Rapid Adoption of Telemedicine Increases Opioid Prescribing in Orthopedic Surgery.

Background: The COVID-19 pandemic led to health care practitioners utilizing new technologies to deliver health care, including telemedicine. The purpose of this study was to examine the effect of rapidly proliferative use of video visits on opioid prescribing to orthopedic patients at a large academic health system that had existing procedure-specific opioid prescribing guidelines. Methods: This IRB-exempt study examined 651 opioid prescriptions written to patients who had video (visual and audio), telephone (audio only), or in-person encounters at our institution from March 1 to June 1, 2020 and compared them with 963 prescriptions written during the same months in 2019. Prescriptions were converted into daily milligram morphine equivalents (MMEs) to facilitate direct comparison. Chi-square testing was used to compare categorical data, whereas analysis of variance and Mann-Whitney tests were used to compare numerical data between groups. Statistical significance was set at <0.05. Results: Six hundred fifty-one of 1,614 prescriptions analyzed (40.3%) occurred during the pandemic. Patients prescribed opioids during video visits were prescribed 53.3 ± 37 MME, significantly higher than in-person (p = 0.002) or audio visits (p < 0.001) before or during the pandemic. Prepandemic, significantly higher MME were prescribed for in-person versus audio only visits (41.6 ± 89 vs. 30.2 ± 28 MME; p = 0.026); during the pandemic, there was no difference between these groups (p = 0.91). Significantly higher MME were prescribed by Nurse Practitioners and Physician Associates versus MD or DO prescribers for both time periods (51.3 ± 109 vs. 27.9 ± 42 MME; p < 0.001; 42.9 ± 70 vs. 28.2 ± 42 MME; p < 0.001). Conclusion: During crisis and with new technology, we should be vigilant about prescribing of opioid analgesics. Despite well-established protocols, patients received significantly higher MME through video than for other encounter types, including in-person encounters. In addition, significantly higher MME were prescribed by mid-level prescribers compared with DOs or MDs. Institutions should ensure these prescribers are involved during creation of opioid prescribing protocols after orthopedic surgery.

Telemedicine Utilization at an Academic Medical Center During COVID-19 Pandemic: Are Some Patients Being Left Behind?

Introduction: The purpose of this study was to examine the use of telemedicine at one academic health care center during the COVID-19 pandemic to identify opportunities to improve access to this novel delivery method of care. Methods: All patients who underwent telemedicine visits at one urban academic medical center between March 2020 and June 2020 were included. All departments were included including surgical and nonsurgical. Demographic data, primary language, and visit type were collected. Primary zip code was used as surrogate for socioeconomic status through use of the zip code median household income. The demographics of the New York metropolitan area were obtained through the U.S. Census Bureau and used as a control cohort. Results: A total of 362,413 telemedicine visits met inclusion criteria with the majority of visits performed in April and May; 127,851 (35.3%) and 110,166 (30.4%), respectively. The highest performing department was Internal Medicine, which performed 72,796 visits or 20% of the total cohort. In our cohort of telemedicine patients, 59.6% identified as White, 11.4% as Black, and 5.7% as Asian. This is less diverse than the overall population of the metropolitan area, which is 17.5% Black and 11.5% Asian. There was also a large gender gap in the utilization of telemedicine services in general, where women (60.2%) were more likely than men (39.8%) to utilize the virtual visits. In addition, although over a third of patients in the Metropolitan area have median household incomes of <50,000, this population only represented 13.6% of our total cohort. Conclusions: This study highlights both the capability of telemedicine to provide care at a large urban academic medical center during a pandemic in addition to identifying potential gaps in care with telemedicine. The disparities highlighted in our cohort stress the importance of outreach to non-White older patients of lower socioeconomic status.

Emergency Department Observation Versus Readmission Following total Joint Arthroplasty: Can We Avoid the Bundle Buster?

BACKGROUND: As the Center for Medicare and Medicaid (CMS) moves toward bundled payment plans for total joint arthroplasty (TJA), it becomes necessary to reduce factors that increase cost for an episode of care such as readmissions. The goal of this study is to evaluate the payment for observation stay versus readmission for patients who present to the emergency department. METHODS: A retrospective review from 2014-2019 was conducted identifying all Medicare patients who had a primary, elective TJA and visited the ED within 90 days postoperatively. If a readmission was one midnight or less or had an equivalent diagnosis to an observation stay patient, it was characterized as a readmission that could have qualified as an observation stay. Using our institution's average payment for Medicare readmissions and observations, actual and potential savings were calculated. RESULTS: Sixty-nine out of 523 (13.2%) patients were placed under observation, while 454 (86.8%) patients were readmitted. Eighty-six out of 523 (18.9%) patients qualified for observation status. There was an actual savings of 11.8% by placing patients on observation status and readmission rate was decreased by 13.2%. Savings could have increased by a total of 27.7% and readmissions decreased by a total of 29.6% if all patients who qualified had been placed on observation status. CONCLUSION: At our institution, the implementation of observation stay has led to a savings of 11.8% and a potential total savings of 27.7%. The rate of readmissions was decreased by 13.2% and had the potential to decrease by a total of 29.6%.

The Effect of Medicare's Bundled Payments for Care Initiative on Patient Risk Factors Prior to Total Knee Arthroplasty.

BACKGROUND: Medicare's Bundled Payments for Care Initiative (BPCI) is a risk-sharing alternative payment model. There is a concern that BPCI providers may avoid operating on obese patients and active smokers to reduce costs. We sought to understand if increased focus on these patient factors has led to a change in patient demographics in Medicare-insured patients undergoing total knee arthroplasty (TKA). METHODS: We retrospectively reviewed all patients who underwent TKA at an academic orthopedic specialty hospital between 1/1/13 and 8/31/19. Surgical date, insurance provider, BMI, and smoking status were collected. Patients were categorized as a current, former, or never smoker. Patients were categorized as obese if their BMI was >30 kg/m2, morbidly obese if their BMI was >40 kg/m2, and super obese if their BMI was >50 kg/m2. RESULTS: In total, 10,979 patients with complete insurance information were analyzed. There was no statistically significant change in the proportion of Medicare patients who were active smokers (4.34% in 2013, 4.85% in 2019, Pearson correlation coefficient = 0.6092, P = .146). The proportion of Medicare patients with BMI >30 kg/m2 increased over the study period (35.84% in 2013, 55.77% in 2019, Pearson correlation coefficient = 0.8505, P = .015). When looking at patients with BMI >40 kg/m2 and >50 kg/m2, there was no significant change. CONCLUSIONS: Despite concern that reimbursement payments could alter access to care for patients with certain risk factors, this study did not find a noticeable difference in the representation of patients with obesity and smoking status undergoing TKA following the installation of BPCI. LEVEL OF EVIDENCE: III, retrospective observational analysis.

Telemedicine Utilization by Orthopedic Patients During COVID-19 Pandemic: Demographic and Socioeconomic Analysis.

Background:The relaxation of telemedicine (TM) restrictions during the COVID-19 pandemic accelerated adoption of this technology by many orthopedic practices. The purpose of this study was to examine the demographics of the orthopedic patients who utilized TM visits during the COVID-19 pandemic to identify opportunities to improve access.Methods:All patients who underwent orthopedic TM visits at one urban academic medical center between January and April 2020 were included. Demographic data including primary zip code, primary language, and visit type were collected. The demographics of the TM cohort were compared with those of patients seen in the outpatient (OP) setting at the same institution the prior year as well as with patients in the metropolitan area (M).Results:Five thousand thirty-five TM visits met the inclusion criteria. The TM cohort was significantly younger than the OP cohort, with mean age of 48.7 ± 19.0 years for TM and 55.2 ± 18.0 years for OP, and with 22% of TM being 65 or older versus 35% of OP being 65 or older (p = 0.001). The TM cohort had a lower percentage of minority patients (41.3%) than the OP cohort (48.2%). The TM cohort had a significantly lower percentage of black 12.9% versus 14.1%, Asian. 5.1% versus 5.8%, and Spanish/Hispanic 1.9% versus 15.4%, than the M and the OP cohort from the prior year (p < 0.026, p < 0.001, p < 0.001). For socioeconomic status, only 13.8% of TM patients were from ZIP codes with median household incomes <50k. A total of 96.2% of TM visits were performed in English, where only 61% of individuals in the metropolitan area report English as their primary language.Conclusions:As the largest analysis of the use of TM in orthopedics, this study highlights both the future potential of TM and areas of improvement to ensure better access to care for all patient populations. Maintenance of the provisions to allow audio-only visits to be considered TM and billed as such is one important measure.

Outcomes of Same-Day Discharge After Total Hip Arthroplasty in the Medicare Population.

BACKGROUND: There is an increasing utilization of same-day discharge total hip arthroplasty (SDD THA). As the Center for Medicare and Medicaid Services considers removing THA from the inpatient-only list, there is likely to be a significant increase in the number of Medicare patients undergoing SDD THA. Thus, there is a need to report on outcomes of SDD THA in this population. METHODS: A retrospective review was performed on 850 consecutive SDD THA patients including 161 Medicare patients. We compared failure to launch, complication, emergency department visit, and 90-day readmission rates between the Medicare and non-Medicare cohorts. RESULTS: The Medicare group was older and had less variability in their admission diagnosis. There was no significant difference in failure to launch, complication, emergency department visit, or 90-day readmission rates between Medicare and non-Medicare groups. CONCLUSION: The benefits of SDD THA can be safely extended to the carefully indicated and motivated Medicare patient.

Are HCAHPS Scores Higher for Private vs Double-Occupancy Inpatient Rooms in Total Joint Arthroplasty Patients?

BACKGROUND: Private hospital rooms have a number of potential advantages compared to shared rooms, including reduced noise and increased control over the hospital environment. However, the association of room type with patient experience metrics in total joint arthroplasty (TJA) patients is currently unclear. METHODS: For private versus shared rooms, we compared our institutional Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in patients who underwent primary TJA over a 2-year period. Regression model odds ratios (ORs) were adjusted for surgeon, date of surgery, and length of stay. RESULTS: Patients in private rooms were more likely to report a top-box score for overall hospital rating (85.6% vs 79.4%, OR = 1.53, P = .011), hospital recommendation (89.3% vs 83.0%, OR = 1.78, P = .002), call button help (76.0% vs 68.7%, OR = 1.40, P = .028), and quietness (70.4% vs 59.0%, OR = 1.78, P < .001). There were no significant differences on surgeon metrics including listening (P = .225), explanations (P = .066), or treatment with courtesy and respect (P = .396). CONCLUSION: For patients undergoing TJA, private hospital rooms were associated with superior performance on patient experience metrics. This association appears specific for global and hospital-related metrics, with little impact on surgeon evaluations. With the utilization of HCAHPS data in value-based initiatives, placement of TJA patients in private rooms may lead to increased reimbursement and higher hospital rankings. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Total Joint Arthroplasty in Ambulatory Surgery Centers: Analysis of Disqualifying Conditions and the Frequency at Which They Occur.

BACKGROUND: The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible. METHODS: We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities. RESULTS: Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m2 (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%). CONCLUSION: A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.

Hip Arthroplasty for Fracture vs Elective Care: One Bundle Does Not Fit All.

BACKGROUND: To quantify how baseline differences in patients undergoing hip arthroplasty for fracture vs elective care potentially lead to significant differences in immediate health care outcomes and whether these differences affect feasibility of current bundled payment models. METHODS: New York Statewide Planning and Research Cooperative System database for the years 2000-2014. RESULTS: A total of 76,654 patients underwent total hip arthroplasty or hemiarthroplasty between 2010 and 2014; 82.8% of the sample was for elective care and 17.2% for fracture-related etiology. Fracture patients were significantly older, more likely to be female, Caucasian, reimbursed by Medicare, and receive general anesthesia. Comorbidity burden and postoperative complications were significantly higher in the fracture group, and hospital charges were significantly greater for fracture patients as compared with those of the elective cohort. CONCLUSION: Patients undergoing hip arthroplasty for fracture care are significantly older and have more medical comorbidities than patients treated on an elective basis, leading to more in-hospital complications, greater length of stay, increased hospital costs, and significantly more hospital readmissions. The present bundled payment system, even with the recent modification, still unfairly penalizes hospitals that manage fracture patients and has the potential to incentivize hospitals to defer providing definitive surgical management for these patients. Future amendments to the bundled payment system should consider further separating hip arthroplasty patients based on etiology and comorbidities, allowing for a more accurate reflection of these distinct patient groups.

Joint Replacement Volume Positively Correlates With Improved Hospital Performance on Centers for Medicare and Medicaid Services Quality Metrics.

BACKGROUND: The Center for Medicare and Medicaid Services (CMS) is transitioning Medicare from a fee-for-service program into a value-based pay-for-performance program. In order to accomplish this goal, CMS initiated 3 programs that attempt to define quality and seek to reward high-performing hospitals and penalize poor-performing hospitals. These programs include (1) penalties for hospital-acquired conditions (HACs), (2) penalties for excess readmissions for certain conditions, and (3) performance on value-based purchasing (VBP). The objective of this study was to determine whether high-volume total joint hospitals perform better in these programs than their lower-volume counterparts. METHODS: We analyzed data from the New York Statewide Planning and Research Cooperative System database on total New York State hospital discharges from 2013 to 2015 for total knee and total hip arthroplasty. This was compared to data from Hospital Compare on HAC's, excess readmissions, and VBP. From these databases, we identified 123 hospitals in New York, which participated in all 3 Medicare pay-for-performance programs and performed total joint replacements. RESULTS: Over the 3-year period spanning 2013-2015, hospitals in New York State performed an average of 1136.59 total joint replacement surgeries and achieved a mean readmission penalty of 0.005909. The correlation coefficient between surgery volume and combined performance score was 0.277. Of these correlations, surgery volume and VBP performance, and surgery volume and combined performance showed statistical significance (P < .01). CONCLUSION: Our study demonstrates that there is a positive association between joint replacement volumes and overall hospital quality, as well as joint replacement volumes and VBP performance, specifically. These findings are consistent with previously reported associations between patient outcomes and procedure volumes. However, a relationship between joint replacement volume and HAC scores or readmission penalties could not be demonstrated.

The Relationship Between Hospital Payer Mix and Volume Growth in Total Joint Arthroplasty: A 12-Year Analysis.

BACKGROUND: Hospital reimbursement for Medicare/Medicaid/self-pay patients has not kept pace with rising expenses, and even well run efficient organizations struggle to maintain a positive margin on these cases. Therefore, hospitals rely on commercially insured patients to remain economically viable. However, hospitals located in areas with a high Medicare/Medicaid/uninsured population cannot depend on a favorable payer mix for financial sustainability. METHODS: Using the Statewide Planning and Research Cooperative System database, total joint arthroplasties (TJAs) in New York from 2000 to 2012 were identified. Hospitals were divided into quartiles by volume, with quartile 1 representing the lowest volume hospitals. TJA cases were stratified by primary payer type, and the percentage of each primary payer type was calculated and compared among quartiles. RESULTS: The highest number of hospitals performing TJAs was 207 in 2000, and the least number of hospitals was in 2012, with only 178 hospitals performing TJA. Despite the decrease in the number of hospitals, the total number of joint arthroplasties increased from 33,036 in 2000 to 62,104 in 2012. CONCLUSIONS: Our study demonstrates that higher volume hospitals tended to have a more favorable payer mix (less Medicare/Medicaid/self-pay patients). This inequity widened over the 12-year study period. This trend has ethical implications for lower socioeconomic status patients as high-volume centers tend to have superior outcomes compared with low-volume centers. In addition, the lower volume high Medicare/Medicaid/self-pay hospitals are more susceptible to the Center for Medicare and Medicaid Services quality penalties making their economic viability even more tenuous potentially leading to access of care problems for these patients.

End Tidal Carbon Dioxide as a Screening Tool for Computed Tomography Angiogram in Postoperative Orthopaedic Patients Suspected of Pulmonary Embolism.

BACKGROUND: Computed tomography pulmonary angiography (CTA) is the gold standard for diagnosing pulmonary embolism (PE) but involves radiation and iodinated contrast exposure. Of orthopedic patients evaluated for PE, a minority have a positive CTA study. Herein, we evaluate end tidal carbon dioxide (ETCO2) as a method to identify patients at low risk for PE and may not require a CTA. We hypothesize that ETCO2 will be useful for predicting the absence of PE in postoperative orthopedic patients. METHODS: In this prospective study, all patients older than 18 years who were admitted for orthopedic surgery and who had a CTA performed for PE were eligible. These patients underwent an ETCO2 measurement. Patients were determined to have PE if they had a positive PE-protocol CT. RESULTS: Between May 2014 and April 2015, 121 patients met the inclusion criteria for the study. Of these patients, 84 had a negative CTA examination, 25 had a positive examination, and 12 had a nondiagnostic examination. We found a statistically significant difference (P = .03) when comparing the average ETCO2 values for the positive and negative CTA groups. An ETCO2 cutoff value of 43 mm Hg was 100% sensitive with a negative predictive value of 100% for absence of PE on CTA. CONCLUSION: This study demonstrates a significant difference in ETCO2 measurements between postoperative orthopedic patients with and without CTA-detected PE. A cutoff value of >43 mm Hg may be useful in excluding patients from undergoing CTA.

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

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

Applying quality principles to orthopaedic surgery.

The unsustainable rising cost of medical care is creating financial pressures that will critically alter the way that health care is paid for and delivered. Limited resources dictate that physicians must become more efficient at providing high quality care. In an effort to provide financial incentive for delivering quality care, the federal government instituted value-based purchasing to transform Medicare from a passive payer of claims to an active purchaser of medical care. Healthcare providers must follow the basic tenants of certain quality principles to maximize reimbursement under the value-based purchasing system.

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

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

Decreasing total joint implant costs and physician specific cost variation through negotiation.

Reducing the cost of total joint implants can significantly reduce the cost of an episode of care without affecting the quality. In 2011 we began a program to decrease and standardize the pricing of total joint implants. In the first year of the intervention we preformed 1,090 and 1,022 unilateral total knee and total hip arthroplasties respectively. Based on our volume and pricing data, our institution saved over $2 million during the first year of this intervention. It is clear that our initiative to negotiate lower implant cost with our vendors has lead to a significant reduction in the cost of joint arthroplasties and a reduction in the variability in costs between physicians.

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

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

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

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

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

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

Ethical Considerations of Declining Surgical Intervention: Balancing Patient Wishes with Fiduciary Responsibility.

ABSTRACT: Orthopaedic surgeons face increasing pressure to meet quality metrics due to regulatory changes and payment policies. Poor outcomes, including patient mortality, can result in financial penalties and negative ratings. Importantly, adverse outcomes often increase surgeon stress level and lead to job dissatisfaction and burnout. Despite optimization efforts, some orthopaedic patients remain at high risk for complications. In this article, we explore the ethical considerations when surgeons are presented with high-risk surgical candidates. We examine how the ethical tenets of patient interests, namely beneficence, nonmaleficence, autonomy, and justice, apply to such patients. We discuss external forces such as the malpractice environment, financial challenges in health-care delivery, and quality rankings. Informed consent and the challenges of communicating risks to patients are discussed, as well as the role of modifiable and nonmodifiable risk factors. Case examples with varied outcomes highlight the complexities of decision-making with high-risk patients and the potential role of palliative care. We provide recommendations for surgeons and care teams, including the importance of justifiable reasons for not operating, the utilization of institutional resources to help make care decisions, and the robust communication of risks to patients.