Managing an epidemic within a pandemic: orthopedic opioid prescribing trends during COVID-19.

INTRODUCTION: In response to the opioid epidemic, a multitude of policy and clinical-guideline based interventions were launched to combat physician overprescribing. However, the sudden rise of the Covid-19 pandemic disrupted all aspects of healthcare delivery. The purpose of this study was to evaluate how opioid prescribing patterns changed during the Covid-19 pandemic within a large multispecialty orthopedic practice. MATERIALS AND METHODS: A retrospective review of 1,048,559 patient encounters from January 1, 2015 to December 31, 2022 at a single orthopedic practice was performed. Primary outcomes were the percent of encounters with opioids prescribed and total morphine milligram equivalents (MMEs) per opioid prescription. Differences in outcomes were assessed by calendar year. Encounters were then divided into two groups: pre-Covid (1/1/2019-2/29/2020) and Covid (3/1/2020-12/31/2022). Univariate analyses were used to evaluate differences in diagnoses and outcomes between periods. Multivariate analysis was performed to assess changes in outcomes during Covid after controlling for differences in diagnoses. Statistical significance was assessed at p < 0.05. RESULTS: The percentage of encounters with opioids prescribed decreased from a high of 4.0% in 2015 to a low of 1.6% in 2021 and 2022 (p < 0.001). MMEs per prescription decreased from 283.6 ± 213.2 in 2015 to a low of 138.6 ± 100.4 in 2019 (p < 0.001). After adjusting for diagnoses, no significant differences in either opioid prescribing rates (post-COVID OR = 0.997, p = 0.893) or MMEs (post-COVID ß = 2.726, p = 0.206) were observed between the pre- and post-COVID periods. CONCLUSION: During the Covid-19 pandemic opioid prescribing levels remained below historical averages. While continued efforts are needed to minimize opioid overprescribing, it appears that the significant progress made toward this goal was not lost during the pandemic era.

Social vulnerability adversely affects emergency-department utilization but not patient-reported outcomes after total joint arthroplasty.

INTRODUCTION: Multiple studies demonstrate social deprivation is associated with inferior outcomes after total hip (THA) and total knee (TKA) arthroplasty; its effect on patient-reported outcomes is debated. The primary objective of this study evaluated the relationship between social vulnerability and the PROMIS-PF measure in patients undergoing THA and TKA. A secondary aim compared social vulnerability between patients who required increased resource utilization or experienced complications and those who didn't. MATERIALS AND METHODS: A retrospective review of 537 patients from March 2020 to February 2022 was performed. The Centers for Disease Control Social Vulnerability Index (SVI) were used to quantify socioeconomic disadvantage. The cohort was split into THA and TKA populations; univariate and multivariate analyses were performed to evaluate primary and secondary outcomes. Statistical significance was assessed at p < 0.05. RESULTS: 48.6% of patients achieved PROMIS-PF MCID at 1-year postoperatively. Higher levels of overall social vulnerability (0.40 vs. 0.28, p = 0.03) were observed in TKA patients returning to the ED within 90-days of discharge. Increased overall SVI (OR = 9.18, p = 0.027) and household characteristics SVI (OR = 9.57, p = 0.015) were independent risk factors for 90-day ED returns after TKA. In THA patients, increased vulnerability in the household type and transportation dimension was observed in patients requiring 90-day ED returns (0.51 vs. 0.37, p = 0.04). CONCLUSION: Despite an increased risk for 90-day ED returns, patients with increased social vulnerability still obtain good 1-year functional outcomes. Initiatives seeking to mitigate the effect of social deprivation on TJA outcomes should aim to provide safe alternatives to ED care during early recovery.

The effects of hypoalbuminemia in obese patients undergoing total joint arthroplasty.

INTRODUCTION: Total joint arthroplasty (TJA) is a highly effective surgery. However, poor nutritional status has been associated with worse outcomes. In orthopedics, nutrition status is commonly evaluated using serum albumin. When albumin levels fall below 3.0 g/dL, wound healing ability becomes impaired. Typically, malnutrition is associated with low BMI, but malnourished patients can also be obese. The goals of this study were to investigate the relationship between malnourishment represented through albumin levels of obese patients and likelihood of postoperative complications. METHODS: A retrospective review of patients undergoing primary TJA from 2016 to 2020 in the American College of Surgeons National Surgical Quality Improvement Program national database was performed. Patients with an albumin of < 3.5 g/dL were considered to have hypoalbuminemia and those with ≥ 3.5 g/dL were considered normal albumin. Univariate analysis was used to determine demographic and comorbidity differences between those with and without hypoalbuminemia. Outcomes of interest included length of stay, resource utilization, discharge disposition, and unplanned readmissions. Multivariate logistic regression examined albumin as a predictor of increased resource utilization and complications after controlling for possible confounding variables. RESULTS: Of the 79,784 patients, 4.96% of patients had low albumin. Those with hypoalbuminemia were nearly 1.5 years older than those with normal albumin, were more likely to be black, female, and had an overall increased comorbidity burden as shown by percent of patients with ASA > 3 (all p < 0.001). After risk adjustment, those with hypoalbuminemia and a BMI of 35 + had greater risk of complications and increased resource utilization. CONCLUSION: Our results demonstrated the prevalence of malnutrition increases as a patient's BMI increases. Further, hypoalbuminemia was associated with increased resource utilization and increased complication rates in all obese patients. We suggest screening albumin levels in obese patients preoperatively to give surgeons the best opportunity to optimize patient nutrition before undergoing surgery.

Patients From Medically Underserved Areas Are at Increased Risk for Nonhome Discharge and Emergency Department Return After Total Joint Arthroplasty.

BACKGROUND: Maryland Health Enterprise Zones (MHEZs) were introduced in 2012 and encompass underserved areas and those with reduced access to healthcare providers. Across the United States many underserved and minority populations experience poorer total joint arthroplasty (TJA) outcomes seemingly because they reside in underserved areas. The purpose of this study is to identify and quantify the relationship between living in an MHEZ and TJA outcomes. METHODS: Retrospective review of 11,451 patients undergoing primary TJA at a single institution from July 1, 2014 to June 30, 2020 was conducted. Patients were classified based on whether they resided in an MHEZ. Statistical analyses were used to compare outcomes for TJA patients who live in MHEZ and those who do not. RESULTS: Of the 11,451 patients, 1057 patients lived in MHEZ and 10,394 patients did not. After risk adjustment, patients who live in an MHEZ were more likely to return to the emergency department within 90 days postoperatively and were less likely to be discharged home than those patients who do not live in an MHEZ. CONCLUSION: Total joint arthroplasty patients residing in MHEZ appear to present with poorer overall health as measured by increased American Society of Anesthesiologists and Hierarchical Condition Categories scores, and they are less likely to be discharged home and more likely to return to the emergency department within 90 days. Several factors associated with these findings such as socioeconomic factors, household composition, housing type, disability, and transportation may be modifiable and should be targets of future population health initiatives.

Impact of Dexamethasone on Length of Stay and Early Pain Control in Direct Anterior Approach Total Hip Arthroplasty With Neuraxial Anesthesia.

BACKGROUND: Dexamethasone has been shown to reduce postoperative pain and opioid consumption for total joint arthroplasty patients; however, its impact on patients who received neuraxial anesthesia (NA) is not well described. We examined the impact of perioperative dexamethasone on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA) under NA. METHODS: A retrospective review was conducted for 376 THA patients from a single institution. Univariate analysis was used to compare postoperative outcomes for 164 THA patients receiving dexamethasone compared to 212 who did not receive dexamethasone. RESULTS: No differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) Score were observed between the groups. Patients receiving perioperative dexamethasone reported statistically significantly lower postanesthesia care unit (PACU) pain numeric rating scale (Dexamethasone 1.6 vs No dexamethasone 2.3, P = .014) and received lower PACU morphine milligram equivalents (MME) (Dexamethasone 8.57 vs No dexamethasone 11.44, P < .001). Patients receiving dexamethasone had significantly shorter LOS (Dexamethasone 29.40 vs No dexamethasone 35.26 hrs., P < .001). CONCLUSION: Perioperative dexamethasone is associated with decreased postoperative pain and narcotic consumption, and shorter length of stay for patients undergoing primary direct anterior approach THA with NA.

General vs Neuraxial Anesthesia in Direct Anterior Approach Total Hip Arthroplasty: Effect on Length of Stay and Early Pain Control.

BACKGROUND: Recent literature has suggested some benefits for neuraxial anesthesia (NA) as an alternative for general anesthesia (GA) for primary total hip arthroplasty patients. We examined the impact of NA vs GA on outcomes for patients undergoing direct anterior (DA) approach total hip arthroplasty (THA) in an institution with established rapid recovery protocols. METHODS: A retrospective review was conducted for 500 consecutive THA patients from a single institution. Univariate analysis and multivariate linear regression were used to compare outcomes for THA patients receiving NA and GA. RESULTS: There was a significant difference in length of stay with NA patients having a shorter length of stay (NA 32.7 hours vs GA 38.1 hours, P = .003). Patients receiving NA had significantly lower PACU morphine milligram equivalents (MME) (NA 10.2 MME vs GA 15.6 MME, P < .001) and reported a lower score on the PACU pain numeric rating scale (NA 2.1 vs GA 3.7, P < .001). CONCLUSION: Neuraxial anesthesia is associated with decreased LOS, decreased PACU MME, and a lower PACU pain score for patients undergoing primary DA THA. These trends remained consistent when controlling for age, gender, BMI, and ASA.

Preoperative Education for Total Joint Arthroplasty: Does Reimbursement Reduction Threaten Improved Outcomes?

BACKGROUND: Nurse navigation programs have been previously shown to reduce cost and improve outcomes after total joint arthroplasty (TJA). Medicare has proposed a 13.7% reduction in professional fee reimbursement for TJA procedures that may adversely impact providers' and health systems' ability to fund ancillary support resources such as nurse navigators. METHODS: A consecutive series of primary TJAs performed between April 2019 and February 2020 was retrospectively reviewed. Clinical and financial outcomes of patients attending a nurse navigator-led preoperative education class were compared with those who did not attend. RESULTS: There were 2057 TJAs identified during the study period. Most patients attended the preoperative education class (82.7%) and were discharged home (92.8%). Controlling for significant differences between groups, class attendance was associated with reduced length of stay (LOS), increased chance of 0- or 1-day LOS, reduced chance of discharge to a skilled nursing facility, and reduced hospital charges. For this patient sample, a proposed 13.7% reduction in nurse navigator-led classes was modeled to increase overall cost to payers by >$400,000 annually. Complete elimination of this class was estimated to increase the total annual cost by >$5,700,000 and cost per TJA by >$2700. CONCLUSION: The use of a nurse navigator-led preoperative education class was associated with shorter LOS, more frequent 0- and 1-day LOS, reduced discharge to skilled nursing facilities, and lower total hospital charges for those patients who attended. Potential reductions proposed by Medicare may interfere with the ability to support such services and negatively impact both clinical and financial outcomes.

Outpatient, Home-Based Physical Therapy Promotes Decreased Length of Stay and Post-Acute Resource Utilization After Total Joint Arthroplasty.

BACKGROUND: Patients and healthcare systems are increasingly focused on evaluating interventions that increase the value of care delivered. Our objective of this study is to evaluate early post-operative outcomes among those patients who underwent total joint arthroplasty with and without the participation in our piloted Outpatient Physical Therapy Home Visits (OPTHV) program. METHODS: A retrospective analysis of patients undergoing total hip arthroplasty and total knee arthroplasty at a single institution from July 2016 to September 2017 was performed. Matched cohorts were compared according to OPTHV enrollment status. RESULTS: In total, 1729 patients were included in this study. Two hundred ninety-three patients were enrolled in OPTHV, while 1436 patients received institutional standard care. Patients were matched by gender (56.7% vs 57.7% female, P = .751), age (67.75 vs 66.95 years, P = .167), body mass index (30.18 vs 30.12 kg/m2, P = .859), and average American Society of Anesthesiologists score (2.31 vs 2.36, P = .131). OPTHV patients had a shorter length of stay (1.39 vs 1.64 days, P < .001) and were more likely to discharge to home (89.8% vs 74.7%, P < .001). Ninety-day re-admissions (2.7% vs 2.6%, P = .880) and emergency room visits (4.1% vs 4.3%, P = .864) were equivalent. CONCLUSION: OPTHV is a novel program that facilitates discharge home and decreased length of stay after total joint arthroplasty without increasing re-admissions or emergency room visits. Utilization of OPTHV may contribute toward reducing the episode of care costs by reducing utilization of skilled nursing facility and home health services. Further prospective studies are needed to evaluate the effect of OPTHV on the total cost of care and functional outcomes.

Preoperative Predictors of Patients Requiring Inpatient Admission for Total Hip Arthroplasty Following Removal From the Medicare Inpatient-Only List.

BACKGROUND: The Centers for Medicare and Medicaid Services has removed total hip arthroplasty from the inpatient-only (IO) list in January 2020. Given the confusion created when total knee arthroplasty came off the IO list in 2018, this study aims to develop a predictive model for guiding preoperative inpatient admission decisions based upon readily available patient demographic and comorbidity data. METHODS: This is a retrospective review of 1415 patients undergoing elective unilateral primary THA between January 2018 and October 2019. Multiple logistic regression was used to develop a model for predicting LOS ≥2 days based on preoperative demographics and comorbidities. RESULTS: Controlling for other demographics and comorbidities, increased age (odds ratio [OR], 1.048; P < .001), female gender (OR, 2.284; P < .001), chronic obstructive pulmonary disorder (OR, 2.249; P = .003), congestive heart failure (OR, 8.231; P < .001), and number of comorbidities (OR, 1.216; P < .001) were associated with LOS ≥2 days while patients with increased body mass index (OR, 0.964; P = .007) and primary hypertension (OR, 0.671; P = .008) demonstrated significantly reduced odds of staying in the hospital for 2 or more days. The area under the curve was found to be 0.731, indicating acceptable discriminatory value. CONCLUSION: For patients undergoing primary THA, increased age, female gender, chronic obstructive pulmonary disorder, congestive heart failure, and multiple comorbidities are risk factors for inpatient hospital LOS of 2 or more days. Our predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in preoperatively identifying patients requiring inpatient admission with removal of THA from the Medicare IO list.

The Effect of Psychiatric Diagnosis and Psychotropic Medication on Outcomes Following Total Hip and Total Knee Arthroplasty.

BACKGROUND: Nearly 20% of the US adult population lives with mental illness, and less than 50% of these receive treatment. Preoperative mental health may affect postoperative outcomes in patients undergoing total joint arthroplasty (TJA), yet is rarely addressed; poor outcomes increase the cost of care and burden on the healthcare system. This study examines the influence of patients with psychiatric diagnosis (PD) and taking psychotropic medication (PM) on emergency room visits, readmissions, and discharge disposition following TJA. METHODS: Single institution retrospective analysis of a consecutive series of 3020 primary TJA performed between January 2017 and June 2018. Chi-squared, t-tests, and analysis of variance were used to quantify differences between groups. RESULTS: Nine hundred seventy-six (32.3%) patients had a PD, most had depression (10.1%), anxiety (8.6%), or both (8.4%); 808 (26.8%) patients were on PM. Patients with PD were more likely to experience emergency room visits (6.3% vs 10.0%, P = .034) and skilled nursing facility discharge (11.6% vs 17.9%, P = .005). Patients taking PM were more likely to experience skilled nursing facility discharge (12.4 vs 17.1, P = .047); those taking >2 PM had the highest rate (21.6%). CONCLUSION: Patients with PD on or off PM may experience increased healthcare utilization in the postoperative period. Increased patient education and support may reduce these discrepancies. PD is not a deterrent for TJA, but targeted interventions should be developed to provide additional support where needed and avoid unnecessary utilization of resources.

Differences in Perioperative Outcomes and Complications Between African American and White Patients After Total Joint Arthroplasty.

BACKGROUND: Racial disparities in healthcare utilization and outcomes have been reported and have wide-reaching implications for individual patient and healthcare system; as providers we bear an ethical burden to address this disparity and provide culturally competent care. This study will examine the influence of race on length of stay, discharge disposition, and complications requiring reoperation following total joint arthroplasty (TJA). METHODS: Single institution retrospective analysis of a consecutive series of 7208 primary TJA procedures performed between July 2013 and June 2017 was conducted. Chi-squared and t-tests were used to quantify differences between the groups and multiple logistic regression was used to identify race as an independent risk factor. RESULTS: In total, 6182 (84.3%) white and 1026 (14.0%) African American (AA) patients were included. AA patients were younger (63.62 vs 66.84 years, P < .001), more likely female (68.8% vs 57.0%, P < .001), had a longer length of stay (2.19 vs 2.00 days, P < .001), more likely to experience septic complications (1.3% vs 0.5%, P = .002) and manipulation under anesthesia (3.9% vs 1.8%, P < .001), and less likely to discharge home (67.1% vs 81.1%, P < .001). Multiple logistic regression showed that AA patients were more likely to discharge to a facility (adjusted odds ratio 2.63, 95% confidence interval 2.19-3.16, P < .001) and experience a manipulation under anesthesia (adjusted odds ratio 1.90, 95% confidence interval 1.26-2.85, P = .002). CONCLUSION: AA patients undergoing TJA were younger with longer length of stay and a higher rate of nonhome discharge; AA race was identified as an independent risk factor. Further study is required to understand the differences identified in this study. Targeted interventions should be developed to attempt to eliminate the disparity.

Reducing Length of Stay Does Not Increase Emergency Room Visits or Readmissions in Patients Undergoing Primary Hip and Knee Arthroplasties.

BACKGROUND: Total hip and total knee arthroplasty (total joint arthroplasty [TJA]) are 2 of the most common elective surgeries. Identifying which patients are at highest risk for emergency room (ER) visits or readmissions within 90 days of surgery and the reasons for return are crucial to formulate ways to decrease these visits and improve patient outcomes. METHODS: This is a retrospective review of a consecutive series of 7466 unilateral primary TJA performed from July 2013 to June 2017; any patients who had an ER visit or readmission in the first 90 days after surgery were identified, and a detailed chart review was performed. Patients discharged home or to rehab were analyzed separately. RESULTS: Three hundred thirty-six (4.5%) patients had 380 ER visits and 250 (3.3%) patients had 291 readmissions in the first 90 days after TJA. Patients returning to the ER were equivalent to those who did not. Patients who went to a rehab facility on discharge were significantly more likely to be readmitted (P = .000). Patients who were readmitted had a higher American Society of Anesthesiologists score (P = .000). Length of stay decreased over the study period from 2.66 days to 1.63 days, while the number of unplanned interventions remained steady. Pain and swelling was the most common reason for return for ER visits (33.2%) and readmissions (14.1%). CONCLUSION: The overall number of unplanned interventions after TJA in this population was low and remained consistent over time despite decreasing length of stay. Patients who went to rehab were more likely to experience readmission. The majority of unplanned interventions occurred in the first 4 weeks after surgery.

Functional Outcomes and Accuracy of Patient-Specific Instruments for Total Knee Arthroplasty.

BACKGROUND: Patient-specific instruments (PSIs) were developed to improve mechanical axis alignment for patients undergoing total knee arthroplasty (TKA) as neutral alignment (180°) is a predictor of long-term success. This study examines alignment accuracy and functional outcomes of PSI as compared with standard instruments (SIs). METHODS: We retrospectively reviewed a consecutive series of TKA procedures using PSI. A total of 85 PSI procedures were identified, and these were compared with a matched cohort of 85 TKAs using SI. Intraoperative decision-making, estimated blood loss, efficiency, Knee Society Scores, and postoperative radiographs were evaluated. RESULTS: One hundred and seventy patients with comparable patient demographics were reviewed. Eighty-one percent of the PSI procedures were within target (180 ± 3°) mechanical alignment, while the SI group had 70% of cases within the target plane ( P = .132). Mean target alignment (2.0° PSI vs 2.2° SI, P = .477) was similar between groups. Twenty-seven percent of patients in the PSI group had surgeon-directed intraoperative recuts to improve the perceived coronal alignment. The change in hematocrit was reduced in the PSI group (8.89 vs 7.21, P = .000). Procedure time and total operating room time were equivalent. Knee Society Scores did not differ between groups at 6 months or at 1 year. CONCLUSION: Patient-specific instrumentation decreased change in hematocrit, though coronal alignment and efficiency were equivalent between groups. Surgeons must evaluate cuts intraoperatively to confirm alignment. Functional outcomes are equivalent for PSI and SI groups.

Insulin-Dependent Diabetes Is an Independent Risk Factor for Complications and Readmissions After Total Joint Replacements.

This study examined the risk for postoperative complications, reoperations, and readmissions for patients with insulin-dependent diabetes mellitus (IDDM), patients with non-insulin-dependent diabetes mellitus (NIDDM), and patients without diabetes undergoing total joint replacements (TJRs). The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJRs in 2015. The study identified 78,744 TJRs (84.1% nondiabetic patients, 12.0% NIDDM, and 3.9% IDDM). Multiple logistic regression models identified IDDM as an independent risk factor for increased blood loss, myocardial infarctions, pneumonia, renal insufficiency, urinary tract infections, and readmissions when compared with both NIDDM and nondiabetics. Risk for wound complications and reoperations were comparable between all three groups. IDDM increases the risk for medical complications and readmissions after TJRs. Physicians must counsel patients on the increased risks associated with IDDM before elective surgery and provide appropriate medical support for these patients. (Journal of Surgical Orthopaedic Advances 27(4):294-298, 2018).

Opioid Prescriptions After Total Joint Arthroplasty.

Prescription opioids are commonly prescribed for pain relief after total joint arthroplasty (TJA), yet little is known about the quantity of opioids prescribed after surgery. This study retrospectively reviewed a consecutive series of 1000 TJAs from April 2014 through September 2015. Postoperative opioid prescriptions were quantified using standardized morphine milligram equivalents (MME). Eighty-four percent of total knee arthroplasty (TKA) and 77% of total hip arthroplasty (THA) patients were opioid naïve. The median opioid volume of the first prescription for those undergoing TKA was greater than for those undergoing THA (600 vs. 450 MME), as was the proportion of individuals requiring one or more refills (48% vs. 32%). The total volume of opioids after TKA was also higher than for total hip replacement (870 vs. 525 MME). Patients who were not opioid naïve were prescribed substantially more opioids than their counterparts after TKA (mean 1593 vs. 1064 MME, p < .001) and THA (mean 1031 vs. 663 MME, p < .001). Decreasing opioid use before surgery may decrease total volume of opioid prescriptions after TJA. (Journal of Surgical Orthopaedic Advances 27(3):231-236, 2018).

Who Is Not a Candidate for a 1-Day Hospital-Based Total Knee Arthroplasty?

BACKGROUND: Short-stay total knee arthroplasty (TKA), defined as a 1-day length of stay (LOS), is feasible in many patients, yet variables identifying who are candidates for a short stay are not well described in literature. With an emphasis on cost-efficiency, we examined preoperative patient characteristics and perioperative hospital factors that correlated with a longer LOS. METHODS: A retrospective review of 381 primary TKAs was performed. Clinical measures differentiating a 1-day LOS group from that of a ≥2-day LOS group were identified. RESULTS: Multiple logistic regression demonstrated older age (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.34-2.77; P < .001), female gender (OR, 4.22; 95% CI, 2.35-7.57; P < .001), American Society of Anesthesiologists score 3 or 4 (OR, 2.00; 95% CI, 1.01-3.95; P = .046), atrial fibrillation (OR, 8.87; 95% CI, 1.81-43.47; P = .007), and prior TKA on the contralateral side (OR, 3.57; 95% CI, 1.27-10.05; P = .016) as significant preoperative characteristics correlating with the ≥2-day LOS group. The most significant hospital perioperative factor associated with longer stays was patients not ambulating on the day of surgery (OR, 4.09; 95% CI, 1.77-9.48; P = .001). Walking 150 ft (93% sensitive, 35% specific) on the day of surgery was predictive of patients in the 1-day LOS group. Hospital costs were US$1873 (P < .001) lower for patients in the 1-day group. CONCLUSION: Shorter stays decrease costs associated with TKA, and more refined predictive models are needed to optimize discharge protocols. Preoperative data help allocate limited healthcare resources toward patients more likely to leave in 1 day, while perioperative data facilitate learning to create a more efficient hospital process.

The Cost of Unnecessary Hospital Days for Medicare Joint Arthroplasty Patients Discharging to Skilled Nursing Facilities.

BACKGROUND: The 72-hour Medicare mandate (3-night stay rule) requires a 3-day inpatient stay for patients discharging to skilled nursing facilities (SNFs). Studies show that 48%-64% of Medicare total joint arthroplasty (TJA) patients are safe for discharge to SNFs on postoperative day (POD) #2. The purpose of this study was to extrapolate the financial impact of the 3-night stay rule. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJAs performed in 2015. Discharge destination was recorded. Institutional cost accounting examined costs for patients discharging on POD #2 vs POD #3. RESULTS: A total of 42,423 TJAs (14,395 total hip arthroplasties [THAs] and 28,028 total knee arthroplasties [TKAs]) were performed in patients over the age of 65 years. Of these patients, 5252 THAs (36.5%) and 12,022 TKAs (42.9%) were discharged from the hospital on POD #3, with 2404 THAs (16.7%) and 5083 TKAs (18.1%) being discharged to SNFs. Institutional cost accounting revealed hospital costs for THA were $2014 more, whereas hospital costs for TKA were $1814 more for a 3-day length of stay when compared with a 2-day length of stay (P < .001). The mean charge per day for an SNF was $486. CONCLUSION: The National Surgical Quality Improvement Program database is a representative sample of all surgeries performed in the United States. Extrapolating our findings to all Medicare TJAs nationally gives an estimated $63 million in annual savings. Medicare mandated, but potentially medically unnecessary inpatient days at a higher level of care increase the total cost for TJAs. Policies regarding minimum stay requirements before discharge should be re-evaluated.

The Impact of Surgical Technique on Patient Reported Outcome Measures and Early Complications After Total Hip Arthroplasty.

BACKGROUND: This study examines patient and surgeon reported outcome measures, complications during index admission, length of stay (LOS), and discharge disposition in a series of total hip replacements (THR) performed via the direct anterior (DA) or posterolateral (PL) approach. METHODS: Five surgeons performed 2698 total hip replacements (1457 DA vs 1241 PL) between January 2010 and June 2015. Complications during index admission were recorded using billing and claims data. Harris Hip Scores (HHS) and Hip disability and Osteoarthritis Outcome Scores (HOOS) were collected in a subset of patients. RESULTS: Patients in the DA group had shorter LOS (2.3 DA vs 2.7 PL days, P < .001) and a larger proportion of patient discharges to home (79.0% DA vs 68.7% PL, P < .001). Surgical (0.75% DA vs 0.73% PL, P = .961) and medical (8.4% DA vs 8.1% PL, P = .766) complications during index admission were equivalent between groups. HHS (n = 462) favored the DA group at an early follow-up (P < .001), but did not differ at 1 year (P = .478). Logistic regression revealed that patients in the DA group were more likely to report no pain, no limp, walk unlimited distances, and climb stairs without the use of the railing at 3- to 6-month follow-up (P < .001). HOOSs were equivalent at all follow-ups regardless of approach. CONCLUSION: Patients in the DA group had shorter LOS and were more likely to be discharged home. The DA group had better HHS at 3- to 6-month follow-up than patients in the PL group, with no difference in medical or surgical complications during index admission.

Incidence, Risk Factors, and Costs for Hospital Returns After Total Joint Arthroplasties.

BACKGROUND: Unplanned hospital returns after total joint arthroplasty (TJA) reduce any cost savings in a bundled reimbursement model. We examine the incidence, risk factors, and costs for unplanned emergency department (ED) visits and readmissions within 30 days of index TJA. METHODS: We retrospectively reviewed a consecutive series of 655 TJAs (382 total knee arthroplasty and 273 total hip arthroplasty) performed between April 2014 and March 2015. Preoperative diagnosis was osteoarthritis of the hip or knee (97%) or avascular necrosis of the hip (3%). Hospital costs were recorded for each ED visit and readmission episode. RESULTS: Of the 655 TJAs reviewed, 55 (8.4%) returned to the hospital. Of these hospital returns, 35 patients (5.3%) returned for a total of 36 unplanned ED visits whereas the remaining 20 patients (3.1%) presented 22 readmissions within 30 days of index TJA. The 2 most common reasons for unplanned ED visits were postoperative pain/swelling (36%) and medication-related side effects (22%). Avascular necrosis of the hip was a significant risk factor for an unplanned ED visit (7.27 odds ratio [OR], 95% confidence interval [CI] 1.67-31.61, P = .008). Multiple logistic regression analysis revealed the following risk factors for readmission: body mass index (1.10 OR, 95% CI 1.02-1.78, P = .013), comorbidity >2 (2.07 OR, 95% CI 1.06-6.95, P = .037), and prior total knee arthroplasty (2.61 OR, 95% CI 1.01-6.72, P = .047). Ambulating on the day of surgery trended toward a lower risk for readmission (0.13 OR, 95% CI 0.02-1.10, P = .061). The 2 most common reasons for readmission were ileus (23%) and cellulitis (18%). The total cost associated with unplanned ED visits were $15,427 whereas costs of readmissions totaled $142,654. CONCLUSION: Unplanned ED visits and readmissions in the forthcoming bundled payments reimbursement model will reduce cost savings from rapid recovery protocols for TJA. Identifying and mitigating preventable causes of unplanned visits and readmissions will be critical to improving care and controlling costs.

Predictors of Hospital Length of Stay in an Enhanced Recovery After Surgery Program for Primary Total Hip Arthroplasty.

BACKGROUND: Shorter length of stay (LOS) for total hip arthroplasty (THA) is becoming standard, yet variables identifying candidates for a 1-day discharge in an enhanced recovery after surgery program are not well defined. With growing emphasis on cost-efficiency and bundled care for THA, this study looked to identify variables that correlated with LOS. METHODS: A retrospective chart review was performed for 273 primary THAs, from April 2014 to January 2015. Clinical measures differentiating a 1-day LOS cohort from that of a LOS longer than 1 day were identified. Direct medical costs were calculated for services billed during hospitalization. RESULTS: Logistic regression identified the following preoperative patient characteristics to correlate with an LOS >1 day: older age (odds ratio [OR]: 1.06, P < .001), increased body mass index (OR: 1.06, P = .005), female gender (OR: 1.76, P = .031), American Society of Anesthesiologists score 3 or 4 (OR: 1.84, P = .029), and coronary artery disease (OR: 3.90, P = .013). After adjusting for age, body mass index, and gender, the following perioperative variables led to an LOS ≥2 days: general anesthesia (OR: 2.24, P = .007), longer operative time (OR: 1.04, P < .001), and increased blood loss (OR: 1.01, P = .001). Postoperatively, not ambulating on the day of surgery strongly correlated with an LOS ≥2 days (OR: 3.9, P < .001). Hospital costs were approximately $2900 higher for a 2-day LOS. CONCLUSION: With growing emphasis on cost-efficiency, studying the association of clinical factors with LOS is necessary to develop a preoperative and perioperative predictive risk stratification model that may be used to help optimize discharge protocols for patients in an enhanced recovery after surgery program.