Cost-effectiveness of a patient-reported outcome-based remote monitoring and alert intervention for early detection of critical recovery after joint replacement: A randomised controlled trial.

BACKGROUND: While the effectiveness of patient-reported outcome measures (PROMs) as an intervention to impact patient pathways has been established for cancer care, it is unknown for other indications. We assessed the cost-effectiveness of a PROM-based monitoring and alert intervention for early detection of critical recovery paths following hip and knee replacement. METHODS AND FINDINGS: The cost-effectiveness analysis (CEA) is based on a multicentre randomised controlled trial encompassing 3,697 patients with hip replacement and 3,110 patients with knee replacement enrolled from 2019 to 2020 in 9 German hospitals. The analysis was conducted with a subset of 546 hip and 492 knee replacement cases with longitudinal cost data from 24 statutory health insurances. Patients were randomised 1:1 to a PROM-based remote monitoring and alert intervention or to a standard care group. All patients were assessed at 12-months post-surgery via digitally collected PROMs. Patients within the intervention group were additionally assessed at 1-, 3-, and 6-months post-surgery to be contacted in case of critical recovery paths. For the effect evaluation, a PROM-based composite measure (PRO-CM) was developed, combining changes across various PROMs in a single index ranging from 0 to 100. The PRO-CM included 6 PROMs focused on quality of life and various aspects of physical and mental health. The primary outcome was the incremental cost-effectiveness ratio (ICER). The intervention group showed incremental outcomes of 2.54 units PRO-CM (95% confidence interval (CI) [0.93, 4.14]; p = 0.002) for patients with hip and 0.87 (95% CI [-0.94, 2.67]; p = 0.347) for patients with knee replacement. Within the 12-months post-surgery period the intervention group had less costs of 376.43€ (95% CI [-639.74, -113.12]; p = 0.005) in patients with hip, and 375.50€ (95% CI [-767.40, 16.39]; p = 0.060) in patients with knee replacement, revealing a dominant ICER for both procedures. However, it remains unclear which step of the multistage intervention contributes most to the positive effect. CONCLUSIONS: The intervention significantly improved patient outcomes at lower costs in patients with hip replacements when compared with standard care. Further it showed a nonsignificant cost reduction in knee replacement patients. This reinforces the notion that PROMs can be utilised as a cost-effective instrument for remote monitoring in standard care settings. TRIAL REGISTRATION: Registration: German Register for Clinical Studies (DRKS) under DRKS00019916.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review.

PURPOSE OF REVIEW: To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures. RECENT FINDINGS: Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

The environmental impact of hip and knee arthroplasty: An analysis of carbon emissions and disposal costs.

BACKGROUND AND PURPOSE: The rise in hip and knee arthroplasty for osteoarthritis requires addressing healthcare system pollution to support Ireland's climate change goals. This research aimed to quantify waste generated and determine environmental and economic impacts to promote sustainable strategies in joint arthroplasty and shed light on the suboptimal waste management practices. METHODS: The study was conducted at National Orthopaedic Hospital Cappagh (NOHC), measuring waste generated during hip and knee arthroplasty. Clinical, domestic, and recycled waste weights were recorded, including the segregation of Central Sterile Supply Department (CSSD) Blue Wrap waste in ten operations. Kilograms of carbon dioxide emissions (kgCO2e) and disposal costs were calculated. RESULTS: In a sample of 100 joint arthroplasty operations, the study found that revision knees produced 23.58 â€‹kgCO2e per case, revision hips 23.50 â€‹kgCO2e, primary knees 15.82 â€‹kgCO2e, and primary hips 14.64 â€‹kgCO2e. CSSD Blue Wrap contributed on average 13.5% of OT waste. Extrapolating these findings to the estimated number of joint arthroplasties performed in 2022 â€‹at NOHC (1556 hip and knee joint arthroplasties), the emissions were estimated to be 24,576 kgCO2e, with the cost of disposal up to €29,228. Strategies to mitigate this waste have been identified and proposed. CONCLUSION: The research aimed to address the environmental impact of orthopaedic joint arthroplasties, offering strategies to reduce waste generation, carbon emissions, and cost. Utilising our methodology to calculate greenhouse gas emissions will empower sustainability offices to conduct their own waste audits and implementing our strategies for waste management practices can help minimise environmental waste.

The Financial Feasibility of Bilateral Total Knee Arthroplasty: A Matched Cohort Analyses of Revenue and Contribution Margin Between Simultaneous and Staged Procedures.

BACKGROUND: Financial analyses of simultaneous bilateral total knee arthroplasty versus staged bilateral total knee arthroplasty (simBTKA and staBTKA, respectively) have shown improved cost-effectiveness of simBTKA, though revenue and contribution margin (CM) for these procedures have not been investigated. Our analyses compared surgical outcomes, revenues, and CMs between simBTKA and staBTKA. METHODS: We retrospectively reviewed all patients who underwent simBTKA (both procedures done on the same day) and staBTKA (procedures done on a different day within one year) between 2012 and 2021. Patients were 1:1 propensity matched based on baseline characteristics. Surgical outcomes, as well as revenue, cost, and CM of the inpatient episode were compared between groups. Of the 2,357 patients evaluated (n = 595 simBTKA, n = 1,762 staBTKA), 410 were included in final matched analyses (205 per group). RESULTS: Total (P < .001) and direct (P < .001) costs were significantly lower for simBTKA procedures compared to overall costs of both staBTKA procedures. Significantly lower revenue for simBTKA procedures (P < .001), resulted in comparable CM between groups (P = .477). Postoperative complications including 90-day readmission (P = 1.000), 90-day revision (P = 1.000) and all-cause revision at latest follow-up (P = .083) were similar between groups. CONCLUSIONS: In our propensity-matched cohort, lower costs for simBTKA compared to staBTKA were matched by lower revenues, with a resulting similar CM between procedures. Given that postoperative complication rates were similar, both procedures had comparable cost-effectiveness. Future research is needed to identify patients for whom simBTKA may represent a better surgical intervention compared to staBTKA with respect to clinical and patient reported outcomes.

Can You Pay Your Way to Readership? Free to Publish Open Access Formats Receive Greater Readership and Citations Than Paid Open Access Formats in Total Knee Arthroplasty Literature.

BACKGROUND: As publishing with open access is becoming increasingly popular within orthopaedics, understanding the types of publishing options available and what each may deliver is critically important. Hybrid articles require a high article processing charge. Open journal articles have a lower fee, while closed license articles are freely accessible at no charge. Open repository articles are peer-reviewed manuscripts posted freely online. The purpose of this study was to determine the relationship between article type and resulting citations, social media attention, and readership in total knee arthroplasty (TKA) literature. METHODS: Open access TKA journal articles published since 2016 were found using the Altmetric Explorer Database. Data gathered included the Altmetric Attention Score (attention), Mendeley Readership Score (readership), and citations per article. Articles were grouped by type: open journal, hybrid, closed license, and open repository. Results were analyzed using descriptive statistics and Tukey's analysis; α = 0.05. RESULTS: A total of 9,606 publications were included. The open repository had the greatest mean citations (14.40), while open journal (9.55) had fewer than all other categories (P < .001). Hybrid had the greatest mean attention (10.35), and open journal (6.16) had a lower mean attention than all other categories (P ≤ .002). Open repository had the greatest mean readership (44.68), and open journal (34.00) had a lower mean readership than all other categories (P ≤ .012). The mean publication fee for paid publication options was $1,792 United States dollars. CONCLUSIONS: In open access TKA literature, free-to-publish open repositories had the greatest mean citations and readership. Free publication options, open repositories and closed licenses, had greater readership compared to paid publication options.

Risk Versus Reward: Hospitals Incentivized More Than Surgeons to Care for Riskier Arthroplasty Patients.

BACKGROUND: The purpose of this study was to assess the relationship between risk and reimbursement for both surgeons and hospitals among Medicare patients undergoing primary total joint arthroplasty (TJA). METHODS: The "2021 Medicare Physician and Other Provider" and "2021 Medicare Inpatient Hospitals" files were used. Patient comorbidity profiles were collected, including the mean patient hierarchal condition category (HCC) risk score. Surgeon data included all primary TJA procedures (inpatient and outpatient) billed to Medicare in 2021, while hospital data included all such inpatient episodes. Surgeon and hospital reimbursements were collected. All episodes were split into a "sicker cohort" with an HCC risk score of 1.5 or more and a "healthier cohort" with HCC risk scores less than 1.5. Variables were compared across cohorts. RESULTS: In 2021, 386,355 primary total hip and knee arthroplasty procedures were billed to Medicare and were included. The mean surgeon reimbursement among the sicker cohort was $1,021.91, which was less than for the healthier cohort of $1,060.13 (P < .001). Meanwhile, for the hospital analysis, 112,012 Medicare TJA patients were admitted as inpatients and included. The mean reimbursement to hospitals was significantly greater for the sicker cohort at $13,950.66, compared to the healthier cohort of $8,430.46. For both analyses, the sicker patient cohorts had a significantly higher rate of all comorbidities assessed (P < .001). CONCLUSIONS: This study demonstrates that mean surgeon reimbursement was lower for primary TJA among sicker patients in comparison to their healthier counterparts, while hospital reimbursement was higher for sicker patients. This represents a discrepancy in the incentivization of care for complex patients, as hospitals receive increased remuneration for taking on extra risk, while surgeons get paid less on average for performing TJA on sicker patients. Such data should inform future policy to assure continued access to arthroplasty care among complex patients.

Identification of Surgeon Outliers to Improve Cost Efficiency: A Novel Use of the Centers for Medicare and Medicaid Quality Payment Program.

BACKGROUND: Bundled payment programs for total joint arthroplasty (TJA) have become popular among both private and public payers. Because these programs provide surgeons with financial incentives to decrease costs through reconciliation payments, there is an advantage to identifying and emulating cost-efficient surgeons. The objective of this study was to utilize the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) in combination with institutional data to identify cost-efficient surgeons within our region and, subsequently, identify cost-saving practice patterns. METHODS: Data was obtained from the CMS QPP for total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeons within a large metropolitan area from January 2019 to December 2021. A simple linear regression determined the relationship between surgical volume and cost-efficiency. Internal practice financial data determined whether patients of identified surgeons differed with respect to x-ray visits, physical therapy visits, out-of-pocket payments to the practice, and whether surgery was done in hospital or surgical center settings. RESULTS: There were 4 TKA and 3 THA surgeons who were cost-efficiency outliers within our area. Outliers and nonoutlier surgeons had patients who had similar body mass index, American Society of Anesthesiologists Physical Status Score, and age-adjusted Charlson Comorbidity Index scores. Patients of these surgeons had fewer x-ray visits for both TKA and THA (1.06 versus 1.11, P < .001; 0.94 versus 1.15, P < .001) and lower out-of-pocket costs ($86.10 versus $135.46, P < .001; $116.10 versus $177.40, P < .001). If all surgeons performing > 30 CMS cases annually within our practice achieved similar cost-efficiency, the savings to CMS would be $17.2 million for TKA alone ($75,802,705 versus $93,028,477). CONCLUSIONS: The CMS QPP can be used to identify surgeons who perform cost-efficient surgeries. Practice patterns that result in cost savings can be emulated to decrease the cost curve, resulting in reconciliation payments to surgeons and institutions and cost savings to CMS.

Is It Getting More Expensive to Treat Patients Who Have a High Comorbidity Burden? Financial Trends in Total Knee Arthroplasty From 2013 to 2021.

BACKGROUND: Utilization of total knee arthroplasty (TKA) continues to rise among patients who have a high comorbidity burden (HCB). With changes in reimbursement models over the past decade, it is essential to assess the financial impact of HCB TKA on healthcare systems. This study aimed to examine trends in revenue and costs associated with TKA in HCB patients over time. METHODS: Of 14,978 TKA performed at a large, urban academic medical center between 2013 and 2021, we retrospectively analyzed HCB patients (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores of 3 or 4). A total of 1,156 HCB TKA patients who had complete financial data were identified. Patient demographics, perioperative data, revenue, costs, and contribution margin were collected for each patient. Changes in these financial values over time, as a percentage of 2013 values, were analyzed. Linear regression was performed with a trend analysis to determine significance. RESULTS: From 2013 to 2021, the percentage of HCB TKAs per year increased from 4.2% in 2013 to 16.5% in 2021 (P < .001). The revenue of TKA in HCB patients remained steady (P = .093), while direct costs increased significantly (32.0%; P = .015), resulting in a decline of contribution margin to a low of 82.3% of 2013 margins. There was no significant change in rates of 90-day complications or home discharge following HCB TKA during the study period. CONCLUSIONS: The results of this study indicate a major rise in cost for TKA among HCB patients, without a corresponding rise in revenue. As more patients who have HCB become candidates for TKA, the negative financial impact on institutions should be considered, as payments to institutions do not adequately reflect patient complexity. A re-evaluation of institutional payments for medically complex TKA patients is warranted to maintain patient access among at-need populations.

The 22-Modifier in Total Hip and Knee Arthroplasty: A Comprehensive Analysis.

BACKGROUND: The 22-modifier requests additional compensation for increased case complexity. Unfortunately, there is little to guide physicians on the application, which may increase successful reimbursement. We sought to evaluate various factors affecting reimbursement of the 22-modifier in primary total joint arthroplasty (TJA) and report which factors contributed to successful utilization. METHODS: In this retrospective study, all cases from a single practice where the 22-modifier was added to Current Procedural Terminology codes: 27130 (total hip arthroplasty) and 27447 (total knee arthroplasty) from October 2018 to March 2022 were evaluated. Out of the 6,869 total cases performed, 816 22-modifier cases were identified (11.9%). Operative reports, demographics, insurance type, billing information, and clinical records were assessed. T-tests were used to determine statistical significance. RESULTS: Of the 816 cases, 221 (27.1%) were successfully reimbursed. Cases justified 22-modifier application with obesity, anatomic variations, or intraoperative factors. Some cases lacked justification, or operative reports were not submitted. Reimbursement was successful for 27.6% of obesity cases, 29.7% of intraoperative complications, and 35.7% of anatomic variations. There was a significantly higher likelihood of Medicare reimbursement than third-party payers or Medicaid (69.6 versus 20.5 and 6.9%) (P < .0001). Additionally, Medicare was more likely to reimburse for obesity (76.6 versus 20.0, and 5.2%), anatomic variations (77.3 versus 22.0%), and intraoperative factors (66.6 versus 21.1, and 1.7%). CONCLUSIONS: Reimbursement for 22-modifier cases in TJA is unlikely. Obesity was cited for most 22-modifier justifications, but anatomic variation justification was successfully reimbursed most often. Medicare was most likely to reimburse compared to third-party payers or Medicaid. These findings should be considered when applying a 22-modifier to TJA procedures.

Financial Conflicts of Interest and Industry Funding are Associated With Conclusions Favorable to New Technologies: A Review of Published Economic Analyses in Hip and Knee Arthroplasty.

BACKGROUND: New technologies in hip and knee arthroplasty are commonly evaluated using cost-effectiveness analyses and similar economic assessments. There is a wide variation in the methodology of these studies, introducing the potential for bias. The purpose of this study was to evaluate associations between potential financial conflicts of interest (COI) and the outcomes of economic analyses. We hypothesized that authors' COI and industry funding would be associated with conclusions favorable to a new technology. METHODS: Economic analyses making cost-effectiveness or economic implementation claims on patient-specific instrumentation, robotics, and implants used in hip and knee arthroplasty published from 2010 to 2022 were identified. Papers were evaluated to determine if conclusions were favorable to the new technology being studied. Fisher's exact test was utilized to determine the relationship between the presence of COI and an article's conclusions. RESULTS: Of 43 eligible articles, 76.7% were cost-effectiveness analyses, 23.2% were cost analyses, and 67.4% of articles had conclusions favorable to a technology. Of the 29 articles with favorable conclusions, 26 had an author with a financial COI (89.7%), and 14 had industry funding (48.3%). Of the 33 articles with a financial COI, 26 (78.8%) had favorable conclusions, and of the 16 articles with industry funding, 14 (87.5%) had favorable conclusions. Fisher's exact test revealed a statistically significant association between an article having favorable conclusions and the presence of an author's COI or industry funding (odds ratio, 13.5; 95% CI [confidence interval], 2.3 to 79.9; P = .003). CONCLUSIONS: Financial COIs were present in 79.1% of lower extremity arthroplasty economic analyses on technologies and were associated with an article having conclusions favorable to the new technology. Surgeons and decision-makers should be aware of the variability and assumptions in these studies and the potential bias of the conclusions.

Demographic and Socioeconomic Trends of Patients Undergoing Total Knee Arthroplasty From 2013 to 2022-An Analysis From an Urban Orthopaedic Hospital.

BACKGROUND: As worldwide utilization of total knee arthroplasty (TKA) broadens, demographic trends can help make projections to inform access to care. This study aimed to assess the temporal trends in the socioeconomic and medical demographics of patients undergoing TKA. METHODS: A retrospective review of 15,848 patients who underwent primary, elective TKA at an urban, New York City-based academic medical center between January 2013 and September 2022 was performed. Trends in patients' age, body mass index (BMI), socioeconomic status (SES) (based on median income by patients' ZIP code), race, and Charlson comorbidity index were evaluated using the Mann-Kendall test. RESULTS: In the last decade, mean patient age (65 to 68 years, P < .001) and Charlson comorbidity index (1.4 to 2.3, P < .001) increased significantly. The proportion of patients who had a BMI ≥ 30 and < 40 increased (43.8 to 51.2%, P = .002), while the proportion of patients who had a BMI ≥ 40 (13.7 to 12.1%, P = .015) and BMI < 30 (42.5 to 36.8%, P = .020) decreased. The distribution of patients' race and SES did not change from 2013 to 2022; Black (18.1 to 16.8%, P = .211) and low SES (12.9 to 11.3%, P = .283) patients consistently represented a minority of TKA patients. CONCLUSIONS: Over the last decade, the average age and comorbidity burden of TKA patients at our institution have increased. This portends the need for higher levels of preoperative optimization and postoperative management for TKA patients. A decreased prevalence of BMI ≥40 could reflect optimization efforts. However, the consistently low prevalence of Black and low-SES patients suggests that recent payment models did not improve access to care for these populations. LEVEL OF EVIDENCE: IV.

Revision Arthroplasty Among Medicare Patients in the United States - Arthroplasty Surgeons are Doing More for Less.

BACKGROUND: Previously documented trends of major joint arthroplasty demonstrate increasing volume and decreasing reimbursement for primary total knee and total hip arthroplasty procedures. As such, the purpose of this study was to evaluate trends in revision knee and hip arthroplasty volume and true Medicare reimbursements to physicians. METHODS: The publicly accessible Centers for Medicare and Medicaid files were evaluated. Data were retrieved from the Part B National Summary Data File and queried for revision knee and hip arthroplasty billed to Medicare from 2000 to 2021. The total charge submitted to Medicare, Medicare reimbursement, number of revision arthroplasty surgeries performed, and average reimbursement per surgery were collected for each year. All monetary data were adjusted for inflation to 2021 dollars. RESULTS: There were 492,360 revision total knee arthroplasty surgeries and 424,163 revision hip arthroplasty procedures billed to Medicare from 2000 to 2021. Medicare was billed a total of $919,603,674.86 for revision knee and $862,979,761.57 for revision hip arthroplasty during that time. Medicare reimbursed physicians an average of $1,499.89 per knee revision and $1,603.32 per hip revision surgery. The total volume of revision knee arthroplasty increased by 9,380 (62%) and revision hip decreased by 1,743 (9%) from the year 2000 to 2021. However, there was a decrease of average reimbursement per procedure of more than 37% ($1,987.14 to 1,254) and 39% ($2,149.87 to 1,311.17), respectively. CONCLUSIONS: Despite a notable increase in the volume of revision total knee and stagnant revision hip arthroplasty, total billings to and reimbursements from Medicare for these procedures have not changed markedly per year. Importantly, this means that physicians are conducting more of these high-impact procedures yearly, while being reimbursed per procedure at a declining rate. This may indicate a need to re-assess billing and reimbursement rates for revision arthroplasty, in the context of the ever-increasing inflation rate.

Practice Management Strategies Among Current Members of the American Association of Hip and Knee Surgeons.

BACKGROUND: A survey was conducted at the 2023 Annual Meeting of the American Association of Hip and Knee Surgeons (AAHKS) to assess practice management strategies among current AAHKS members. METHODS: Members of AAHKS used an app to answer both multiple-choice and "yes or no" questions related to a variety of issues related to their practices. RESULTS: The number of AAHKS members in private practice (37%) continues to decline, and 4% are now in private equity-employed practices. Fee for service (30%) and relative value units (30%) are the major forms of compensation. The number of AAHKS members that perform total joint arthroplasties at ambulatory surgery centers continues to increase, and supply chain issues (91%) remain a problem. There has been a decrease in surgeon participation in bundled payment programs and gainsharing arrangements with hospitals. CONCLUSIONS: This member's survey provides valuable information regarding practice patterns. The shift to outpatient surgery has continued. Future surveys will be performed to monitor changes in practice patterns over time.

Revision Total Knee Arthroplasty in an Outpatient Setting: A Growing Alternative.

BACKGROUND: Recent studies have focused on the safety and efficacy of performing primary total knee arthroplasty (TKA) in an outpatient setting. Despite being associated with greater costs, much less is known about the accompanying impact on revision TKA (rTKA). The purpose of this study was to describe the trends in costs and outcomes of patients undergoing inpatient and outpatient rTKA. METHODS: An observational cohort study was conducted using commercial claims databases. Patients who underwent 1-component and 2-component rTKA in an inpatient setting, hospital outpatient department (HOPD), or ambulatory surgery center (ASC) from 2018 to 2020 were included. The primary outcome was the 30-day episode-of-care costs following rTKA. Secondary outcomes included surgical cost, 90-day readmission rate, and emergency department visit rate. Covariates for analyses included patient demographics, surgery type, and indication for revision. RESULTS: There were 6,515 patients who were identified, with 17.0% of rTKAs taking place in an outpatient setting. On adjusted analysis, patients in the highest quartile of 30-day postoperative costs were more likely to be those whose rTKA was performed in an inpatient setting. One-component revisions were more common in an outpatient setting (HOPD, 50.7%; ASC, 62.0%) compared to an inpatient setting (39.6%). The 90-day readmission rates were higher (P = .003) for rTKAs performed in inpatient (+9.2%) and HOPD (+8.6%) settings compared to those in an ASC. CONCLUSIONS: The ASC may be a suitable setting for simpler revisions performed for less severe indications and is associated with lower costs and 90-day readmission and emergency department visit rates.

Inpatient Hospital Costs, Emergency Department Visits, and Readmissions for Revision Hip and Knee Arthroplasty.

BACKGROUND: Revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) tremendously burden hospital resources. This study evaluated factors influencing perioperative costs, including emergency department (ED) visits, readmissions, and total costs-of-care within 90 days following revision surgery. METHODS: A retrospective analysis of 772 revision TKAs and THAs performed on 630 subjects at a single center between January 2007 and December 2019 was conducted. Cost data were available from January 2015 to December 2019 for 277 patients. Factors examined included comorbidities, demographic information, preoperative Anesthesia Society of Anesthesiologists score, implant selection, and operative indication using mixed-effects linear regression models. RESULTS: Among 772 revisions (425 THAs and 347 TKAs), 213 patients required an ED visit, and 90 required hospital readmission within 90 days. There were 22.6% of patients who underwent a second procedure after their initial revision. Liver disease was a significant predictor of ED readmission for THA patients (multivariable odds ratio [OR]: 3.473, P = .001), while aseptic loosening, osteolysis, or instability significantly reduced the odds of readmission for TKA patients (OR: 0.368, P = .014). In terms of ED visits, liver disease increased the odds for THA patients (OR: 1.845, P = .100), and aseptic loosening, osteolysis, or instability decreased the odds for TKA patients (OR: 0.223, P < .001). Increased age was associated with increased costs in both THA and TKA patients, with significant cost factors including congestive heart failure for TKA patients (OR: $7,308.17, P = .004) and kidney disease for THA patients. Revision surgeries took longer than primary ones, with TKA averaging 3.0 hours (1.6 times longer) and THA 2.8 hours (1.5 times longer). CONCLUSIONS: Liver disease increases ED readmission risk in revision THA, while aseptic loosening, osteolysis, or instability decreases it in revision TKA. Increased age and congestive heart failure are associated with increased costs. These findings inform postoperative care and resource allocation in revision arthroplasty. LEVEL OF EVIDENCE: Economic and Decision Analysis, Level IV.

The Utility of the Social Vulnerability Index as a Proxy for Social Disparities Following Total Knee Arthroplasty.

BACKGROUND: In 2021, alternative payment models accounted for 40% of traditional Medicare reimbursements. As such, we sought to examine health disparities through a standardized categorization of social disparity using the social vulnerability index (SVI). We examined (1) risk factors for SVI ≥ 0.50, (2) incidences of complications, and (3) risk factors for total complications between patients who have SVI < 0.50 and SVI ≥ 0.50 who had a total knee arthroplasty (TKA). METHODS: Patients who underwent TKA between January 1, 2022 and December 31, 2022 were identified in the state of Maryland. A total of 4,952 patients who had complete social determinants of health data were included. Patients were divided into 2 cohorts according to SVI: < 0.50 (n = 2,431) and ≥ 0.50 (n = 2,521) based on the national mean SVI of 0.50. The SVI identifies communities that may need support caused by external stresses on human health based on 4 themed scores: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. The SVI theme of household composition and disability encompassed patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies. The higher the SVI, the more social vulnerability or resources are needed to thrive in a geographic area. RESULTS: When controlling for risk factors and patient comorbidities, the theme of household composition and disability (odds ratio 2.0, 95% confidence interval 1.1 to 5.0, P = .03) was the only independent risk factor for total complications. Patients who had an SVI ≥0.50 were more likely to be women (65.8% versus 61.0%, P < .001), Black (34.4% versus 12.9%, P < .001), and have a median household income < $87,999 (21.3% versus 10.2%, P < .001) in comparison to the patients who had an SVI < 0.50, respectively. CONCLUSIONS: The SVI theme of household composition and disability, encompassing patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies, were independent risk factors for total complications following TKA. Together, these findings offer opportunities for interventions with selected patients to address social disparities.

Significant Cost Savings and Improved Early Clinical Outcomes in Medicare Patients Utilizing a Clinician-Controlled Telerehabilitation System Following Total Knee Arthroplasty.

BACKGROUND: The costs and benefits of different rehabilitation protocols following total knee arthroplasty are unclear. The emergence of telerehabilitation has introduced the potential for enhanced patient convenience and cost reduction. The purpose of this study was to assess the cost difference between standard physical therapy (SPT) and a telerehabilitation home-based clinician-controlled therapy system (HCTS). METHODS: A prospectively enrolled, consecutive series of 109 Medicare patients who received SPT were compared to 101 Medicare patients who were treated with a HCTS. The analysis focused on total rehabilitation costs and the assessment of outcome measures: knee range of motion, visual analog scale pain levels, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement. RESULTS: The HCTS group demonstrated not only statistically significantly lower average costs but also faster and sustained knee range of motion improvements. Furthermore, in comparison to SPT, the HCTS group exhibited superior visual analog scale pain scores and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement functional scores at all assessment points postoperatively, which were statistically significant (all P < .001) and surpassed the minimal clinically important difference thresholds. CONCLUSIONS: The HCTS used in this study exhibited a remarkable cost-saving advantage of $2,460 per patient compared to standard therapy. As approximately 500,000 primary total knee arthroplasties in the United States are covered by Medicare annually, a switch to HCTS could yield total cost savings of more than $1.23 billion per year for our taxpayer-funded health care system. Furthermore, the HCTS cohort demonstrated superior functional outcomes and improved pain scores across all assessment time points, exceeding the minimal clinically important difference.

Preoperative Depression Screening for Primary Total Knee Arthroplasty: An Evaluation of Its Modifiability on Outcomes in Patients Who Have Depression.

BACKGROUND: Few studies have evaluated preoperative depression screenings in patients who have depression. We studied whether depression screenings before total knee arthroplasty (TKA) were associated with lower: 1) medical complications; 2) emergency department (ED) utilizations and readmissions; 3) implant complications; and 4) costs. METHODS: A nationwide sample from January 1, 2010, to April 30, 2021, was collected using an insurance database. Depression patients were 1:1 propensity-score matched based on those who had (n = 29,009) and did not have (n = 29,009) preoperative depression screenings or psychotherapy visits within 3 months of TKA. A case-matched population who did not have depression was compared (n = 144,994). A 90-day period was used to compare complications and health-care utilization and 2-year follow-up for periprosthetic joint infections (PJIs) and implant survivorship. Costs were 90-day reimbursements. Logistic regression models computed odds ratios (ORs) of depression screening on dependent variables. P values less than .001 were significant. RESULTS: Patients who did not receive preoperative screening were associated with higher medical complications (18.7 versus 5.2%, OR: 4.15, P < .0001) and ED utilizations (11.5 versus 3.2%, OR: 3.93, P < .0001) than depressed patients who received screening. Patients who had screening had lower medical complications (5.2 versus 5.9%, OR: 0.88, P < .0001) and ED utilizations compared to patients who did not have depression (3.2 versus 3.8%, OR: 0.87, P = .0001). Two-year PJI incidences (3.0 versus 1.3%, OR: 2.63, P < .0001) and TKA revisions (4.3 versus 2.1%, OR: 2.46, P < .0001) were greater in depression patients who were not screened preoperatively versus screened patients. Depression patients who had screening had lower PJIs (1.3 versus 1.8%, OR: 0.74, P < .0001) compared to nondepressed patients. Reimbursements ($13,949 versus $11,982; P < .0001) were higher in depression patients who did not have screening. CONCLUSIONS: Preoperative screening was associated with improved outcomes in depression patients. LEVEL OF EVIDENCE: III.

Direct Hospital Costs per Case of Periprosthetic Hip and Knee Joint Infections in Europe - A Systematic Review.

BACKGROUND: The rise of periprosthetic joint infections (PJIs) due to aging populations is steadily increasing the number of arthroplasties and treatment costs. This study analyzed the direct health care costs of PJI for total hip arthroplasty and total knee arthroplasty (TKA) in Europe. METHODS: The databases PubMed, Scopus, Embase, Cochrane, and Google Scholar were systematically screened for direct costs of PJI in Europe. Publications that defined the joint site and the procedure performed were further analyzed. Mean direct health care costs were calculated for debridement, antibiotics, and implant retention (DAIR), one-stage, and 2-stage revisions for hip and knee PJI, respectively. Costs were adjusted for inflation rates and reported in US-Dollar (USD). RESULTS: Of 1,374 eligible publications, 12 manuscripts were included in the final analysis after an abstract and full-text review. Mean direct costs of $32,933 were identified for all types of revision procedures for knee PJI. The mean direct treatment cost including DAIR for TKA after PJI was $19,476. For 2-stage revisions of TKA, the mean total cost was $37,980. For all types of hip PJI procedures, mean direct hospital costs were $28,904. For hip DAIR, one-stage and 2-stage treatment average costs of $7,120, $44,594, and $42,166 were identified, respectively. CONCLUSIONS: Periprosthetic joint infections are associated with substantial direct health care costs. As detailed reports on the cost of PJI are scarce and of limited quality, more detailed financial data on the cost of PJI treatment are urgently required.

A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Health Care Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient.

BACKGROUND: Socioeconomic status has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in the following: (1) medical complications; (2) emergency department (ED) utilizations; (3) readmissions; and (4) costs of care. METHODS: A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P values less than .003 were significant. RESULTS: High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = .0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = .001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < .0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = .0008). The 90-day expenditures ($15,066 versus $12,459; P < .0001) were higher in patients who have a high ADI. CONCLUSIONS: Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform health care policy and improve postdischarge care. The socioeconomic status metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost. LEVEL OF EVIDENCE: III.