Comparison of Long-Term Healthcare Cost and Utilisation of Nonoperative and Surgical Management of Thumb CMC Arthritis.

Background: Thumb carpometacarpal joint (CMC) osteoarthritis is the most symptomatic hand arthritis but the long-term healthcare burden for managing this condition is unknown. We sought to compare total healthcare cost and utilisation for operative and nonoperative treatments of thumb CMC arthritis. Methods: We conducted a retrospective longitudinal analysis using a large nationwide insurance claims database. A total of 18,705 patients underwent CMC arthroplasty (trapeziectomy with or without ligament reconstruction tendon interposition) or steroid injections between 1 October 2015 and 31 December 2018. Primary outcomes, healthcare utilisation and costs were measured from 1 year pre-intervention to 3 years post-intervention. Generalised linear mixed effect models adjusted for potentially confounding factors such as the Elixhauser comorbidity score with propensity score matching were applied to evaluate the association between the primary outcomes and treatment type. Results: A total of 13,646 patients underwent treatment through steroid injections, and 5,059 patients underwent CMC arthroplasty. At 1 year preoperatively, the surgery group required $635 more healthcare costs (95% CI [594.28, 675.27]; p < 0.001) and consumed 42% more healthcare utilisation (95% CI [1.38, 1.46]; p < 0.0001) than the steroid injection group. At 3 years postoperatively, the surgery group required $846 less healthcare costs (95% CI [-883.07, -808.51], p < 0.0001) and had 51% less utilisation (95% CI [0.49, 0.53]; p < 0.0001) annually. Cumulatively over 3 years, the surgical group on average was $4,204 costlier than its counterpart secondary to surgical costs. Conclusions: CMC arthritis treatment incurs high healthcare cost and utilisation independent of other medical comorbidities. At 3 years postoperatively, the annual healthcare cost and utilisation for surgical patients were less than those for patients who underwent conservative management, but this difference was insufficient to offset the initial surgical cost. Level of Evidence: Level III (Therapeutic).

A prospective study of lumbar facet arthroplasty in the treatment of degenerative spondylolisthesis and stenosis: cost-effective assessment from the Total Posterior Spine system (TOPSTM) IDE Study: 2-year model revision and sensitivity analyses based on 305 subjects.

BACKGROUND CONTEXT: A previous cost-effectiveness analysis published in 2022 found that the Total Posterior Spine (TOPSTM) system was dominant over transforaminal lumbar interbody fusion (TLIF). This analysis required updating to reflect a more complete dataset and pricing considerations. PURPOSE: To evaluate the cost-effectiveness of TOPSTM system as compared with TLIF based on an updated and complete FDA investigational device exemption (IDE) data set. STUDY DESIGN/SETTING: Cost-utility analysis of the TOPSTM system compared to TLIF. PATIENT SAMPLE: A multicenter, FDA IDE, randomized control trial (RCT) investigated the efficacy of TOPSTM compared to TLIF with a current population of n=305 enrolled and n=168 with complete 2-year follow-up. OUTCOME MEASURES: Cost and quality adjusted life years (QALYs) were calculated to determine our primary outcome measure, the incremental cost-effectiveness ratio. Secondary outcome measures included: net monetary benefit as well at willingness-to-pay (WTP) thresholds. METHODS: The primary outcome of cost-effectiveness is determined by incremental cost-effectiveness ratio. A Markov model was used to simulate the health outcomes and costs of patients undergoing TOPSTM or TLIF over a 2-year period. alternative scenario sensitivity analysis, one-way sensitivity analysis, and probabilistic sensitivity analysis were conducted to assess the robustness of the model results. RESULTS: The updated base case result demonstrated that TOPSTM was immediately and longitudinally dominant compared with the control with an incremental cost-effectiveness ratio of -9,637.37 $/QALY. The net monetary benefit was correspondingly $2,237, both from the health system's perspective and at a WTP threshold of 50,000 $/QALY at the 2-year time point. This remained true in all scenarios tested. The Alternative Scenario Sensitivity Analysis suggested cost-effectiveness irrespective of payer type and surgical setting. To remain cost-effective, the cost difference between TOPSTM and TLIF should be no greater than $1,875 and $3,750 at WTP thresholds of $50,000 and 100,000 $/QALY, respectively. CONCLUSIONS: This updated analysis confirms that the TOPSTM device is a cost-effective and economically dominant surgical treatment option for patients with lumbar stenosis and degenerative spondylolisthesis compared to TLIF in all scenarios examined.

Hospital resource use after hip reconstruction surgery in children with neurological complex chronic conditions.

AIM: To assess how co-occurring conditions influence recovery after hip reconstruction surgery in children with neurological complex chronic conditions (CCCs). METHOD: This was a retrospective analysis of 4058 children age 4 years or older with neurological CCCs who underwent hip reconstructive surgery between 1st January 2015 and 31st December 2018 in 49 children's hospitals. The presence of co-occurring chronic conditions was assessed using the Agency for Healthcare Research Chronic Condition Indicator system. Multivariable, hierarchical regression was used to assess the relationship between co-existing conditions and postoperative hospital length of stay (LOS), cost, and 30-day readmission rate. RESULTS: The most common co-occurring conditions were digestive (60.1%) and respiratory (37.9%). As the number of co-existing conditions increased from one to four or more, median LOS increased 67% (3d [interquartile range {IQR} 2-4d] to 5d [IQR 3-8d]); median hospital cost increased 41% ($20 248 [IQR $14 921-$27 842] to $28 692 [IQR $19 236-$45 887]); and readmission rates increased 250% (5.5-13.9%), p<0.001 for all. Of all specific co-existing chronic conditions, malnutrition was associated with the greatest increase in postoperative hospital resource use. INTERPRETATION: Co-occurring conditions, and malnutrition in particular, are a significant risk factor for prolonged, in-hospital recovery after hip reconstruction surgery in children with a neurological CCC. Further investigation is necessary to assess how improved preoperative optimization of multiple co-occurring conditions may improve postoperative outcomes and resource utilization. WHAT THIS PAPER ADDS: Children with neurological complex chronic conditions (CCCs) often develop hip disorders which require hip reconstruction surgery. Co-occurring conditions are common in children with neuromuscular CCCs. Having four or more chronic conditions was associated with a longer length of stay, increased costs, and higher odds of readmission. Malnutrition was a significant risk factor for prolonged hospitalization after hip reconstruction surgery.

Value of Cervical Disk Arthroplasty.

Over the last decade, several of the Food and Drug Administration-regulated investigational device exemption (IDE) trials have compared multiple cervical disk arthroplasty (CDA) devices to anterior cervical decompression and fusion (ACDF) showing comparable and even superior patient-reported outcomes. CDA has been an increasingly attractive option because of the positive outcomes and the motion-preserving technology. However, with the large burden that health care expenditures place on the economy, the focus is now on the value of treatment options. Cost-effectiveness studies assess value by evaluating both outcomes and cost, and recently several have been conducted comparing CDA and ACDF. The results have consistently shown that CDA is a cost-effective alternative, however, in comparison to ACDF the results remain inconclusive. The lack of incorporation of disease specific measures into health state utility values, the inconsistent methods of calculating cost, and the fact that a vast majority of the results have come from industry-sponsored studies makes it difficult to form a definitive conclusion. Despite these limitations, both procedures have proven to be safe, effective, and cost-efficient alternatives.

Shoulder arthroplasty volume standards: the more the better?

INTRODUCTION: The wide use of hip and knee arthroplasty has led to implementation of volume standards for hospitals and surgeons. For shoulder arthroplasty, the effect of volume on outcome has been researched, but no volume standard exists. This review assessed literature reporting on shoulder arthroplasty volumes and its relation to patient-reported and functional outcomes to define an annual volume threshold. MATERIALS AND METHODS: MEDLINE and EMBASE were searched for articles published until February 2018 reporting on the outcome of primary shoulder arthroplasty in relation to surgeon or hospital volume. The primary outcome was predefined as any patient-reported outcome. The secondary outcome measures were length of stay, costs, rates of mortality, complications, readmissions, and revisions. A meta-analysis was performed for outcomes reported by two or more studies. RESULTS: Eight retrospective studies were included and did not consistently show any associations of volume with in-hospital complications, revision, discharge to home or cost. Volume was consistently associated with length of stay (shorter length of stay for higher volume) and in-hospital complications (fewer in-hospital complications for higher volume). It was not consistently associated with mortality. Functional outcomes were not reported. CONCLUSIONS: There is insufficient evidence to support the concept that only the number of shoulder arthroplasties annually performed (either per hospital or per surgeon) results in better patient-reported and functional outcomes. Currently, published volume thresholds are only based on short-term parameters such as length and cost of hospital stay.

Comparative cost-effectiveness analysis of the subacromial spacer for irreparable and massive rotator cuff tears.

PURPOSE: There is ongoing debate regarding the optimal surgical treatment of irreparable rotator cuff tears (IRCT). This study aimed to assess within the Italian health care system the cost-effectiveness of subacromial spacer as a treatment modality for patients with IRCT. METHODS: An expected-value decision analysis was created comparing costs and outcomes of patients undergoing arthroscopic subacromial spacer implantation, rotator cuff repair (RCR), total shoulder arthroplasty, and conservative treatment for IRCTs. A broad literature search provided input data to extrapolate and inform treatment success and failure rates, costs, and health utility states for these outcomes. The primary outcome assessed was an incremental cost-effectiveness ratio (ICER) of subacromial spacer implantation versus shoulder arthroplasty, RCR, and conservative treatment. RESULTS: Subacromial spacer is favorable over both arthroscopic partial repair and shoulder arthroplasty since it costs less than both options and increases effectiveness by 0.06 and 0.10 quality-adjusted life years (QALYs), respectively. While conservative treatment is the least costly management strategy, subacromial spacer results in a gain of 0.05 QALYs for the additional cost of 522 €, resulting in an ICER of 10,440 €/QALY gain, which is below the standard willingness to pay ratio of $50,000 USD. Strategies with an ICER of less than 50,000 USD are considered to be cost-effective. CONCLUSIONS: Based on the available evidence and reasonably conservative assumptions, subacromial spacer is likely to provide a safe, effective, and cost-effective option for patients with massive IRCTs. Furthermore, this cost-effectiveness analysis may ultimately serve as a guide for development of health care system and insurer policy as well as clinical practice.

The Association Between Provider Price and Complication Rates for Outpatient Surgical Services.

BACKGROUND: Wide variations exist in price and quality for health-care services, but the link between price and quality remains uncertain. OBJECTIVE: This paper used claims data from a large commercially insured population to assess the association between both procedure- and provider-level prices and complication rates for three common outpatient surgical services. DESIGN: This is a retrospective cohort study. SETTING: The study used medical claims data from commercial health plans between 2009 and 2013 for three outpatient surgical services-joint arthroscopy, cataract surgery, and colonoscopy. MAIN MEASURES: For each procedure, price was assessed as the sum of patient, employer, and insurer spending. Complications were identified using existing algorithms specific to each service. Multivariate regressions were used to risk-adjust prices and complication rates. Provider-level price and complication rates were compared by calculating standardized differences that compared provider risk-adjusted price and complication rates with other providers within the same geographic market. The association between provider-level risk-adjusted price and complication rates was estimated using a linear regression. KEY RESULTS: Across the three services, there was an inverse association between both procedure- and provider-level prices and complication rates. For joint arthroscopy, cataract surgery, and colonoscopy, a one standard deviation increase in procedure-level price was associated with 1.06 (95% CI 1.05-1.08), 1.14 (95% CI 1.11-1.16), and 1.07 (95% CI 1.06-1.07) odds increases in the rate of procedural complications, respectively. A one standard deviation increase in risk-adjusted provider price was associated with 0.09 (95% CI 0.07 to 0.11), 0.02 (95% CI 0.003 to 0.05), and 0.32 (95% CI 0.29 to 0.34) standard deviation increases in the rate of provider risk-adjusted complication rates, respectively. LIMITATIONS: Results may be due to unobserved factors. Only three surgical services were examined, and the results may not generalize to other services and procedures. Quality measurements did not include patient satisfaction or experience measures. CONCLUSIONS: For three common outpatient surgical services, procedure- and provider-level prices are associated with modest increased rates of complication rates.

Robotics in Orthopedics: A Brave New World.

Future health-care projection projects a significant growth in population by 2020. Health care has seen an exponential growth in technology to address the growing population with the decreasing number of physicians and health-care workers. Robotics in health care has been introduced to address this growing need. Early adoption of robotics was limited because of the limited application of the technology, the cumbersome nature of the equipment, and technical complications. A continued improvement in efficacy, adaptability, and cost reduction has stimulated increased interest in robotic-assisted surgery. The evolution in orthopedic surgery has allowed for advanced surgical planning, precision robotic machining of bone, improved implant-bone contact, optimization of implant placement, and optimization of the mechanical alignment. The potential benefits of robotic surgery include improved surgical work flow, improvements in efficacy and reduction in surgical time. Robotic-assisted surgery will continue to evolve in the orthopedic field.

Trends in resource utilization and rate of cervical disc arthroplasty and anterior cervical discectomy and fusion throughout the United States from 2006 to 2013.

BACKGROUND CONTEXT: The typically accepted surgical procedure for cervical disc pathology has been the anterior cervical discectomy and fusion (ACDF), although recent trials have demonstrated equivalent or improved outcomes with cervical disc arthroplasty (CDA). Trends for these two procedures regarding utilization, revision procedures, and other demographic information have not been sufficiently explored. PURPOSE: The present study aims to provide data regarding ACDF and CDA from 2006 to 2013 in the United States. DESIGN: The present study is a retrospective national database analysis. PATIENT SAMPLE: The present study included 20% sample of discharges from US hospitals, which is weighted to provide national estimates. OUTCOME MEASURES: Functional measures such as national incidence, hospital costs, length of stay (LOS), routine discharge, revision burden, and patient characteristics were used in the present study. METHODS: Patients from the National Inpatient Sample (NIS) database who underwent primary ACDF, revision ACDF, primary CDA, and revision CDA from 2006 to 2013 were included. Demographic and economic data for the procedures' respective International Classification of Diseases, Ninth Revision, Clinical Modification codes were collected. RESULTS: A total of 1,059,403 ACDF and 13,099 CDA surgeries were performed in the United States from 2006 to 2013. The annual number of ACDF increased by 5.7% nonlinearly from 120,617 in 2006 to 127,500 in 2013 (mean per year 132,425; range 120,617-147,966); CDA increased by 190% nonlinearly from 540 in 2006 to 1,565 in 2013 (mean per year 1,637; range 540-2,381). Cervical disc arthroplasty patients were younger and had more private or "other" insurance, including worker's compensation (p<.0001). Mean LOS was longer for ACDF (ACDF 2.3 days vs. CDA 1.5; p<.0001). Routine discharge was higher in the CDA group (CDA 96% vs. ACDF 89%; p-value<.0001). The mean hospital-related cost was more expensive for ACDF (ACDF $16,178 vs. CDA $13,197; p-value=.0007). Cervical disc arthroplasty mean revision burden, defined as the ratio of revision procedures to the sum of primary and revision procedures, was greater (CDA 5.9% vs. ACDF 2.3%, p-value=.01). CONCLUSIONS: Nationally approximately 132,000 ACDFs are done each year compared with only 1,600 CDAs. The number of ACDF surgeries performed far outpaces CDA by a ratio of 81:1 in the United States without a clear direction in the trend for utilization given recent fluctuations. Cervical disc arthroplasty revision burden was more than double compared with the ACDF revision burden (5.9% vs. 2.3%), which was not accounted for by patient baseline demographics. The etiologies of these findings are likely multifactorial and require further research.

Early Lessons on Bundled Payment at an Academic Medical Center.

INTRODUCTION: Orthopaedic care is shifting to alternative payment models. We examined whether New York University Langone Medical Center achieved savings under the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement initiative. METHODS: This study was a difference-in-differences study of Medicare fee-for-service patients hospitalized from April 2011 to June 2012 and October 2013 to December 2014 for lower extremity joint arthroplasty, cardiac valve procedures, or spine surgery (intervention groups), or for congestive heart failure, major bowel procedures, medical peripheral vascular disorders, medical noninfectious orthopaedic care, or stroke (control group). We examined total episode costs and costs by service category. RESULTS: We included 2,940 intervention episodes and 1,474 control episodes. Relative to the trend in the control group, lower extremity joint arthroplasty episodes achieved the greatest savings: adjusted average episode cost during the intervention period decreased by $3,017 (95% confidence interval [CI], -$6,066 to $31). For cardiac procedures, the adjusted average episode cost decreased by $2,999 (95% CI, -$8,103 to $2,105), and for spinal fusion, it increased by $8,291 (95% CI, $2,879 to $13,703). Savings were driven predominantly by shifting postdischarge care from inpatient rehabilitation facilities to home. Spinal fusion index admission costs increased because of changes in surgical technique. DISCUSSION: Under bundled payment, New York University Langone Medical Center decreased total episode costs in patients undergoing lower extremity joint arthroplasty. For patients undergoing cardiac valve procedures, evidence of savings was not as strong, and for patients undergoing spinal fusion, total episode costs increased. For all three conditions, the proportion of patients referred to inpatient rehabilitation facilities upon discharge decreased. These changes were not associated with an increase in index hospital length of stay or readmission rate. CONCLUSION: Opportunities for savings under bundled payment may be greater for lower extremity joint arthroplasty than for other conditions.

Reducing Length of Stay, Direct Cost, and Readmissions in Total Joint Arthroplasty Patients With an Outcomes Manager-Led Interprofessional Team.

The purpose of this quality improvement project was to determine whether an outcomes manager-led interprofessional team could reduce length of stay and direct cost without increasing 30-day readmission rates in the total joint arthroplasty patient population. The goal was to promote interprofessional relationships combined with collaborative practice to promote coordinated care with improved outcomes. Results from this project showed that length of stay (total hip arthroplasty [THA] reduced by 0.4 days and total knee arthroplasty [TKA] reduced by 0.6 days) and direct cost (THA reduced by $1,020 per case and TKA reduced by $539 per case) were significantly decreased whereas 30-day readmission rates of both populations were not significantly increased.

Subscapularis- and deltoid-sparing vs traditional deltopectoral approach in reverse shoulder arthroplasty: a prospective case-control study.

BACKGROUND: With the growth of reverse shoulder arthroplasty (RSA), it is becoming increasingly necessary to establish the most cost-effective methods for the procedure. The surgical approach is one factor that may influence the cost and outcome of RSA. The purpose of this study was to compare the clinical results of a subscapularis- and deltoid-sparing (SSCS) approach to a traditional deltopectoral (TDP) approach for RSA. The hypothesis was that the SSCS approach would be associated with decreased length of stay (LOS), equal complication rate, and better short-term outcomes compared to the TDP approach. METHODS: A prospective evaluation was performed on patients undergoing RSA over a 2-year period. A deltopectoral incision was used followed by either an SSCS approach or a traditional tenotomy of the subscapularis (TDP). LOS, adverse events, physical therapy utilization, and patient satisfaction were collected in the 12 months following RSA. RESULTS: LOS was shorter with the SSCS approach compared to the TDP approach (from 8.2 ± 6.4 days to 15.2 ± 11.9 days; P = 0.04). At 3 months postoperative, the single assessment numeric evaluation score (80 ± 11% vs 70 ± 6%; P = 0.04) and active elevation (130 ± 22° vs 109 ± 24°; P = 0.01) were higher in the SSCS group. The SSCS approach resulted in a net cost savings of $5900 per patient. Postoperative physical therapy, pain levels, and patient satisfaction were comparable in both groups. No immediate intraoperative complications were noted. CONCLUSION: Using a SSCS approach is an option for patients requiring RSA. Overall LOS is minimized compared to a TDP approach with subscapularis tenotomy. The SSCS approach may provide substantial healthcare cost savings, without increasing complication rate or decreasing patient satisfaction.

Increased Utilization of Cervical Disk Arthroplasty in University Hospitals with Regional Variation and Socioeconomic Discrepancies.

OBJECTIVE: Treatment of cervical radiculopathy with disk arthroplasty has been approved by the U.S. Food and Drug Administration since 2007. Recently, a significant increase in clinical data including mid- and long-term follow-up has become available, demonstrating the superiority of disk arthroplasty compared with anterior discectomy and fusion. The aim of this project is to assess the nationwide use of cervical disk arthroplasty. METHODS: The University Healthcare Consortium database was accessed for all elective cases of patients treated for cervical radiculopathy caused by disk herniation (International Classification of Diseases [ICD] 722.0) from the fourth quarter of 2012 to the third quarter of 2015. Within this 3-year window, temporal and socioeconomic trends in the use of cervical disk replacement for this diagnosis were assessed. RESULTS: Three thousand four hundred forty-six cases were identified. A minority of cases (10.7%) were treated with disk arthroplasty. Median hospital charges were comparable for cervical disk replacement ($15,606) and anterior cervical fusion ($15,080). However, utilization was seen to increase by nearly 70% during the timeframe assessed. Disk arthroplasty was performed in 8% of patients in 2012 to 2013, compared with 13% of cases in 2015. Disk replacement use was more common for self-paying patients, patients with private insurance, and patients with military-based insurance. There was widespread variation in the use of cervical disk replacement between regions, with a nadir in northeastern states (8%) and a peak in western states (20%). CONCLUSION: Over a short, 3 -year period there has been an increase in the treatment of symptomatic cervical radiculopathy with disk arthroplasty. The authors predict a further increase in cervical disk arthroplasty in upcoming years.

Total Joint Arthroplasty Patients' Education on Financial Issues and Its Connection to Reported Out-of-Pocket Costs-A European Study.

PURPOSE: Total joint arthroplasty is accompanied by significant costs. In nursing, patient education on financial issues is considered important. Our purpose was to examine the possible association between the arthroplasty patients' financial knowledge and their out-of-pocket costs. METHODS: Descriptive correlational study in five European countries. Patient data were collected preoperatively and at 6 months postoperatively, with structured, self-administered instruments, regarding their expected and received financial knowledge and out-of-pocket costs. FINDINGS: There were 1,288 patients preoperatively, and 352 at 6 months. Patients' financial knowledge expectations were higher than knowledge received. Patients with high financial knowledge expectations and lack of fulfillment of these expectations had lowest costs. CONCLUSION: There is need to establish programs for improving the financial knowledge of patients. Patients with fulfilled expectations reported higher costs and may have followed and reported their costs in a more precise way. In the future, this association needs multimethod research.

You Want a Successful Bundle: What About Post-discharge Care?

BACKGROUND: The postacute care strategies after total joint arthroplasty, including the use of postacute rehabilitation centers and home therapy services are associated with different costs. Providers in bundled payment programs are incentivized to use the most cost-effective strategies while maintaining quality and value for patients. METHODS: We discuss the impact of postacute care on a bundled payment program and strategies for optimizing the value of this component of the care episode using the experience of a large academic urban medical center participating in the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement Initiative. RESULTS: The results of this analysis show that efforts to increase the use of home discharge and decrease the use of postacute facilities after elective primary total hip and knee arthroplasties can lead to cost-effective quality care with a high degree of patient satisfaction. CONCLUSION: The postdischarge period is a significant part of a bundled payment episode. To manage a successful bundled payment program in total joint arthroplasty, significant efforts to coordinate care during this episode are needed for patients to receive quality care that meets their expectations.

Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act.

BACKGROUND: The purpose of this study was to assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to foot and ankle surgeons for total ankle arthroplasty. METHODS: We called 240 foot and ankle surgeons who performed total ankle arthroplasty in 8 representative states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for a fictitious patient to be evaluated for a total ankle arthroplasty. Each office was called 3 times to assess the responses for Medicaid, Medicare, and BlueCross. From each call, we recorded appointment success or failure and any barriers to an appointment, such as need for a referral. RESULTS: Patients with Medicaid were less likely to receive an appointment compared to patients with Medicare (19.8% vs 92.0%, P < .0001) or BlueCross (19.8% vs 90.4%, P < .0001) and experienced more requests for referrals compared to patients with Medicare (41.9% vs 1.6%, P < .0001) or BlueCross (41.9% vs 4%, P < .0001). Waiting periods were longer for patients with Medicaid compared to those with Medicare (22.6 days vs 11.7 days, P = .004) or BlueCross (22.6 days vs 10.7 days, P = .001). Reimbursement rates did not correlate with appointment success rate or waiting period. CONCLUSION: Despite the passage of the PPACA, patients with Medicaid continue to have difficulty finding a surgeon who will provide care, increased need for a primary care referral, and longer waiting periods for appointments. LEVEL OF EVIDENCE: Level II, prognostic study.

Bundled Payments: Our Experience at an Academic Medical Center.

BACKGROUND: The landscape of health care is transitioning from a fee-for-service model to value-based purchasing. METHODS: We developed evidence-based clinical pathways and risk stratification measures to effectively implement the Bundled Payments for Care Improvement model of value-based purchasing. RESULTS: We decreased patients' length of stay, discharge to inpatient facilities, and cost of an episode of patient care. CONCLUSION: The bundled care payment initiative has been successfully implemented for Diagnosis Related Groups 469 and 470, delivering high-quality patient care at a reduced price.

Cost Analysis of Tranexamic Acid in Anemic Total Joint Arthroplasty Patients.

BACKGROUND: Preoperative anemia is present in 20% of total joint arthroplasty patients. Current preoperative treatment options, including iron supplementation (FE) and erythropoietin (EPO), are expensive. Tranexamic acid (TXA) has been adopted as an intraoperative adjunct to decrease blood loss. Our hypothesis is that TXA is a cost-effective treatment compared to FE and EPO in anemic patients. METHODS: In this study, a cost analysis was performed, comparing the material costs of TXA and packed red blood cells (PRBCs) to the theoretical administration and material costs of FE and EPO per standard preoperative anemia protocol. RESULTS: A total of 243 patients were included in the study. Of this group, 18.5% (45/243) had preoperative anemia. The rate of transfusion was 6.7% (3/45), and 5 units of PRBCs was transfused. The combined cost of TXA and PRBCs was $5317.08. Even assuming a best-case scenario with FE or EPO treatment without a postoperative PRBC requirement, the cost of treatment would range from 2 to 17 times more than treatment with TXA. An additional 50 units of PRBC (1.1 units per patient) would need to be transfused for the cost of TXA treatment to be equivalent to FE or EPO treatment. CONCLUSION: Tranexamic acid is significantly less expensive than FE or EPO as a treatment option for total joint arthroplasty patients presenting with preoperative anemia. It is a cost-effective adjunct for limiting transfusion rates in this patient population. We recommend that new preoperative anemia levels that necessitate preoperative intervention be established.

Are Financial Conflicts of Interest for the Surgeon A Source of Concern for the Patient?

We surveyed 269 consecutive patients (81% response rate) with an anonymous questionnaire to assess their attitudes toward conflicts-of-interest (COIs) resulting from three financial relationships between orthopedic surgeons and orthopedic industry: (1) being paid as a consultant; (2) receiving research funding; (3) receiving product design royalties. The majority perceived these relationships favorably, with 75% agreeing that surgeons in such relationships are top experts in the field and two-thirds agreeing that surgeons engage in such relationships to serve patients better. Patients viewed surgeons who designed products more favorably than those who are consultants (P=0.03). The majority (74%) agreed that these COIs should be disclosed to patients. Given patients' desires for disclosure and their favorable perceptions of these relationships, open discussions about financial COIs is appropriate.