The Cost-Effectiveness of Computer-Assisted Compared with Conventional Total Knee Arthroplasty: A Payer's Perspective.

BACKGROUND: Recent evidence showing that computer-assisted total knee arthroplasty (TKA) is associated with better outcomes compared with conventional TKA for patients with end-stage knee osteoarthritis has not been included in economic evaluations of computer-assisted TKA, which are needed to support coverage decisions. This study evaluated the cost-effectiveness of computer-assisted TKA from a payer's perspective, incorporating recent evidence. METHODS: We compared computer-assisted TKA with conventional TKA with regard to costs (in 2022 U.S. dollars) and quality-adjusted life-years (QALYs) using Markov models for elderly patients (≥65 years of age) and patients who were not elderly (55 to 64 years of age). Costs and QALYs were estimated in the lifetime for elderly patients and in the short term for patients who were not elderly, under a bundled payment program and a Fee-for-Service program. Transition probabilities, costs, and QALYs were retrieved from the literature, a national knee arthroplasty registry, and the National Center for Health Statistics. Threshold and probabilistic sensitivity analyses were conducted to examine the robustness of key estimates used in the base-case analysis. Using projected estimates of TKA utilization, the total cost savings of performing computer-assisted TKA rather than conventional TKA were estimated. RESULTS: Compared with conventional TKA, computer-assisted TKA was associated with higher QALYs and lower costs for both elderly patients and patients who were not elderly, regardless of payment programs, making computer-assisted TKA a favorable treatment option. Widespread adoption of computer-assisted TKA in all U.S. patients would result in an estimated total cost saving of $1 billion for payers. CONCLUSIONS: Compared with conventional TKA, computer-assisted TKA reduces costs to payers while providing favorable outcomes. Payers may consider providing additional payment incentives to providers for performing computer-assisted TKA, to achieve outcome improvement and cost control by facilitating widespread adoption of computer-assisted TKA. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Clinicians' perspectives on wearable sensor technology as an alternative bedside monitoring tool in two West African countries.

OBJECTIVE: Healthcare facilities in low- and middle-income countries (LMICs), especially in Africa, suffer from a lack of continuous bedside monitoring capability, adversely affecting timely detection of hemodynamic deterioration and the opportunity for life-saving intervention. Wearable device technologies can overcome many of the challenges of conventional bedside monitors and could be viable alternatives. We assessed clinicians' perspectives on the use of a novel experimental wearable device ("biosensor") to improve bedside monitoring of pediatric patients in two West African LMICs. METHODS: Focus groups were conducted in 3 hospitals (2 in Ghana and 1 in Liberia), in both urban and rural settings and of variable size, to elucidate clinicians' attitudes about the biosensor and to identify potential implementation needs. The focus group sessions were coded using a constant comparative method. Deductive thematic analysis was applied to pair themes with Consolidated Framework for Implementation Research (CFIR) contextual factors and domains. RESULTS: Four focus groups were conducted in October 2019, and included 9 physicians, 20 nurses, and 20 community health workers. Fifty-two codes in four thematic areas were linked to 3 CFIR contextual factors and 9 domains. Key themes were durability and cost of the biosensor, hospital setting, and staffing concerns, which were related to the "Inner Setting" and "Characteristics of the Intervention" CFIR contextual factors. Participants, who recognized the limitations of current vital sign monitoring systems, further identified 21 clinical settings in which a biosensor could potentially be useful and expressed willingness to implement the biosensor. CONCLUSION: Clinicians who provide care to pediatric patients in two West African LMICs suggested multiple uses of a novel experimental wearable biosensor and expressed willingness to use it for continuous bedside vital sign monitoring. They identified device design (e.g., durability, cost), hospital setting (rural vs urban), and staffing as important factors to consider during further development and implementation.

Is there variation in utilization of preoperative tests among patients undergoing total hip and knee replacement in the US, and does it affect outcomes? A population-based analysis.

STUDY OBJECTIVE: To describe recent practice patterns of preoperative tests and to examine their association with 90-day all-cause readmissions and length of stay. DESIGN: Retrospective cohort study using the New York Statewide Planning and Research Cooperative System (SPARCS). SETTING: SPARCS from March 1, 2016, to July 1, 2017. PARTICIPANTS: Adults undergoing Total Hip Replacement (THR) or Total Knee Replacement (TKR) had a preoperative screening outpatient visit within two months before their surgery. INTERVENTIONS: Electrocardiogram (EKG), chest X-ray, and seven preoperative laboratory tests (RBCs antibody screen, Prothrombin time (PT) and Thromboplastin time, Metabolic Panel, Complete Blood Count (CBC), Methicillin Resistance Staphylococcus Aureus (MRSA) Nasal DNA probe, Urinalysis, Urine culture) were identified. PRIMARY AND SECONDARY OUTCOME MEASURES: Regression analyses were utilized to determine the association between each preoperative test and two postoperative outcomes (90-day all-cause readmission and length of stay). Regression models adjusted for hospital-level random effects, patient demographics, insurance, hospital TKR, THR surgical volume, and comorbidities. Sensitivity analysis was conducted using the subset of patients with no comorbidities. RESULTS: Fifty-five thousand ninety-nine patients (60% Female, mean age 66.1+/- 9.8 SD) were included. The most common tests were metabolic panel (74.5%), CBC (66.8%), and RBC antibody screen (58.8%). The least common tests were MRSA Nasal DNA probe (13.0%), EKG (11.7%), urine culture (10.7%), and chest X-ray (7.9%). Carrying out MRSA testing, urine culture, and EKG was associated with a lower likelihood of 90-day all-cause readmissions. The length of hospital stay was not associated with carrying out any preoperative tests. Results were similar in the subset with no comorbidities. CONCLUSIONS: Wide variation exists in preoperative tests before THR and TKR. We identified three preoperative tests that may play a role in reducing readmissions. Further investigation is needed to evaluate these findings using more granular clinical data.

Revisiting Short-term Outcomes of Conventional and Computer-Assisted Total Knee Arthroplasty: A Population-based Study.

BACKGROUND: Population-based studies showing the advantage of computer-assisted total knee arthroplasty (CATKA) over conventional total knee arthroplasty (TKA) are outdated. More recent institution-based studies with relatively small sample sizes may hinder wider adoption. This cohort-based study aimed to compare postoperative CATKA and TKA in-hospital complications and 90-day all-cause readmissions using 2017-2018 data. METHODS: Patients who underwent a primary unilateral CATKA or TKA were identified in the New York Statewide Planning and Research Cooperative System database. In-hospital complications were defined based on the 2020 Centers for Medicare & Medicaid Services total hip arthroplasty and TKA complications measure. Ninety-day readmissions were identified using unique patient identifiers. Logistic regression with a generalized estimating equation was used to assess associations of computer assistance with in-hospital complications and 90-day all-cause readmissions. RESULTS: A total of 80,468 TKAs were identified during the study period, of which 7,395 (9.2%) were CATKAs. Significantly fewer complications occurred among patients who had CATKAs compared with conventional TKAs (0.4% of total CATKAs vs 2.6% of total conventional TKAs, P < 0.001); patients who had CATKAs had fewer 90-day all-cause readmissions compared with those who underwent TKAs (363 vs 4,169 revisits, P < 0.01). Computer assistance was associated with significantly lower odds of in-hospital complications (odds ratio, 0.15, 95% confidence interval, 0.09 to 0.24; P < 0.05) but not 90-day all-cause readmissions. CONCLUSION: Patients undergoing CATKAs had markedly lower odds of in-hospital complications, compared with patients having TKAs, which has implications for both patient outcomes and hospital reimbursement. These more recent cohort-based findings encourage wider CATKA adoption.

Trends in Practice Patterns of Conventional and Computer-assisted Knee Arthroplasty: An Analysis of 570,671 Knee Arthroplasties Between 2010 and 2017.

BACKGROUND: Despite advances in computer-assisted knee arthroplasty (CAKA), little is known about the uptake of this technology in recent years. We aimed to explore the utilization trends and practice variation of CAKA from 2010 to 2017 and investigate the predictors of CAKA adoption. METHODS: Patients undergoing conventional knee arthroplasty and CAKA were identified from the states of New York and Florida's administrative databases using the International Classification of Diseases version 9 and 10 procedure codes. Quarterly proportions of CAKA were calculated over the study period, and logistic regression was used to estimate predictors of CAKA utilization. RESULTS: Between 2010 and 2017, quarterly proportion of CAKAs increased from 4.89% in 2010Q1 to 9.45% in 2017Q3 in New York and from 4.03% in 2010Q1 to 5.73% in 2017Q3 in Florida. The general CA code was used to code most of the procedures (81%). Being Black (odds ratio [OR]: 0.63, 95% confidence interval [CI], 0.60 to 0.67), Hispanic (OR: 0.45, CI, 0.41 to 0.50), and having Medicaid coverage (OR: 0.46, CI, 0.40 to 0.53) were associated with lower likelihood of receiving CAKA in New York; similar findings were found in Florida. CONCLUSION: Utilization of CAKA has increased substantially in both New York and Florida from 2010 to 2017; however, with most CAKAs reported using the general code, understanding adoption rates of various modalities was not possible. Black and Hispanic patients and those with Medicaid insurance are least likely to receive this high-precision technology, illustrating the presence of disparities in the adoption of CAKA.