The Effects of Patient Point of Entry and Medicaid Status on Postoperative Opioid Consumption and Pain After Primary Total Hip Arthroplasty.

INTRODUCTION: Medicaid expansion has allowed more patients to undergo total hip arthroplasty (THA). Given the continued focus on the opioid epidemic, we sought to determine whether patients with Medicaid insurance differed in their postoperative pain and narcotic requirements compared with privately or Medicare-insured patients. METHODS: A single-institution database was used to identify adult patients who underwent elective THA between 2016 and 2019. Patients in the Medicaid group received Medicaid insurance, while the non-Medicaid group was insured commercially or through Medicare. Subgroup analysis was done, separating the private pay from Medicare patients. RESULTS: A total of 5,845 cases were identified: 326 Medicaid (5.6%) and 5,519 non-Medicaid (94.4%). Two thousand six hundred thirty-five of the non-Medicaid group were insured by private payors. Medicaid patients were younger (56.1 versus 63.28 versus 57.4 years; P < 0.001, P < 0.05), less likely to be White (39.1% versus 78.2% versus 76.2%; P < 0.001), and more likely to be active smokers (21.6% versus 8.8% versus 10.5%; P < 0.001). Surgical time (113 versus 96 versus 98 mins; P < 0.001) and length of stay (2.7 versus 1.7 versus 1.4 days; P < 0.001) were longer for Medicaid patients, with lower home discharge (86.5% versus 91.8% versus 97.2%; P < 0.001). Total opioid consumption (178 morphine milligram equivalents [MMEs] versus 89 MME versus 82 MME; P < 0.001) and average MME/day in the first 24 hours and 24 to 48 hours (52.3 versus 44.7 versus 44.45; P < 0.001 and 73.8 versus 28.4 versus 29.8; P < 0.001) were higher for Medicaid patients. This paralleled higher pain scores (2.71 versus 2.31 versus 2.38; P < 0.001) and lower Activity Measure for Post-Acute Care scores (18.77 versus 20.98 versus 21.61; P < 0.001). CONCLUSIONS: Medicaid patients presenting for THA demonstrated worse postoperative pain and required more opioids than their non-Medicaid counterparts. This highlights the need for preoperative counseling and optimization in this at-risk population. These patients may benefit from multidisciplinary intervention to ensure that pain is controlled while mitigating the risk of continuation to long-term opioid use.

Payments, Policy, Patients, and Practice Evolution and Impact of Reimbursements in Total Joint Arthroplasty.

Current trajectories are set to create a large gap between total joint arthroplasty (TJA) supply and demand. Economics dictates that when the demand of consumers (TJA patients) exceeds supply (surgeons performing TJA), a new equilibrium should ideally be established at a higher price point. However, in TJA, the price is set by the government and, therefore, not subject to traditional economic models. Thus, reimbursements for TJA have decreased steadily over time. Fee for service is no longer the dominant reimbursement model for most orthopedic care. Surgeons play a critical role in the evolution and success of Value-Based Care (VBC) models, but this work is not reflected in recent payment changes for TJA. The regulatory environment is notoriously complex and affects our patients, surgeons, and institutions. It is imperative for orthopedic surgeons to continue to advocate for themselves by engaging with leadership, responding to surveys, and balancing outside influences to preserve patient access to TJA. Future payment models for musculoskeletal care must risk-stratify patients, appropriately reimburse for the work of revision TJA, and consider non-modifiable socioeconomic factors. Perioperative orthopedic surgical home (POSH) tools can ensure early appropriate care and proper care coordination for discharge. All of these factors, despite being framed within payment policy, ultimately affect access to orthopedic care for our patients.

Effect of Marital Status on Outcomes Following Total Joint Arthroplasty.

INTRODUCTION: The purpose of this study is to investigate whether the specific socioeconomic factor such as marital status has any effect on clinical outcomes and patient-reported outcome measures (PROMs) after primary total hip (THA) and knee (TKA) arthroplasty. MATERIALS AND METHODS: We retrospectively reviewed patients who underwent primary THA or TKA from January 2019 to August 2019 who answered all PROM questionnaires. Both THA and TKA patients were separated into two groups based on their marital status at the time of surgery (married vs. non-married). Demographics, clinical data, and PROMs (FJS-12, HOOS, JR, KOOS, JR, and VR-12 PCS&MCS) were collected at various time-periods. Demographic differences were assessed using chi-square and independent sample t tests. Clinical data and mean PROMs were compared using multilinear regressions while accounting for demographic differences. RESULTS: This study included 389 patients who underwent primary THA and 193 that underwent primary TKA. In the THA cohort, 256 (66%) patients were married and 133 (34%) were non-married. In the TKA cohort, there were 117 (61%) married patients and 76 (39%) non-married patients. Length of stay was significantly shorter for married patients in both the THA (1.30 vs. 1.64; p = 0.002) and TKA (1.89 vs. 2.36; p = 0.024) cohorts. Surgical-time, all-cause emergency department visits, discharge disposition, and 90-day all-cause adverse events (readmissions/revisions) did not statistically differ between both cohorts. Both HOOS, JR and KOOS, JR score improvements from baseline to 1-year did not statistically differ for the THA and TKA cohorts, respectively. Although VR-12 PCS (p = 0.012) and MCS (p = 0.004) score improvement from baseline to 1-year statistically differed for the THA cohort, they did not for the TKA cohort. CONCLUSION: Total joint arthroplasty may yield similar clinical benefits in all patients irrespective of their marital status. Although some PROMs statistically differed among married and non-married patients, the differences are likely not clinically significant. Surgeons should continue to assess levels of psychosocial support in their patients prior to undergoing TJA to optimize outcomes. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

What Are the Effects of Patient Point of Entry and Medicaid Status on Postoperative Opioid Consumption and Pain Following Primary Total Knee Arthroplasty?

BACKGROUND: Total knee arthroplasty (TKA) provides excellent results across a variety of pathologies. As greater focus is placed on the opioid epidemic, we sought to determine if patients presenting for TKA via the Medicaid clinic (Medicaid) differed in terms of their opioid requirements compared to patients presenting via private office clinics (non-Medicaid). METHODS: A single-institution total joint arthroplasty database was utilized to identify patients who underwent elective TKA between January 2016 and May 2019. Medicaid clinic patients were insured by some form of Medicaid, whereas private office patients had commercial or Medicare insurance. Morphine milligram equivalents (MMEs) and Activity Measure for Post-Acute Care scores were calculated. RESULTS: A total of 6509 patients were identified: 413 (6.35%) Medicaid and 6096 (93.65%) non-Medicaid. Medicaid patients were younger (63.32 vs 66.21 years, P < .0001), less likely to be of Caucasian race (21.31% vs 56.82%, P < .0001), and more likely to be active smokers (11.14% vs 7.73%, P < .0001). Although surgical time and home discharge rates were similar, Medicaid patients had longer length of stay (2.80 vs 2.46 days, P < .0001). Opioid requirements were higher for Medicaid patients (200.1 vs 132.2 MMEs, P < .0001), paralleling higher pain scores (3.03 vs 2.55, P < .0001). No differences were found in Activity Measure for Post-Acute Care scores (18.47 vs 18.77, P = .1824). CONCLUSION: Medicaid patients tended to be younger, of minority race, and active smokers compared to non-Medicaid patients. Medicaid patients demonstrated worse postoperative pain scores and required 51% greater MMEs immediately following TKA, highlighting the need for preoperative counseling in traditionally at-risk socioeconomic groups. LEVEL OF EVIDENCE: III, Retrospective Observational Analysis.

Total Hip Arthroplasty for Secondary Causes of Arthritis An Increase in Time and Money.

BACKGROUND: Total hip arthroplasty (THA) is a frequently performed, highly successful orthopedic procedure. Although primary osteoarthritis (PA) is the most common reason for (THA), there are several secondary conditions that lead to degenerative hip disease that are successfully treated with THA. The purpose of this study was to examine the incidence of these secondary causes of arthritis (SA) leading to THA and to compare the relative surgical costs, operating times, and hospital length of stay (LOS) for THA done for PA versus SA. METHODS: Electronic medical records from 836 continuous patients undergoing primary THA over a 2-year period were reviewed at a single high-volume joint arthroplasty center. Data obtained included age, sex, laterality, diagnosis leading to THA, surgical costs based on hospital fees, operating room time, and hospital LOS. Using operative reports, office visit notes, and radiology reports or images, patients were categorized into PA or SA groupings. PA was defined as osteoarthritis of no other known etiology, whereas SA was defined when a known underlying diagnosis led to degenerative joint disease of the hip. SA included hip dysplasia, post-traumatic arthritis (PTA), avascular necrosis (AVN), inflammatory arthropathy, Perthes disease, and slipped capital femoral epiphysis (SCFE). Means and proportions of the variables from both groups were analyzed and compared using t-tests and chi-squared tests where applicable. RESULTS: There were 599 patients in the PA group and 237 patients in the SA group. The SA group was significantly younger than the PA group (54.4 years versus 64.0 years; p = 0.0001). The SA cohort had significantly higher mean surgical costs ($29,662 versus $27,078; p = 0.0005), operating room times (189 minutes versus 179 minutes; p = 0.0042), and LOS (4.2 days versus 3.9 days; p = 0.0312). Within the SA group, the hip dysplasia subgrouping had the lowest cost and operating room time, whereas the PTA subgrouping had the highest cost and operating room time. CONCLUSIONS: More than a quarter of primary THAs are performed due to secondary arthritis, most commonly due to hip dysplasia. Cases of THA due to secondary arthritis are associated with significantly increased hospital costs, operating time, and postoperative length of stay compared to THA's performed for primary osteoarthritis. Patients with post-traumatic hip arthritis may contribute the highest economic burden and present the most complex cases for arthroplasty surgeons.

Patients with atrial fibrillation undergoing total joint arthroplasty increase hospital burden.

BACKGROUND: More than 3 million people in the United States have atrial fibrillation, most of whom are being managed with anticoagulation therapy for life. The goal of the present study was to examine the effect of chronic anticoagulation therapy on patients with atrial fibrillation who undergo total joint arthroplasty. METHODS: We retrospectively reviewed all patients undergoing aseptic primary or revision total joint arthroplasty at our facility from March 2007 to August 2011. One hundred and sixty-one patients with atrial fibrillation (Group A) were compared with 161 matched controls (Group B). A total of 112 hips and 210 knees underwent 239 primary arthroplasties and eighty-three revisions. The groups were compared with use of conditional logistic regression (with matching on the basis of the involved joint [hip or knee], type of procedure [revision or primary], age, and sex) with regard to the length of hospital stay, postoperative hemoglobin levels, transfusion requirements, and readmissions. RESULTS: The preoperative length of stay (1.7 versus 0.2 days; p < 0.0001), postoperative length of stay (4.6 versus 3.2 days; p = 0.0002), and total length of stay (6.3 versus 3.4 days; p < 0.0001) were significantly longer for patients with atrial fibrillation (Group A). Hemoglobin levels were lower (but not significantly so) for Group A at baseline (13.1 versus 13.8 mg/dL), on Postoperative Day 2 (10.1 versus 10.6 mg/dL), on Postoperative Day 3 (9.8 versus 10.2 mg/dL), on Postoperative Day 4 (9.6 versus 10.1 mg/dL), on Postoperative Day 5 (9.7 versus 9.9 mg/dL), and at discharge (9.9 versus 10.3 mg/dL). Group A had a significantly higher prevalence of blood transfusion (15.5% versus 3.7%; p = 0.0005) and periprosthetic joint infection (5.6% versus 0.62%; p = 0.0196). A diagnosis of atrial fibrillation (odds ratio, 4.09; 95% confidence interval, 2.05 to 8.18; p < 0.0001) significantly increased the odds of total joint arthroplasty complication and the need for hospital readmission. CONCLUSIONS: Patients with preoperative atrial fibrillation undergoing total joint arthroplasty had an increased length of hospital stay, increased transfusion requirements, and an increased risk of periprosthetic joint infection and unplanned hospital readmission.