Treating Hepatitis C Before Total Knee Arthroplasty is Cost-Effective: A Markov Analysis.

BACKGROUND: Patients who have the hepatitis C virus (HCV) have increased mortality and complication rates following total knee arthroplasty (TKA). Recent advances in HCV therapy have enabled clinicians to eradicate the disease using direct-acting antivirals (DAAs); however, its cost-effectiveness before TKA remains to be demonstrated. The aim of this study was to perform a cost-effectiveness analysis comparing no therapy to DAAs before TKA. METHODS: A Markov model using input values from the published literature was performed to evaluate the cost-effectiveness of DAA treatment before TKA. Input values included event probabilities, mortality, cost, and health state quality-adjusted life-year (QALY) values for patients who have and do not have HCV. Patients who have HCV were modeled to have an increased rate of periprosthetic joint infection (PJI) infection (9.9 to 0.7%). The incremental cost-effectiveness ratio (ICER) of no therapy versus DAA was compared to a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to investigate the effects of uncertainty associated with input variables. RESULTS: Total knee arthroplasty in the setting of no therapy and DAA added 8.1 and 13.5 QALYs at a cost of $25,000 and $114,900. The ICER associated with DAA in comparison to no therapy was $16,800/QALY, below the willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses demonstrated that the ICER was affected by patient age, inflation rate, DAA cost and effectiveness, HCV-associated mortality, and DAA-induced reduction in PJI rate. CONCLUSION: Direct-acting antiviral treatment before TKA reduces risk of PJI and is cost-effective. Strong consideration should be given to treating patients who have HCV before elective TKA. LEVEL OF EVIDENCE: Cost-effectiveness Analysis; Level III.

Treating Hepatitis C Prior to Total Hip Arthroplasty is Cost-effective: A Markov Analysis.

BACKGROUND: Patients infected with the hepatitis C virus (HCV) have high complication rates following total hip arthroplasty (THA). Advances in HCV therapy now enable clinicians to eradicate the disease; however, its cost-effectiveness from an orthopaedic perspective remains to be demonstrated. We sought to conduct a cost-effectiveness analysis comparing no therapy to direct-acting antiviral (DAA) therapy prior to THA among HCV-positive patients. METHODS: A Markov model was utilized to evaluate the cost-effectiveness of treating HCV with DAA prior to THA. The model was powered with event probabilities, mortality, cost, and quality-adjusted life year (QALY) values for patients with and without HCV that were obtained from the published literature. This included treatment costs, successes of HCV eradication, incidences of superficial or periprosthetic joint infection (PJI), probabilities of utilizing various PJI treatment modalities, PJI treatment success/failures, and mortality rates. The incremental cost-effectiveness ratio was compared to a willingness-to-pay threshold of $50,000/QALY. RESULTS: Our Markov model indicates that in comparison to no therapy, DAA prior to THA is cost-effective for HCV-positive patients. THA in the setting of no therapy and DAA added 8.06 and 14.39 QALYs at a mean cost of $28,800 and $115,800. The incremental cost-effectiveness ratio associated with HCV DAA in comparison to no therapy was $13,800/QALY, below the willingness-to-pay threshold of $50,000/QALY. CONCLUSION: Hepatitis C treatment with DAA prior to THA is cost-effective at all current drug list prices. Given these findings, strong consideration should be given to treating patients for HCV prior to elective THA. LEVEL OF EVIDENCE: Cost-effectiveness Analysis; Level III.

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.

Machine Learning With Electronic Health Record Data Outperforms a Risk Assessment Prediction Tool in Predicting Discharge Disposition After Total Joint Arthroplasty.

The Risk Assessment Prediction Tool (RAPT) predicts discharge disposition after total joint arthroplasty with only 75% accuracy. The goal of this study was to evaluate whether higher accuracy can be achieved with basic electronic health record (EHR) data combined with machine learning (ML) algorithms. Three ML analysis models were developed: model 1 (M1) evaluated the accuracy of predicted discharge disposition in concordance with the RAPT; model 2 (M2) used the RAPT questionnaire to develop an ML algorithm to predict the likelihood of discharge to home vs facility; and model 3 (M3) was developed with non-RAPT data (age, surgeon, and discharge preference) with the same ML training process as M2. Evaluation metrics included accuracy for home discharge (HD), positive predictive value for HD (PPV-HD), negative predictive value for HD (NPV-HD), sensitivity, specificity, and area under the receiver operating curve (AUROC). A total of 1405 patients were included. With M1, the overall accuracy for HD was 83.5%, PPVHD was 92.1%, NPV-HD was 45%, sensitivity was 0.88, and specificity was 0.56. With M2, the overall accuracy for HD decreased to 82.8%, PPV-HD was 91.7%, NPV-HD was 43.1%, sensitivity was 0.87, specificity was 0.53, and mean AUROC was 0.87±0.03. With M3, overall accuracy for HD increased to 90.3%, PPV-HD was 95.2%, NPV-HD was 68.6%, sensitivity was 0.93, specificity was 0.76, and AUROC was 0.91±0.02. The use of basic EHR data combined with ML can exceed the accuracy of the RAPT. Applying big data on an individual level for this purpose may allow for safer and more appropriate discharge planning. [Orthopedics. 2022;45(4):e211-e215.].

The effect of patient point of entry and Medicaid status on quality outcomes following total hip arthroplasty.

AIMS: Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon's practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA. METHODS: The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution's Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days. RESULTS: A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or 'other' race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated ß coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups. CONCLUSION: After controlling for patient variables, there was a statistically significant Medicaid effect on LOS and facility discharge. These results indicate that clinically similar outcomes can be achieved for Medicaid patients; however, further work is needed on maximizing social support and preoperative patient education with a focus on successful home discharge. Cite this article: Bone Joint J 2020;102-B(7 Supple B):78-84.

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.

The Impact of Arthroplasty Fellowship Training on Total Joint Arthroplasty: Comparison of Peri-Operative Metrics between Fellowship-Trained Surgeons and Non-Fellowship-Trained Surgeons.

BACKGROUND: We sought to identify differences between total joint arthroplasties (TJAs) performed by adult reconstruction fellowship-trained surgeons (FT) than non-fellowship-trained surgeons (NFT). METHODS: A single-institution database was utilized to identify patients who underwent elective TJA between 2016 and 2019. RESULTS: In total, 16,882 TJAs were identified: 9111 total hip arthroplasties (THAs) and 7771 total knee arthroplasties (TKAs). Patients undergoing THA by FT surgeons were older (63.11 vs 61.84 years, P < .001), more likely to be white, insured by Medicare, and less likely to be active smokers (P < .0001). Both surgical time (90.03 vs 113.1 minutes, P < .0001) and mean length of stay (LOS) (1.85 vs 2.72 days, P < .0001) were significantly shorter for THAs performed by FT surgeons than NFT surgeons. A significantly greater percentage of patients were discharged home after THA by FT surgeons than NFT surgeons (88.7% vs 85.2%, P = .002). FT patients were quicker to mobilize with therapy and required 25% less opioids. TKAs performed by FT surgeons were associated with shorter surgical times (87.4 vs 94.92 minutes, P < .0001), LOS (2.62 vs 2.84 days, P < .0001), and nearly 19% less opioid requirement in the peri-operative period. In addition to higher Activity Measure for Post-Acute Care scores associated with FT surgeons after TKA, a significantly greater percentage of patients were discharged home after TKA by FT surgeons than NFT surgeons (83.97% vs 80.16%, P < .001). CONCLUSION: For both THA and TKA, patients had significantly shorter surgical times, LOS, and required less opioids when their procedure was performed by FT surgeons compared to NTF surgeons. Patients who had their TJA performed by a FT surgeon achieved higher Activity Measure for Post-Acute Care scores and were discharged home more often than NFT surgeons. In an era of value-based care, more attention should be paid to the patient outcomes and financial implications associated with arthroplasty fellowship training. LEVEL III EVIDENCE: Retrospective Cohort Study.

Barriers to Revision Total Hip Service Lines: A Surgeon's Perspective Through a Deterministic Financial Model.

BACKGROUND: Revision THA represents approximately 5% to 10% of all THAs. Despite the complexity of these procedures, revision arthroplasty service lines are generally absent even at high-volume orthopaedic centers. We wanted to evaluate whether financial compensation is a barrier for the development of revision THA service lines as assessed by RVUs. QUESTIONS/PURPOSES: Therefore, we asked: (1) Are physicians fairly compensated for revision THA on a per-minute basis compared with primary THA? (2) Are physicians fairly compensated for revision THA on a per-day basis compared with primary THA? METHODS: Our deterministic financial model was derived from retrospective data of all patients undergoing primary or revision THA between January 2016 and June 2018 at an academic healthcare organization. Patients were divided into five cohorts based on their surgical procedure: primary THA, head and liner exchange, acetabular component revision THA, femoral component revision THA, and combined femoral and acetabular component revision THA. Mean surgical times were calculated for each cohort, and each cohort was assigned a relative value unit (RVU) derived from the 2018 Center for Medicaid and Medicare assigned RVU fee schedule. Using a combination of mean surgical time and RVUs rewarded for each procedure, three models were developed to assess the financial incentive to perform THA services for each cohort. These models included: (1) RVUs earned per the mean surgical time, (2) RVUs earned for a single operating room for a full day of THAs, and (3) RVUs earned for two operating rooms for a full day of primary THAs versus a single rooms for a full day of revision THAs. A sixth cohort was added in the latter two models to more accurately reflect the variety in a typical surgical day. This consisted of a blend of revision THAs: one acetabular, one femoral, and one full revision. The RVUs generated in each model were compared across the cohorts. RESULTS: Compared with primary THA by RVU per minute, in revision THA, head and liner exchange demonstrated a 4% per minute deficit, acetabular component revision demonstrated a 29% deficit, femoral component revision demonstrated a 32% deficit, and full revision demonstrated a 27% deficit. Compared with primary service lines with one room, revision surgeons with a variety of revision THA surgeries lost 26% potential relative value units per day. Compared with a two-room primary THA service, revision surgeons lost 55% potential relative value units per day. CONCLUSIONS: In a comparison of relative value units of a typical two-room primary THA service line versus those of a dedicated revision THA service line, we found that revision specialists may lose between 28% and 55% of their RVU earnings. The current Centers for Medicare and Medicaid Services reimbursement model is not viable for the arthroplasty surgeon and limits patient access to revision THA specialists. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Do Patient Point of Entry and Medicaid Status Affect Quality Outcomes Following Total Knee Arthroplasty?

BACKGROUND: The effect of surgeon practice and patient care setting have not been studied in the Medicaid population undergoing total knee arthroplasty (TKA). This study aims to evaluate whether point of entry and Medicaid status affect outcomes following TKA. METHODS: The electronic medical record at our urban, academic, tertiary care hospital system was retrospectively reviewed for all primary, unilateral TKA during January 2016 and January 2018. Outpatient visits within the 6-month preoperative period categorized TKA recipients as either Hospital Ambulatory Clinic Centers patients with Medicaid insurance or private office patients with non-Medicaid insurers. RESULTS: There were 174 Medicaid patients and 317 non-Medicaid patients for 491 total patients. Medicaid patients were significantly younger (62.6 ± 1.6 vs 65.4 ± 1.1 years, P < .01), of "other' ethnicity (43.1% vs 25.6%, P < .01), and to be a current smoker (9.3% vs 6.6%, P = .02). There was no difference in gender, body mass index, and American Society of Anesthesiologists score. After controlling for patient factors, the Medicaid effect was insignificant for surgical time (exponentiated ß 0.93, 95% confidence interval [CI] 0.86-1.01, P = .076) and facility discharge (odds ratio 1.58, 95% CI 0.71-3.51, P = .262). Medicaid status had a significant effect on length of stay (LOS) (rate ratio 1.21, 95% CI 1.02-1.43, P = .026). CONCLUSION: Multivariable analysis controlling for patient factors demonstrated that Medicaid coverage had minimal effect on surgical time and facility discharge. Medicaid patients had significantly longer LOS by one-half day. These results indicate that comparable outcomes can be achieved for Medicaid patients following TKA provided that the surgeon and care setting are similar. However, increased care coordination and preoperative education may be necessary to normalize disparities in hospital LOS. LEVEL OF EVIDENCE: III, retrospective observational analysis.

Hospital Consumer Assessment of Healthcare Providers and Systems: Do Patient Demographics Affect Outcomes in Total Hip Arthroplasty?

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient's hospital experience. This study aims to assess whether HCAHPS scores vary by demographic or surgical factors in patients undergoing primary total hip arthroplasty. METHODS: Patients who completed an HCAHPS survey after a primary total hip arthroplasty between October 2011 and November 2016 were included in this study. Patient demographics and surgical factors were evaluated for correlations with individual HCAHPS questions. RESULTS: One thousand three hundred eighty-three HCAHPS questionnaires were reviewed for this study. Patients with a submitted HCAHPS response had an average age of 63.83 ± 10.17 years. Gender distribution was biased toward females at 57.27% (792 females) versus 42.73% (591 males). The average body mass index (BMI) was 28.68 ± 5.86 kg/m2. Race distribution was predominantly Caucasian at 81.49% (1127 patients), followed by "unknown" at 8.60% (119 patients) and African-American at 8.46% (117 patients). Home discharge occurred for 93.06% (1287 patients) versus 6.94% for facility discharge (96 patients). Mean length of stay was 2.41 ± 1.17 days. Each 1-year increase in age was positively correlated with a 0.16% increase in top-box response rate (ß = 0.0016 ± 0.0008; P < .05). Male gender was correlated with a 4.61% increase in top-box response rate when compared to female gender (ß = 0.0461 ± 0.0118; P < .01). BMI was found to be correlated with a 0.20% increase in HCAHPS response rates for each 1 kg/m2 increase (ß = 0.0020 ± 0.0010; P < .05). For each day increase in length of stay, HCAHPS top-box response rates decrease by 3.41% (ß = -0.0341 ± 0.0051; P < .0001). Race, marital status, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCAHPS top-box response rate (P > .05). CONCLUSION: The HCAHPS quality measurement metric affects physician reimbursement and may be biased by a number of variables including sex, length of stay, and BMI, rather than a true reflection of the quality of their hospital experience. Further research is warranted to determine whether HCAHPS scores are an appropriate measure of the quality of care received.

Hospital Consumer Assessment of Healthcare Providers and Systems: Do Patient Demographics Affect Outcomes in Total Knee Arthroplasty?

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally standardized tool to assess patient experience between hospitals. The HCAHPS survey can affect hospital reimbursement. This study aims to determine if HCAHPS scores vary by a number of demographic variables in patients undergoing primary total knee arthroplasty (TKA). METHODS: Patients who underwent primary TKA and returned a completed HCAHPS survey were included in this study. HCAHPS surveys were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried, and multivariable linear regression was performed. RESULTS: In total, 1028 HCAHPS questionnaires after primary TKA were evaluated. The average age of patients was 65.9 ± 9.0 years and 67.9% (698 patients) were female. Average body mass index was 32.5 ± 6.9 kg/m2. Sixty-nine percent of the patients (1287 patients) were discharged home versus 10.3% (106 patients) to another facility. Mean length of stay was 2.9 ± 1.4 days. Age was correlated with a 0.3% decrease in top-box response rate (P < .01) for each 1-year increase in age. Compared to Caucasian race, African American race was correlated with a 5.6% increased rate for top-box response (P < .01), while Asian race (P = .42) and unknown race (P = 1.00) demonstrated no significant difference. Marital status demonstrated that divorced/separated status resulted in a significant 5.4% decrease in top-box response rates (P < .05). Similarly, single (P = .12) and widowed (P = .09) statuses also demonstrated a trend toward lower top-box response rates when compared to married or partnered patients. For each day increase in length of stay, HCAHPS top-box response rates decrease by 1.6% (P < .01). Gender, body mass index, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCHAPS top-box response rate (P > .05). CONCLUSION: HCAHPS scores in patients undergoing primary TKA are influenced not just by hospital and surgeon factors such as length of stay but by demographic variables such as age, race, and marital status. As surgeons become more involved with the burden of improving patient experience, they should be aware that static demographic variables can have a significant effect on HCAHPS scores.

Modifying Patient Expectations Can Enhance Total Hip Arthroplasty Postoperative Satisfaction.

BACKGROUND: A better understanding of patient expectations within the perioperative setting will enable clinicians to better tailor care to the needs of the total hip arthroplasty (THA) recipient. Such an approach will promote patient-centered decision-making and optimize recovery times while enhancing mandated hospital quality metrics. In the present study, we preoperatively and postoperatively surveyed THA candidates to elucidate the relationship between patient expectations and length of stay (LOS). METHODS: This is a multi-institutional prospective study among THA candidates. Patients were surveyed regarding discharge planning 1 week preoperatively and postoperatively to capture perioperative patient expectations and correlate with inpatient LOS. RESULTS: In total, 93 THAs performed by 6 high-volume orthopedic surgeons at 2 medical centers. Our results demonstrated that patients of male gender and commercial insurance had significantly (P < .05) shorter LOS. Shorter LOS patients demonstrated significantly higher levels of LOS acceptance ("very comfortable" rate in same-day discharge: 75.0% and next-day discharge: 63.8%; 2 days: 40.7%; 3+ days: 42.9%; P < .05) and a higher likelihood to participate in SDD programs. Postoperatively, patients with a shorter LOS had more acceptance to their LOS, albeit not statistically significant (P = .20). CONCLUSION: Our results suggest that guiding patient expectations within the perioperative setting is an essential component for successful and timely discharge after THA. Having clear and transparent discussion with the surgical team regarding the perioperative course can improve a THA candidate's understanding and buy-in with the postoperative plan, regardless of LOS. Finally, inpatient LOS does not appear to affect patient satisfaction. LEVEL OF EVIDENCE: Level II, prospective observational study.

Revision Versus Primary Hospital Consumer Assessment of Healthcare Providers and Systems Scores in Total Joint Arthroplasty.

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient's inpatient experience. This study aims to assess whether HCAHPS scores differ between patients undergoing primary total joint arthroplasty (TJA) and patients undergoing revision TJA. METHODS: Patients who underwent primary or revision total hip or total knee arthroplasty (THA or TKA) and returned a completed HCAHPS survey were included in this study. HCAHPS scores were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried. Appropriate statistical analyses were performed using MatLab 2017a and P-values less than .05 were deemed significant. RESULTS: In total, 523 primary and 59 revision THA recipients completed HCAHPS surveys at our institution between October 2011 and November 2016. During this same period, 507 primary TKA recipients and 40 revision TKA recipients completed HCAHPS surveys. Compared to revision THA, primary THA patients had a significantly higher top box for overall hospital ratings (58.46% vs 41.38%), felt that nurses listened to them carefully (84.3% vs 72.88%), and felt that they clearly understood the role of each medication (69.48% vs 56.90%). Moreover, 18 of 20 HCAHPS question responses favored primary THA despite not reaching significance for the majority of HCAHPS questions. Patients with revision TKA demonstrated a significantly higher incidence of "top box" choices for quieter rooms and a trend favoring better HCAHPS scores in revision TKA in a further 12 of 20 HCAHPS responses. CONCLUSION: Patients undergoing primary THA report higher HCAHPS scores than those undergoing revision THA, while revision TKA demonstrated a general trend toward higher scores when compared to primary TKA patients. This publicly reported quality measurement metric which factors into physician reimbursement may be biased by the patient's health status, the complexity of the surgical procedure, and length of stay in hospital rather than a true reflection of the quality of their hospital experience.

The Risk Assessment and Prediction Tool Is Less Accurate in Extended Length of Stay Patients Following Total Joint Arthroplasty.

BACKGROUND: Although preoperative risk assessment tools have been effective in predicting discharge disposition after total joint arthroplasty (TJA), studies reporting on discharge planning in extended length of stay (ELOS), >3 days, patients are lacking. The purpose of this study was to describe the predictive utility of the Risk Assessment and Prediction Tool (RAPT) for discharge disposition in ELOS patients. METHODS: Our study included 260 patients with LOS >3 days who underwent primary TJA between 2014 and 2016. Patients were separated into 3 cohorts, based on their RAPT score: low risk (9-12), medium risk (6-9), and high risk for discharge to a facility (1-6). Scores were compared among cohorts and correlated with discharge disposition for patients who stayed beyond 3 days. RESULTS: In ELOS, RAPT had a higher utility in predicting discharge disposition in the low-risk (76.5% to home) and high-risk (62.9% to facility) patient cohorts, while medium-risk patients (56.5% to home) were the least accurate. Responses that significantly correlated with discharge home included male gender (odds ratio [OR], 1.81; P < .05), ambulation without walking aids (OR, 2.94; P < .01) or a single-point cane (OR, 2.95; P < .0001), <1 community support visit per week preoperatively (OR, 1.86; P < .05), and having support from someone at home (OR, 3.43; P < .0001). CONCLUSION: The RAPT score in ELOS patients is better correlated with the low-risk and high-risk cohorts than in medium-risk patients. Conversely, medium-risk ELOS patients constituted 56.8% of our sample size, but only predicted 56.5% of discharge dispositions correctly. Future discharge disposition risk assessment tools are needed to stratify medium-risk patients.

The Historical Development of Value-Based Care: How We Got Here.

The original architects of Medicare modeled the payment system on the existing fee-for-service (FFS) structure that historically dominated the health-insurance market. Under the FFS paradigm, health-care expenditures experienced an exponential rise. In response, the managed care and capitation models of health-care delivery were developed. However, changes in Medicare reimbursement, along with an increasing volume of orthopaedic procedures and escalating implant costs, call into question the cost-effectiveness of this service line. The success of the Medicare Acute Care Episode (ACE) Demonstration Project proved the feasibility of value-based care and ushered in a new era of bundled payment initiatives.

Rapid Discharge in Total Hip Arthroplasty: Utility of the Outpatient Arthroplasty Risk Assessment Tool in Predicting Same-Day and Next-Day Discharge.

BACKGROUND: Hospital length of stay is a major driver of cost in the total hip arthroplasty (THA) episode of care, and as a result, significant efforts are being made to minimize it. This study aims to assess the utility of the Outpatient Arthroplasty Risk Assessment (OARA) screening tool in accurately identifying patients for safe and early discharge after THA. METHODS: A retrospective review was conducted on 332 consecutive patients who underwent primary THA at a single tertiary academic center. Patients were evaluated using the OARA score, a tool that has been proposed to identify patients who can safely undergo early discharge after THA. The validity of these claims was assessed by analyzing the OARA score's positive and negative predictive values for high vs low OARA scores between patients enrolled in our (1) same-day discharge (SDD) and 2) next-day discharge (NDD) pathways. RESULTS: When comparing the utility of the OARA score in accurately predicting length of stay, the OARA score demonstrated a (1) higher, but constant, positive predictive value for discharge on postoperative day (POD) 0 for SDD (86.1%) than POD1 for NDD (35.5%) and (2) lower negative predictive value for discharge on POD0 (23.1%) for SDD than POD1 for NDD (86.1%). CONCLUSION: The OARA score was developed to risk-stratify patients who can safely undergo SDD or NDD after THA. In this study, the OARA score was a highly predictive tool in identifying NDD patients at risk for failure of discharge by POD1.

Home Health Services Are Not Required for Select Total Hip Arthroplasty Candidates: Assessment and Supplementation With an Electronic Recovery Application.

BACKGROUND: At our institution, all postoperative total hip arthroplasty (THA) candidates have received home health services (HHS), consisting of visiting nurses, physical and occupational therapists. However, with a more technologically inclined patient population, electronic patient rehabilitation applications (EPRAs) can be used to deliver perioperative care at the comfort of the patient's home. The aim of this study is to investigate the clinical utility and economic burden associated with digital rehabilitation applications in primary THA recipients. METHODS: We conducted a single-center, retrospective review of patients operated between November 2016 and November 2017. Before surgery, and at the discretion of the surgeon, patients were assigned to EPRA with HHS or EPRA alone. Patient baseline demographics, EPRA engagement, and validated patient-reported outcomes (PROs) were collected (Veterans Rand 12-Item Health Survey [VR-12] and Hip Disability and Osteoarthritis Outcome Score Junior) at baseline and 12 weeks. These PRO scores were correlated with cohort assignments to assess noninferiority of EPRA alone. RESULTS: In total, 268 patients received either EPRA-HHS (n = 169) or EPRA (n = 99) alone. Patients receiving EPRA only were on average younger (60.8 vs 65.8; P < .0001), but otherwise similar to patients in the EPRA-HHS cohort. EPRA-only patients demonstrated no differences in VR-12 (P > .05) and Hip Disability and Osteoarthritis Outcome Score Junior (P > .05) when compared with EPRA-HHS. CONCLUSION: The integration of electronic rehabilitation tools is gaining acceptance within the orthopedic community. Our study demonstrated that EPRA alone was clinically noninferior while substantially less costly than EPRA-HHS.