Factors Complicating Discharge to Home following Total Knee Arthroplasty-A Single Institution Initiative.

Recently, with the Medicare bundled payments initiative for total knee arthroplasty (TKA), there has been a move by many institutions to further streamline costs associated with the entire operative and perioperative process. One of these cost-saving strategies has been to favor discharging patients to home with outpatient services as opposed to discharging to the relatively more expensive rehabilitation facilities. Our aim was to determine the success of a teaching institute's initiative in discharging patients to home instead of a rehabilitation facility. Specifically, we evaluated if there were differences in discharge disposition based off of (1) surgeon/patient preference, (2) length of stay, (3) demographics, and (4) postoperative complications. A retrospective review of all patients who had a TKA from 2015 to 2017 at a single teaching institution was performed and assessed discharge to home or to a rehabilitation facility. If they were not discharged to home, we evaluated why that did not happen, stratified the reason they were discharged to a rehabilitation facility into four groups based on (1) physician and occupational health team assessment, (2) patient preference, (3) physician preference, and (4) family or caretaker preference. A total of 229 patients were enrolled in this initiative, with 107 patients (47%) discharged to home with outpatient physical therapy services and 122 (53%) discharged to a rehabilitation facility. Of these, 35 patients (29%) went to these facilities because of physician and occupational health team assessment. However, 31 (25%) patients were due to patient preference, 32 (26%) were because of surgeon's preference, and 24 (20%) were not discharged to home because of family or caretaker preference. There were no differences in length of stay, gender, or complication rates between cohorts. Many patients can be safely discharged to home following TKA at a community teaching institution; however, there continues to be a strong prejudice by patients, physicians, and caretakers to be discharged to a rehabilitation facility despite the home discharge initiative.

Cervical Spinal Stenosis in the Setting of Recurrent Shoulder Instability: A Nationwide Review of Records from 2007 to 2014.

Recurrent shoulder instability (RSI) and cervical spinal stenosis (CSS) may present with similar clinical symptoms. There is a paucity of data available investigating the incidence of CSS in patients with recurrent shoulder instability. For this reason, we investigated the incidence of CSS in patients with RSI and patient demographics, and compared characteristics of patients with CSS-RSI with those of patients with RSI alone. The Medicare Standard Analytical Files database in the PearlDiver supercomputer (Warsaw, Indiana) was carefully analyzed to identify all patients who had both CSS and RSI from 2007 to 2014. Patients were identified based on the international classification of disease codes (9th ed.). Annual national trends based on age, gender, body mass index (BMI), and geographic location were assessed. We identified 38,073 patients in the database during our study period. There was a significant increase in incidence of CSS in recurrent shoulder instability patients from 6.5% in 2007 to 9.2% in 2014 (p = 0.0027). Patients who were female (p = 0.0018), 65 to 80 years (46.3%; p < 0.0001), and with a BMI of 30-40 kg/m2 (34.1%; p < 0.0001) represented the greatest proportion of concomitant patients. Age less than 80 years was an independent risk factor for coexisting conditions (OR 1.47, 95% CI 1.32 to 1.64). In conclusion, the incidence of cervical spinal stenosis is increasing in patients with recurrent shoulder instability. Physicians should maintain high clinical suspicion for concurrent cervical spinal pathology, particularly in obese, young female patients with recurrent instability. Further investigation into the influence of these concurrent pathologies on patient outcomes is warranted.

The Epidemiology of Vertebral Osteomyelitis in the United States From 1998 to 2013.

STUDY DESIGN: This is a epidemiological database analysis. OBJECTIVES: The objectives of this article are to assess the following characteristics of vertebral osteomyelitis (VO): (1) incidence and patient demographics, (2) mortality rate, (3) length-of-stay (LOS), and (4) admission costs. SUMMARY OF BACKGROUND: VO is a serious disease with potentially devastating clinical consequences. At present, there is limited data on the epidemiology of VO in the United States as previous reports are based on older studies with small sample sizes. METHODS: We used the Nationwide Inpatient Sample database and estimated that 228,044 patients were admitted for VO in the United States between 1998 and 2013. Data were extracted on patient demographics, comorbidities, inpatient mortality, LOS, and inflation-adjusted hospitalization charges. Multivariable regression analyses were performed. RESULTS: The incidence of VO admission was 4.8 per 100,000, increasing from 8021 cases (2.9/ 100,000) in 1998 to 16,917 cases (5.4/100,000) in 2013. Majority of patients were white (74%), male (51%), younger than 59 years of age (49.5%), and carried Medicare insurance (50%). The increase in incidence for male and females was similar. The mortality rate during hospital stay was 2.1%, decreasing from 2% in 1998 to 1.7% in 2006 and increasing to 2.2% in 2013. Risk factors for mortality included increased age, male sex, and higher comorbidity score. History of congestive heart failure [odds ratio (OR)=2.45], cerebrovascular disease (OR=1.92), liver disease (OR=2.33), hepatitis C (OR=2.36), and renal disease (OR=1.88) was associated with higher mortality rate. Mean LOS was 9.2 days, decreasing from 9.1 days in 1998 to 8.8 days in 2013. The mean estimated hospital charges for admission were $54,599, however, this increased from $24,102 in 1998 (total of $188.8 millions) to $80,786 in 2013 (total of $1.3 billions). CONCLUSION: This condition is associated with lengthy and expensive hospital stays resulting in a significant burden to patients and the health care system.

Inpatient Cruciate Ligament Reconstruction in the United States: A Nationwide Database Study From 1998 to 2010.

This study evaluated inpatient cruciate ligament reconstruction in the United States during a 13-year period. The Nationwide Inpatient Sample database was used to identify inpatient cruciate ligament reconstructions performed from 1998 to 2010. National trends in incidence, patient demographics, perioperative complications, length of stay, and total admission costs were evaluated. The impact of various contributing factors on these outcomes was further evaluated using multivariable regression analyses. The rate of inpatient cruciate ligament reconstruction has decreased significantly in the United States during the past decade. The outcome data from this study can be used as a comparison cohort for future outpatient analyses of anterior cruciate ligament reconstruction in the United States.

Unnecessary magnetic resonance imaging of hips: an economic burden to patients and the healthcare system.

Patients referred to orthopedists for hip pain due to arthritis may already have MRI studies ordered by their referring physicians despite plain radiographs being sufficient in most cases. Hence, we prospectively evaluated every patient referred to our institution during a 36-month period to identify the number of new patients with hip osteoarthritis who had an unnecessary MRI, the additional costs of these MRIs, and the extrapolated cost to the United States healthcare system during the next 10years. Overall, 15.4% of the patients presented with unnecessary MRIs, approximately, 330 to 440.5 million dollars may be spent on unnecessary hip MRIs in this patient population in America. We believe that referring physicians should not simultaneously order a radiograph and an MRI to evaluate hip pain.

Patient-specific instrumentation in total knee arthroplasty.

Patient-specific instrumentation (PSI) is a technology that allows the surgeon to perform a total knee arthroplasty (TKA) potentially more easily with preformed cutting blocks and jigs, which are developed from preoperative computed tomographic or magnetic resonance image scans of the knee. It was introduced with the goal of reducing surgical time, minimizing costs, improving alignment, and reducing radiographic outliers when performing a TKA. Although multiple reports have demonstrated that PSI can reduce the amount of trays and instrumentation required, operative time, and turnover rates, this has not been extrapolated to an overall cost reduction. This is potentially related to the costs of preoperative imaging and the intrinsic costs of production of the patient-specific guides. With the present technology, it is also controversial whether improvements in alignment can be achieved. In addition, it remains to be seen whether this will lead to a reduction in costs and improvements in clinical, radiographic, and functional outcomes. As PSI is relatively new, there is a paucity of long-term studies, which makes it difficult to predict whether long-term improvements in implant survivorship will lead to substantial improvements in patient function, overall outcomes, or cost benefits.

The economic impact of periprosthetic infections following total knee arthroplasty at a specialized tertiary-care center.

The purpose of this study was to measure the impact of periprosthetic joint infections (PJIs) on the length of hospitalization, readmissions, and the associated costs. Between 2007 and 2011, our prospectively collected infection database was reviewed to identify PJIs that occurred following primary total knee arthroplasty (TKA), which required a two-stage revision. We identified 21 consecutive patients and matched them to 21 non-infected patients who underwent uncomplicated primary TKA. The patients who had PJIs had significantly longer hospitalizations (5.3 vs. 3.0 days), more readmissions (3.6 vs. 0.1), and more clinic visits (6.5 vs. 1.3) when compared to the matched group, respectively. The mean annual cost was significantly higher in the infected cohort ($116,383; range, $44,416 to $269,914) when compared to the matched group ($28,249; range, $20,454 to $47,957). Periprosthetic infections following TKA represent a tremendous economic burden for tertiary-care centers and to patients.

Economic evaluation of chlorhexidine cloths on healthcare costs due to surgical site infections following total knee arthroplasty.

The purpose of this study was to evaluate the overall annual healthcare cost savings of adding a pre-operative chlorhexidine cloth preparation protocol. We used reports from the National Healthcare Safety Network and previously published reports to determine a range of surgical site infection rates following total knee arthroplasty and the cost per revision procedure. The savings listed are potential, but may be less. The cost benefit of using chlorhexidine at our institution per 1,000 total knee arthroplasty patients was a net savings of approximately $2.1 million. The annual healthcare savings ranged from $0.78 to $3.18 billion. This epidemiologic evaluation of using chlorhexidine prior to undergoing total knee arthroplasty has demonstrated the potential to decrease healthcare costs primarily by decreasing the incidence of surgical site infections.

Single-use cutting blocks and trials lower costs in primary total knee arthroplasty.

Because total knee arthroplasty is one of the most common orthopaedic procedures, it is important that the medical community continually strive for cost reductions. This prospective controlled trial aimed to determine if cost decreases could be achieved in non-navigated and navigated procedures by replacing traditional saws, cutting blocks, and trials with a specialized single-use system. Costs were lowered by an estimated $140.00-220.00 per surgery as a result of fewer instrument trays being reprocessed, and an estimated $75.00-330.00 per instrument case due to a 10-24-minute time savings during tray rewrapping. This study has positive financial implications for patients, hospitals, institutions, and third-party carriers.

Assessment of static progressive stretch for the treatment of shoulder stiffness: a prospective case series.

INTRODUCTION: The purpose of this study was to evaluate the use of a patient-directed static progressive stretch orthosis for the treatment of shoulder stiffness. METHODS: Twenty-three patients who had limitations in range of motion of the shoulder and who had failed conventional physical therapy methods were studied. This cohort included 15 women and 8 men with a mean age of 53 years. Treatment comprised one to three 30- to 60-minute sessions per day with a patient-controlled orthosis utilizing static progressive stretch. The patients adjusted the degree of stretch at 5-minute intervals as tolerated. Compliance, range of motion, patient satisfaction, and complications were assessed, and a two-way repeated measure ANOVA was performed to assess the effects of age or gender. RESULTS: After a mean treatment duration of 10 weeks (range, 4 to 19 weeks), the patients gained a mean of 22° (range, -47 to 57°) of external rotation, 18° (range, -19 to 55°) of internal rotation, 46° (range, 3 to 97°) of abduction, and 23° (range, 3 to 40°) of forward flexion. In total, 22 of 23 patients (96%) experienced increases in range of motion that were maintained at 1 year following treatment. Statistically significant increases in range of motion and clinical function scores were noted; age and gender did not appear to influence the outcomes. DISCUSSION: This device compared favorably to other treatment methods for shoulder stiffness. An orthosis utilizing static progressive stretch was a useful adjunct for the treatment of shoulder stiffness refractory to conventional therapy.