Use of The Risk Assessment and Prediction Tool to Predict Same-day Discharge After Primary Hip and Knee Arthroplasty.

INTRODUCTION: The Risk Assessment and Prediction Tool (RAPT) is a preoperative screening tool developed to predict discharge disposition after total hip arthroplasty (THA) and total knee arthroplasty (TKA), but its predictive value for same-day discharge (SDD) has not been investigated. The aims of this study were (1) to assess RAPT's ability to predict SDD after primary THA and TKA and (2) to determine a cutoff RAPT score that may recognize patients appropriate for SDD. METHODS: Data were retrospectively collected from patients undergoing primary THA and TKA at a single tertiary care center between February 2020 and May 2021. A receiver operating characteristic curve was generated to choose a cutoff value to screen for SDD. Logistic regression analysis was done to identify factors including age, BMI, or RAPT score that may be associated with SDD. RESULTS: Three hundred sixty-one patients with preoperative RAPT scores were included in the analysis of whom 147 (42.6%) underwent SDD. A cutoff of ≥9 was identified for TKA and ≥11 for THA. RAPT had a predictive accuracy of only 66.7% for SDD, whereas the discharge plan documented in the preoperative note was 91.7% accurate. DISCUSSION: Although there is a positive association between RAPT and SDD, it is not a useful screening tool given its low predictive accuracy.

Is There an Implicit Racial Bias in the Case Order of Elective Total Joint Arthroplasty?

INTRODUCTION: Identifying ways to improve equitable access to healthcare is of the utmost important. In this study, we analyzed whether patient race was negatively associated with surgical start times for total joint arthroplasties (TJA). METHODS: The surgical case order and start times of all primary TJAs performed at a large academic medical center between May 2014 and May 2018 were retrospectively reviewed. Patients were included if > 21, had a documented self-reported race, and were operated on by an arthroplasty fellowship-trained surgeon. Operations were categorized as first-start, early (7:00 AM-11:00 AM), mid-day (11:00 AM-3:00 PM), or late (after 3:00 PM). Multivariable logistic regression (MLR) was performed, and odds ratios (OR) were calculated. RESULTS: This study identified 1663 TJAs-871 total knee (TKA) and 792 total hip arthroplasties (THA) who met inclusion criteria. Overall, there was no association between race and surgical start time. Upon sub-analysis by surgical type, this held true for TKA patients, but self-identifying Hispanic and non-Hispanic Black patients undergoing THA were more likely to have later surgical start times (ORs: 2.08 and 1.88; p < 0.05). DISCUSSION: Although there was no association between race and overall TJA surgical start times, patients with marginalized racial and ethnic identities were more likely to undergo elective THA later in the surgical day. Surgeons should be aware of potential implicit bias when determining case order to potentially prevent adverse outcomes due to staff fatigue or lack of proper resources later in the day.

Is the Direct Anterior Approach to THA Cost-effective? A Markov Analysis.

BACKGROUND: The use of the direct anterior approach, a muscle-sparing technique for THA, has increased over the years; however, this approach is associated with longer procedure times and a more expensive direct cost. Furthermore, studies have shown a higher revision rate in the early stages of the learning curve. Whether the clinical advantages of the direct anterior compared with the posterior approach-such as less soft tissue damage, decreased short-term postoperative pain, a lower dislocation rate, decreased length of stay in the hospital, and higher likelihood of being discharged home-outweigh the higher cost is still debatable. Determining the cost-effectiveness of the approach may inform its utility and justify its use at various stages of the learning curve. QUESTIONS/PURPOSES: We used a Markov modeling approach to ask: (1) Is the direct anterior approach more likely to be a cost-effective approach than the posterior approach over the long-term for more experienced or higher volume hip surgeons? (2) How many procedures does a surgeon need to perform for the direct anterior approach to be a cost-effective choice? METHODS: A Markov model was created with three health states (well-functioning THA, revision THA, and death) to compare the cost-effectiveness of the direct anterior approach with that of the posterior approach in five scenarios: surgeons who performed one to 15, 16 to 30, 31 to 50, 51 to 100, and more than 100 direct anterior THAs during a 6-year span. Procedure costs (not charges), dislocation costs, and fracture costs were derived from published reports, and model was run using two different cost differentials between the direct anterior and posterior approaches (USD 219 and USD 1800, respectively). The lower cost was calculated as the total cost differential minus pharmaceutical and implant costs to account for differences in implant use and physician preference regarding postoperative pain management. The USD 1800 cost differential incorporated pharmaceutical and implant costs. Probabilities were derived from systematic review of the evidence as well as from the Australian Orthopaedic Association National Joint Replacement Registry. Utilities were estimated from best available literature and disutilities associated with dislocation and fracture were incorporated into the model. Quality of life was expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in that health state. The primary outcome measure was the incremental cost-effectiveness ratio, or the change in costs divided by the change in QALYs when the direct anterior approach was used for THA. USD 100,000 per quality-adjusted life years was used as a threshold for willingness to pay. One-way and probabilistic sensitivity analyses were performed for the scenario in which the direct anterior approach is cost-effective to further account for uncertainty in model inputs. RESULTS: At a cost differential of USD 219 (95% CI 175 to 263), the direct anterior approach was associated with lower cost and higher effectiveness compared with the posterior approach for surgeons with an experience level of more than 100 operations during a 6-year span. At a cost differential of USD 1800 (95% CI 1440 to 2160), the direct anterior approach remained a cost-effective strategy for surgeons who performed more than 100 operations. At both cost differentials, the direct anterior approach was not cost-effective for surgeons who performed fewer than 100 operations. One-way sensitivity analyses revealed the model to be the most sensitive to fluctuations in the utility of revision THA, probability of revision after the posterior approach THA, probability of dislocation after the posterior approach THA, fluctuations in the probability of dislocation after direct anterior THA, cost of direct anterior THA, and probability of intraoperative fracture with the direct anterior approach. At the cost differential of USD 219 and for surgeons with a surgical experience level of more than 100 direct anterior operations, the direct anterior approach was still the cost-effective strategy for the entire range of values. CONCLUSION: For high-volume hip surgeons, defined here as surgeons who perform more than 100 procedures during a 6-year span, the direct anterior approach may be a cost-effective strategy within the limitations imposed by our analysis. For lower volume hip surgeons, performing a more familiar approach appears to be more cost-effective.

Effects of Skilled Nursing Facility Partnerships on Outcomes Following Total Joint Arthroplasty.

INTRODUCTION: Post-total joint arthroplasty (TJA) discharge to a skilled nursing facility (SNF) is associated with higher costs and more complications than home discharge; however, some patients still require postoperative SNF care. To improve outcomes for patients requiring postoperative SNF care, this article analyzed the effect of SNF-surgeon partnerships on TJA postoperative costs and patient outcomes. METHODS: This was a retrospective study of primary TJA patients who were part of Medicare's Comprehensive Care for Joint Replacement (CJR) pilot program at our urban, academic medical center. We identified all patients discharged to SNF and designated SNFs as "preferred" if they maintained a partnership with our surgical team. SNF costs, total 90-day postoperative costs, average length of stay in SNF, 90-day readmission rates, and readmission diagnoses were recorded. Data were compared using Student t-tests. Readmission rates and the presence of a readmission diagnosis were analyzed using z-scores. RESULTS: Our search identified 189 patients (22.9%) discharged to SNFs, with 128 (67.8%) discharged to preferred and 61 (32.2%) discharged to nonpreferred facilities. Over the 4-year CJR pilot program, SNF costs ($10,981.23 versus $7,343.34; P < 0.005) and overall postdischarge costs ($23,952.52 versus $18,339.26; P = 0.07) were higher for patients discharged to nonpreferred SNFs versus preferred SNFs. Patients discharged to nonpreferred SNFs also had increased length of stay (14.8 versus 10.1 days; P < 0.005) and increased readmission rates (19.7% versus 3.9%; P < 0.005). These differences became more pronounced across the study period. CONCLUSION: For patients undergoing primary TJA, hospital partnership with SNFs can improve CJR performance by cost reduction and overall outcomes for TJA patients.

Does Femoral Component Cementation Affect Costs or Clinical Outcomes After Hip Arthroplasty in Medicare Patients?

BACKGROUND: Bundled payment initiatives were introduced to reduce costs and improve quality of care. Cemented vs cementless femoral fixation is a modifiable variable that may influence the cost and quality of care. New bundled payment data from the Centers for Medicare and Medicaid Services allowed us to study the influence of femoral fixation strategy on (1) 90-day costs; (2) readmission rates; (3) reoperation rates; (4) length of stay (LOS); and (5) discharge disposition for Medicare patients undergoing total hip arthroplasty. METHODS: We retrospectively studied 1671 primary total hip arthroplasty Medicare cases, comparing 359 patients who received cemented femoral fixation to 1312 patients who received cementless fixation. Centers for Medicare and Medicaid Services cost data as well as clinical data were reviewed. Demographic differences were present between the 2 cohorts. Statistical analyses were performed, including multiple regression models to adjust for baseline differences. RESULTS: Controlling for cohort differences, cemented patients were significantly more likely to be discharged home compared to cementless patients. Cemented patients also demonstrated trends toward lower costs, lower readmission rates, and shorter LOS compared to cementless patients. All reoperations within the early postoperative period occurred in patients managed with cementless femoral fixation. CONCLUSION: Among Medicare patients, cemented femoral fixation outperformed cementless fixation with respect to discharge disposition and also trended toward superiority with regards to LOS, readmission, cost of care, and reoperation. Cemented femoral fixation remains relevant and useful despite the rising popularity of cementless fixation.

Average Operative Times for 1,313 Primary Total Hip Arthroplasty and 1,300 Primary Total Knee Arthroplasty Over 39 Months Are Roughly Equal to Medicare Attributed Operative Times.

BACKGROUND: Primary arthroplasty current procedural terminology codes have been proposed for reexamination due to concern that the intraservice skin-to-skin time is overestimated at 100 minutes. We sought to determine actual intraservice times for primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). METHODS: We queried hospital administrative databases to determine average intraservice times for 4 fellowship-trained arthroplasty surgeons at an urban, academic institution. RESULTS: There were 1313 primary THA performed over the study period. The mean intraservice time was 102 minutes (standard deviation 26 minutes). There were no consistent trends over time. There were 1300 primary TKA performed over the study period. The mean intraservice time was 116 minutes (standard deviation 25 minutes). There were no consistent trends over time. CONCLUSIONS: We found an average operative time that was very close to the current benchmarked times for THA and 16% longer than the benchmarked times for TKA. The incentives of for-profit insurance companies and third-party organizations must be considered when considering requests for a rereview of the physician work and carefully weighed against real data, such as presented here, and the impact on access to care for patients.

Isolated Polyethylene Exchange With Increased Constraint Is Comparable to Component Revision TKA for Instability in Properly Selected Patients.

BACKGROUND: Symptomatic instability following total knee arthroplasty (TKA) is a leading cause of early failure. Most reports recommend component revision as the preferred treatment because of poor outcomes and high failure rates with isolated tibial polyethylene insert exchange (ITPIE). However, these ideas have not been tested in modern implant systems that allow insert constraint to be increased. METHODS: We retrospectively reviewed 90 consecutive patients with minimum 2-year (mean 3.7 years) follow-up who underwent revision TKA for instability at a single institution. Mean age was 62.0 years (range, 41 to 83 years), and 73% of patients were women. Forty percent of patients were treated with ITPIE when standardized preoperative and intraoperative criteria were met; 60% underwent revision of one or both components when these criteria were not met. RESULTS: Patients experienced significant improvements in Knee Society (KS) knee (48.4 to 82.6; P < .001) and function (49.0 to 81.0; P < .001) scores. There were no significant differences in improvements in KS knee scores (38.1 vs 33.1; P = .18), KS function scores (36.0 vs 34.0; P = .63), or arc of motion (5° vs 6°; P = .88) between those treated with ITPIE and component revision. Failure rates were 19.4% in the ITPIE group vs 18.5% in the component revision group (odds ratio, 1.06; P = .91). Re-revision rates were significantly lower (6.3% vs 30.8%; odds ratio, 0.15; P = .004) when polyethylene insert constraint was increased. CONCLUSION: In selected patients, ITPIE is not inferior to component revision at addressing symptomatic instability following TKA. Degree of constraint should be increased whenever possible during revision surgery for instability.

Variation in Treatment Patterns Correlate With Resource Utilization in the 30-Day Episode of Care of Displaced Femoral Neck Fractures.

BACKGROUND: We evaluated which treatment decisions in the management of displaced femoral neck fractures (FNFs) may associate with measures of resource utilization relevant to a value-based episode-of-care model. METHODS: A total of 1139 FNFs treated with hip arthroplasty at 7 hospitals were retrospectively reviewed. Treatment choices were procedure (hemiarthroplasty vs total hip arthroplasty [THA]), surgeon training status, admitting service, and time to surgery. Dependent variables were length of stay, discharge disposition, 30-day readmission, and in-hospital mortality. Variation across hospitals was evaluated with analysis of variance and chi-square tests. Treatment choices were evaluated for the dependent variables of interest with univariable and multivariable regression. RESULTS: There was significant variation between hospitals regarding proportion of cases treated with THA (range = 3.0%-73.2%, P < .001), proportion treated by arthroplasty fellowship-trained surgeons (range = 0%-74.9%, P < .001), proportion admitted to the orthopedic service (range = 2.8%-91.3%, P < .001), mean time to surgery (range = 0.9-2.1 days, P < .001), and proportion of discharge home (range = 63.9%-97.8%, P < .001). Multivariable analysis adjusting for age, gender, and Charlson Comorbidity Index demonstrated correlations between (1) decreased length of stay and admission to orthopedics (B = -1.256, P < .001); (2) lower 30-day readmission and THA (odds ratio [OR] = .376, P = .004), and (3) decreased discharge to a care facility and admission to orthopedics (OR = 0.402, P = <.001), THA (OR = 0.435, P = .002), and treatment by an arthroplasty fellowship-trained surgeon (OR = 0.572, P = .016). None of the treatment variables tested associated with in-hospital mortality. CONCLUSION: We observed significant variation in the treatment of displaced FNF patients across 7 hospitals and identified treatment choices that associated with resource utilization within the episode of care. Future, prospective study is necessary to understand whether care pathways that adapt some combination of these characteristics may result in more value-based care.