An Evaluation of Risk Factors for Patient "No Shows" at an Urban Joint Arthroplasty Clinic.

BACKGROUND: Patient physical health and provider financial health are both affected when patients are unable to attend scheduled clinic appointments. The purpose of this study is to identify risk factors for patients missing appointments to better target interventions to improve appointment attendance. METHODS: We reviewed scheduled arthroplasty appointments at an urban academic orthopaedic clinic over a 3-year period. We collected information including sex, race, distance to clinic, language, insurance, median income of home zip code, appointment day, time, precipitation, and temperature. Mixed-level multiple logistic regression was used to model the odds of missing appointments in Stata v14. RESULTS: Overall, 8,185 visits for 3,081 unique patients were reviewed and 90.7% of appointments were attended. After controlling for time and day of appointment, distance from the clinic, and the primary language spoken, patients with government insurance were two times as likely to miss an appointment compared with privately insured patients. White patients were two times as likely to attend scheduled appointments compared with black/Hispanic patients. Younger patients (<50 years) and older patients (>73 years) were 2.7 times and 1.8 times, respectively, more likely to miss appointments compared with those aged between 65 and 72 years. Appointments on the most temperate days were more likely to be missed, and those on the coldest days (14°F to 36°F) and warmest days (69°F to 89°F) were less likely to be missed. DISCUSSION: Appointment no shows are associated with sociodemographic and environmental factors. This information is valuable to help better delineate novel ways to better serve these patient populations.

Factors Determining Home Versus Rehabilitation Discharge Following Primary Total Joint Arthroplasty for Patients Who Live Alone.

Patients who are discharged home following primary hip and knee arthroplasty have lower associated costs and better outcomes than patients who are discharged to skilled nursing facilities (SNFs). However, patients who live alone are more likely to be discharged to an SNF. We studied the factors that determine the discharge destination for patients who live alone after total joint arthroplasty (TJA) at an urban tertiary care academic hospital between April 2016 and April 2017. We identified 127 patients who lived alone: 79 (62.2%) were sent home, and 48 (37.8%) were sent to an SNF after surgery. Patients who went home versus to an SNF differed in age, employment status, exercise/active status, patient expectation of discharge to an SNF, ASA score, and the length of stay. After controlling for expectations of discharge to an SNF (OR: 28.98), patients who were younger (OR: 0.03) and employed (OR: 6.91) were more likely to be discharged home. In conclusion, the expectation of discharge location was the strongest predictor of discharge to an SNF even after controlling for age and employment. Future research should include a multi-hospital approach to strengthen the validity of our findings and investigate additional factors that impact discharge destination.

Off the Market: The Percentage of Products Available After Ten Years.

BACKGROUND: We observed that medical devices advertised in journals are often no longer available 5 to 10 years after first being advertised. In this study, we quantified the percentage of products advertised from 2003 to 2008 in the Journal of Bone and Joint Surgery, American, which were still available 5 to 10 years after first being advertised. METHODS: We created a database of 427 unique orthopaedic products advertised in the Journal of Bone and Joint Surgery. In 2013, we classified products into categories: available in advertised form, available in modified form, available under a different manufacturer, and available but temporarily recalled, discontinued voluntarily, or discontinued by forced recall. RESULTS: A total of 13.8% of products were discontinued 5 to 10 years after being advertised. Three percent were discontinued through forced recall, and 10.8% were discontinued voluntarily. Of the products still available, 60.2% were in current form, 12.9% were modified, 11.9% were available under a different company, and 1.2% were available but were temporarily recalled. CONCLUSION: Five to 10 years after the initial advertisement, nearly 40% of products were not available in their original advertised form.

The 22-Modifier in Reimbursement for Orthopedic Procedures: Hip Arthroplasty and Obesity Are Worth the Effort.

BACKGROUND: Orthopedic surgeons utilize the 22-modifier when billing for complex procedures under the American Medical Association's Current Procedural Terminology (CPT) for reasons such as excessive blood loss, anatomic abnormality, and morbid obesity, cases that would ideally be reimbursed at a higher rate to compensate for additional physician work and time. We investigated how the 22-modifier affects physician reimbursement in knee and hip arthroplasty. METHODS: We queried hospital billing data from 2009 to 2016, identifying all cases performed at our urban tertiary care orthopedic center for knee arthroplasty (CPT codes 27438, 27447, 27487, and 27488) and hip arthroplasty (CPT codes 27130, 27132, 27134, 27236). We extracted patient insurance status and reimbursement data to compare the average reimbursement between cases with and without the 22-modifier. RESULTS: We analyzed data from 2605 procedures performed by 10 providers. There were 136 cases with 22-modifiers. For knee arthroplasty (n = 1323), the 22-modifier did not significantly increase reimbursement after adjusting for insurer, provider, and fiscal year (4.2% dollars higher on average, P = .159). For hip arthroplasty (n = 1282), cases with a 22-modifier had significantly higher reimbursement than those without the 22-modifier (6.2% dollars more, P = .049). For hip arthroplasty cases with a 22-modifier, those noting morbid obesity were reimbursed 29% higher than those cases with other etiology. CONCLUSIONS: The effect of the 22-modifier on reimbursement amount is differential between knee and hip arthroplasty. Hip arthroplasty procedures coded as 22-modifier are reimbursed more than those without the 22-modifier. Providers should consider these potential returns when considering submitting a 22-modifier.

National Trends in Primary Total Hip Arthroplasty in Extremely Young Patients: A Focus on Bearing Surface Usage From 2009 to 2012.

BACKGROUND: The ideal bearing surface for primary total hip arthroplasty (THA) in young patients remains a debate. Data on recent national trends are lacking. The purpose of this study is to provide an analysis on the national epidemiologic trends of bearing surface usage in patients aged ≤30 years undergoing THA from 2009 through 2012. METHODS: Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2009 to 2012, 9265 THA discharges (4210 coded by bearing surface) were identified in patients aged ≤30 years. Prevalence of surface type was analyzed along with patient and hospital demographic data. Statistical analysis was performed using SAS (SAS version 9.1; SAS, Inc, Cary, NC). Significance was set at P < .05. RESULTS: Ceramic-on-polyethylene (CoP) bearing surfaces were most commonly used, representing 35.6% of cases, followed by metal-on-polyethylene (MoP; 28.0%), metal-on-metal (MoM; 19.3%), and ceramic-on-ceramic (CoC; 17.0%) bearing surfaces. Hard-on-hard bearing surfaces (MoM and CoC) represented only 36.4% of cases, a significant decrease from previously reported findings (2006-2009) where hard-on-hard bearing surfaces were the majority (62.2%; P < .05). Hard-on-hard bearing surface usage decreased from 2009 to 2012 (MoM: 29.7% to 10.2%; CoC: 20.0% to 14.7%), whereas hard-on-soft bearing surface usage (MoP and CoP) increased. CoP bearing surfaces saw the most significant increase from 25.7% in 2009 to 48.2% in 2012. A cost analysis revealed that CoP discharges were associated with higher hospital charges than other surface types, with an average charge of $66,457 (P < .05). CONCLUSION: Use of hard-on-hard surfaces has decreased significantly in this population, whereas CoP and MoP surfaces have become increasingly common. Determining the optimal bearing surface for extremely young patients continues to be a challenge for orthopedic surgeons as they weigh the risks and benefits of each.

Ethnic Barriers to Utilization of Total Joint Arthroplasty Among Chinese Immigrants in the United States.

BACKGROUND: Previous studies have documented disparities in total joint arthroplasty (TJA) utilization among African American and Hispanic patients, but utilization among non-English-speaking Chinese patients in the United States has not been studied. METHODS: To quantify the utilization rate and detect ethnic factors effecting TJA utilization in non-English-speaking Chinese patients, data were gathered prospectively from the practice of a single fellowship-trained Caucasian surgeon from October 2012 to February 2013. A customized survey was drafted and validated in collaboration with a social scientist. Questions assessed demography, lifestyle factors, socioeconomic status, language skills, cultural beliefs, and prior experience with surgery. Surveys were administered in patients' native language and were collected in a blinded fashion. RESULTS: Overall, 269 patients were surveyed (157 Caucasian and 65 Chinese), 85 of which were recommended surgery (42 Caucasian and 26 Chinese). Seventy-six percent of Caucasian patients elected surgery, compared to 35% of Chinese patients. A multivariate logistic regression showed Chinese ethnicity to be a significant predictor of surgical decision after controlling for age, gender, socioeconomic status, and education. Several questions drafted to detect cultural differences in the aforementioned 6 categories were answered significantly differently (P < .05, chi-square). CONCLUSION: Language, lack of familiarity with surgery, lack of TJA knowledge, family members' role in decision making, and preference for a doctor of the same race may contribute to decreased utilization of TJA in this population. We believe a better understanding of the cultural beliefs and behaviors of Chinese patients will help physicians provide more optimal care to this patient population.

Total Joint Arthroplasty in Patients Taking Methadone or Buprenorphine/Naloxone Preoperatively for Prior Heroin Addiction: A Prospective Matched Cohort Study.

BACKGROUND: Preoperative narcotic use has been associated with poor outcomes after total joint arthroplasty (TJA). The purpose of this study is to compare clinical outcomes of patients undergoing elective TJA while concurrently being treated with methadone or buprenorphine/naloxone for prior heroin addiction to a matched control group. METHODS: From an electronic medical record, we collected age, gender, body mass index, the presence of back pain, smoking status, history of alcohol abuse, preoperative use of a pain clinic, and use of antipsychotics, antidepressants, or systemic corticosteroids. Validated outcome measures including the 12-Item Short Form Survey, Knee Society Score (KSS), and Harris Hip Score were used to assess functional outcomes preoperatively and postoperatively. Perioperative data were retrospectively obtained from patient charts. Postoperative functional outcomes were prospectively collected at follow-up visits. Subjects were matched to 2:1 control group on the basis of procedure, sex, diagnosis, age (±5 years), and body mass index (±5 kg/m(2)). Average follow-up was 27.2 months. RESULTS: Significant preoperative differences between the groups included mean morphine-equivalent requirements (997.1 mg for study group vs 24.8 mg for controls), 12-Item Short Form Survey Mental Component Scores (MCS-12; 37.8 for study group vs 49.0 for controls), smoking history, and antipsychotic medication use. Perioperative referral to inpatient Acute Pain Service and mean in-hospital morphine-equivalent narcotic usage (793 mg/24 h for study group vs 109 mg/24 h for controls) also significantly differed between groups. Knee range of motion differed significantly between the cohorts at 1 year (77.5 for study group vs 109.4); however, no significant difference in KSS pain (87.6 vs 84.4), KSS function (61 vs 80.9), Harris Hip Score (89.2 vs 85.3), MCS-12 (47.1 vs 52.9), or complications was observed. CONCLUSION: Equivalent pain control and successful clinical outcome at 1 year can be achieved in patients who use methadone or buprenorphine/naloxone preoperatively.