical Characteristics as Predictors of 90-Day Cost/Utilization and Complications.

BACKGROUND: With the advent of mandatory bundle payments for total joint arthroplasty (TJA), assessing patients' risk for increased 90-day complications and resource utilization is crucial. This study assesses the degree to which preoperative patient-reported outcomes predict 90-day complications, episode costs, and utilization in TJA patients. METHODS: All TJA cases in 2017 at 2 high-volume hospitals were queried. Preoperative HOOS/KOOS JR (Hip Injury and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score) and Veterans RAND 12-item health survey (VR-12) were administered to patients preoperatively via e-collection platform. For patients enrolled in the Medicare bundle, cost data were extracted from claims. Bivariate and multivariate regression analyses were performed. RESULTS: In total, 2108 patients underwent TJA in 2017; 1182 (56%) were missing patient-reported outcome data and were excluded. The final study population included 926 patients, 199 (21%) of which had available cost data. Patients with high bundle costs tended to be older, suffer from vascular disease and anemia, and have higher Charlson scores (P < .05 for all). These patients also had lower baseline VR-12 Physical Component Summary Score (PCS; 24 vs 30, P ≤ .001) and higher rates of extended length of stay, skilled nursing facility discharge, 90-day complications, and 90-day readmission (P ≤ .04 for all). In multivariate analysis, higher baseline VR-12 PCS was protective against extended length of stay, skilled nursing facility discharge, >75th percentile bundle cost, and 90-day bundle cost exceeding target bundle price (P < .01 for all). Baseline VR-12 Mental Component Summary Score and HOOS/KOOS JR were not predictive of complications or bundle cost. CONCLUSION: Low baseline VR-12 PCS is predictive of high 90-day bundle costs. Baseline HOOS/KOOS JR scores were not predictive of utilization or cost. Neither VR-12 nor HOOS/KOOS JR was predictive of 90-day readmission or complications.