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.

Surgical and Medical Costs for Fibromyalgia Patients Undergoing Total Knee Arthroplasty.

The potential added costs of managing fibromyalgia patients after total knee arthroplasty (TKA) have not been assessed. Therefore, the purpose of this study was to perform a cost analysis of fibromyalgia versus nonfibromyalgia patients who underwent TKA. Specifically, we evaluated the following episodes of care: (1) readmission rates, (2) total costs, (3) total reimbursements, and (4) net losses for surgical and medical complications. Patients who underwent TKAs between 2005 and 2014 from the Medicare Standard Analytical Files of the PearlDiver supercomputer were propensity score matched by patients with and without fibromyalgia in a 1:1 ratio based on age, sex, and the Charlson Comorbidity Index, yielding a total of 305,510 patients distributed equally between the cohorts for analysis. Odds ratios (ORs), 95% confidence intervals (CIs), and p-values were calculated. Mean costs, total costs, and total reimbursements were assessed as along with total net losses, which were defined as total costs minus total reimbursements. Fibromyalgia patients had similar 90-day readmission rates compared with nonfibromyalgia patients (OR: 1.03; 95% CI: 1.00-1.06; p = 0.06) but incurred lower readmission costs (US$2,318,384,295 vs. US$2,534,482,404; p < 0.001). Although fibromyalgia patients had higher total reimbursements for medical complications ($27,758,057 vs. US$18,780,610; p < 0.001), the increased management costs (US$106,049,870 vs. US$66,080,469; p < 0.001) led to greater net losses (US$78,291,813 vs. US$47,299,859; p < 0.001). Similarly, although fibromyalgia patients had higher total reimbursements for surgical complications (US$94,192,334 vs. US$73,969,026; p < 0.001), the increased surgical costs (US$382,122,613 vs. US$306,359,910; p < 0.001) led to greater net losses (US$287,930,279 vs. US$232,390,884; p < 0.001). This study highlights some of the potential financial discrepancies of managing patients with fibromyalgia. Our findings suggest medical and surgical complication costs to be greater than reimbursement, resulting in overall net financial losses. These findings need to be considered in the light of health care reform and cost structuring.

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.