Changes in Total Knee Arthroplasty Utilization since the Implementation of ACA: An Analysis of Patient-Hospital Demographics, Costs, and Charges.

The Patient Protection and Affordable Care Act (PPACA) formed the Center for Medicare and Medicaid Innovation Center which has implemented experimental reimbursement models targeted at high-demand procedures to improve care quality. However, the effect of health care reform on total knee arthroplasty (TKA) procedures has not been explored. This study explores patient-hospital level demographics, inpatient costs, and charges related to TKA procedures between 2009 and 2015. The National Inpatient Sample database was utilized to identify patients who received primary TKA between January 2009 and October 2015 (4,283,387 cases). Categorical, continuous, and ordinal data were analyzed using chi-square/Fisher's exact test, t-test/analysis of variance, or Kruskal-Wallis' test, respectively. There was an increase in proportion of TKA recipients belonging to minority groups and the lowest quartile of median income (p < 0.05). There was a 1.9% increase in recipients using Medicaid as a primary payor and volume shifts from urban nonteaching toward urban teaching hospitals. There was a reduction in mean length of stay and mean inpatient costs. There were increases in hospital charges, but reductions in rates of inpatient mortality, and other postoperative complications. TKA procedures remain the most common surgical procedure; therefore, our study assessed national trends to capture the effect of PPACA. We found an increasing proportion of TKA recipients belonging to minority and low-income groups, volume shifts to urban teaching hospitals, and lower costs of care. These findings may be useful in objectively critiquing the effects of PPACA on TKA-related care.

Are Allogeneic Transfusions Decreasing in Total Knee Arthroplasty Patients? National Inpatient Sample 2009-2013.

BACKGROUND: Allogeneic transfusions are commonly used for substantial blood loss in total knee arthroplasty (TKA), but have been associated with adverse effects and increased costs. The purpose of this study is to provide a detailed description of (1) trends of allogeneic blood transfusion; (2) risk factors and adverse events; and (3) discharge disposition, length-of-stay (LOS), and cost/charge analysis for primary TKA patients who received an allogeneic blood transfusion from 2009-2013. METHODS: A cohort of 3,217,056 primary TKA patients was identified from the National Inpatient Sample database from 2009-2013. Demographic, clinical, economic, and discharge data were analyzed for patients who received allogeneic blood products, and for those who did not receive any type of blood transfusion. Other parameters analyzed include risk factors, adverse events, discharge disposition, and costs/charges. RESULTS: There was a significant decline in use of allogeneic transfusion from 2009-2013 incidence (13.9%-7.3%; P < .001). All comorbidities examined were associated with significantly increased risk of receiving allogeneic transfusion with exception of patients with AIDS, metastatic cancer, and peptic ulcer disease. Allogeneic transfusion was associated with worse outcomes during hospitalization. Patients also had a greater likelihood of discharge to short-term care, greater LOS, and greater median costs/charges. Among TKA patients who received an allogeneic transfusion, costs varied based on hospital ownership and characteristics, primary-payer, region, and bed-size. CONCLUSION: Given the poor outcomes and higher costs associated with allogeneic transfusions, efforts must be undertaken to minimize this risky practice. With the projected increase in demand for TKAs, orthopedists must understand effective blood management strategies.

Risk Factors and Costs Associated With Clostridium difficile Colitis in Patients With Prosthetic Joint Infection Undergoing Revision Total Hip Arthroplasty.

BACKGROUND: With the increased demand for primary total hip arthroplasty (THA) and corresponding rise in revision procedures, it is imperative to understand the factors contributing to the development of Clostridium difficile colitis. We aimed to provide a detailed analysis of: (1) the incidence of; (2) the demographics, lengths of stay, and total costs for; and (3) the risk factors and mortality associated with the development of C. difficile colitis after revision THA. METHODS: The National Inpatient Sample database was queried for all individuals diagnosed with a periprosthetic joint infection and who underwent all-component revision THA between 2009 and 2013 (n = 40,876). Patients who developed C. difficile colitis during their inpatient hospital stay were identified. Multilevel logistic regression analysis was conducted to assess the association between hospital- and patient-specific characteristics and the development of C. difficile colitis. RESULTS: The overall incidence of C. difficile colitis after revision THA was 1.7%. These patients were significantly older (74 vs 65 years), had greater lengths of hospital stay (19 vs 9 days), accumulated greater costs ($51,641 vs $28,282), and were more often treated in an urban hospital compared to their counterparts who did not develop C. difficile colitis (P < .001 for all). Patients with colitis also had a significantly higher in-hospital mortality compared to those without (5.6% vs 1.4%; P < .001). CONCLUSION: While C. difficile colitis infection is an uncommon event following revision THA, it can have potentially devastating consequences. Our analysis demonstrates that this infection is associated with a longer hospital stay, higher costs, and greater in-hospital mortality.

Decline in allogeneic blood transfusion usage in total hip arthroplasty patients: National Inpatient Sample 2009 to 2013.

INTRODUCTION: Although total hip arthroplasty (THA) is an effective treatment for end-stage arthritis, it is also associated with substantial blood loss that may require allogeneic blood transfusion. However, these transfusions may increase the risk of certain complications. The purpose of our study is to evaluate: (i) the incidence/trends of allogeneic blood transfusion; (ii) the associated risk factors and adverse events; and (iii) the discharge disposition, length of stay (LOS), and costs for these patients between 2009 and 2013. METHODS: The National Inpatient Sample database was used to identify 1,542,366 primary THAs performed between 2009 and 2013. Patients were stratified based on demographics, economic data, hospital characteristics, comorbidities, and whether or not allogeneic transfusion was received. Logistic regression was performed to evaluate the risk factors for transfusion and postoperative complications. RESULTS: From 2009 to 2013, allogeneic transfusions were used in 16.9% of primary THAs, with a declining annual incidence. Except for obesity, all comorbidities were associated with increased likelihood of receiving a transfusion. Allogeneic transfusion patients were more likely to experience surgical site infections or pulmonary complications (p<0.001 for all). These patients were more likely to be discharged to a short-term care facility (p<0.001). Additionally, they had a greater mean LOS (p<0.001) and higher median hospital costs and charges when compared to their non-transfused counterparts. CONCLUSIONS: While the observed decline in allogeneic transfusion usage is encouraging, further efforts should focus on preoperative patient optimisation. Given the projected increase in demand for primary THAs, orthopaedic surgeons must be familiar with safe and effective blood conservation protocols.

Current Epidemiology of Revision Total Knee Arthroplasty in the United States.

BACKGROUND: Revision surgery for failed total knee arthroplasty (TKA) continues to pose a substantial burden for the United States healthcare system. The predominant etiology of TKA failure has changed over time and may vary between studies. This report aims to update the current literature on this topic by using a large national database. Specifically, we analyzed: (1) etiologies for revision TKA; (2) frequencies of revision TKA procedures; (3) various demographics including payer type and region; and (4) the length of stay (LOS) and total charges based on type of revision TKA procedure. METHODS: The Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database was used to identify all revision TKA procedures performed between 2009 and 2013. Clinical, economic, and demographic data were collected and analyzed for 337,597 procedures. Patients were stratified according to etiology of failure, age, sex, race, US census region, and primary payor class. The mean LOS and total charges were also calculated. RESULTS: Infection was the most common etiology for revision TKA (20.4%), closely followed by mechanical loosening (20.3%). The most common revision TKA procedure performed was all component revision (31.3%). Medicare was the primary payor for the greatest proportion of revisions (57.7%). The South census region performed the most revision TKAs (33.2%). The overall mean LOS was 4.5 days, with arthrotomy for removal of prosthesis without replacement procedures accounting for the longest stays (7.8 days). The mean total charge for revision TKAs was $75,028.07. CONCLUSION: Without appropriate measures in place, the burden of revision TKAs may become overwhelming and pose a strain on providers and institutions. Continued insight into the etiology and epidemiology of revision TKAs may be the principle step towards improving outcomes and mitigating the need for future revisions.

Effect of Bundled Payments and Health Care Reform as Alternative Payment Models in Total Joint Arthroplasty: A Clinical Review.

BACKGROUND: In an effort to control rising healthcare costs, healthcare reforms have developed initiatives to evaluate the efficacy of alternative payment models (APMs) for Medicare reimbursements. The Center for Medicare and Medicaid Services Innovation Center (CMMSIC) introduced the voluntary Bundled Payments for Care Improvement (BPCI) model experiment as a means to curtail Medicare cost by allotting a fixed payment for an episode of care. The purpose of this review is to (1) summarize the preliminary clinical results of the BPCI and (2) discuss how it has led to other healthcare reforms and alternative payment models. METHODS: A literature search was performed using PubMed and the CMMSIC to explore different APMs and clinical results after implementation. All studies that were not in English or unrelated to the topic were excluded. RESULTS: Preliminary results of bundled payment models have shown reduced costs in total joint arthroplasty largely by reducing hospital length of stay, decreasing readmission rates, as well as reducing the number of patients sent to in-patient rehabilitation facilities. In order to refine episode of care bundles, CMMSIC has also developed other initiatives such as the Comprehensive Care for Joint Replacement (CJR) pathway and Surgical Hip and Femur Fracture (SHFFT). CONCLUSION: Despite the unknown future of the Affordable Care Act, BPCI, and CJR, preliminary results of alternative models have shown promise to reduce costs and improve quality of care. Moving into the future, surgeon control of the BPCI and CJR bundle should be investigated to further improve patient care and maximize financial compensation.

Current Epidemiology of Revision Total Hip Arthroplasty in the United States: National Inpatient Sample 2009 to 2013.

BACKGROUND: Despite the excellent outcomes associated with primary total hip arthroplasty (THA), implant failure and revision continues to burden the healthcare system. THA failure has evolved and displays variability throughout the literature. In order to understand how THAs are failing and how to reduce this burden, it is essential to assess modes of implant failure on a large scale. Thus, we report: (1) etiologies for revision THA; (2) frequencies of revision THA procedures; (3) patient demographics, payor type, and US Census region of revision THA patients; and (4) the length of stay and total costs based on the type of revision THA procedure. METHODS: We queried the National Inpatient Sample database for all revision THA procedures performed between January 1, 2009 and December 31, 2013. This yielded 258,461 revision THAs. Patients specific demographics were identified in order to determine the prevalence of revision procedure performed. RESULTS: Dislocation was the main indication for revision THA (17.3%), followed by mechanical loosening (16.8%). All-component revision was the most common procedure performed (41.8%). Patients were most commonly white (77.4%), aged 75 years and older (31.6%), and resided in the South US Census region (37.0%). The average length of stay for all procedures was 5.29 days. The mean total charge for revision THA procedures was $77,851.24. CONCLUSION: Dislocation and mechanical loosening is the predominant indication for revision THA in the United States. With the frequency of revision THAs projected to double in the next decade, orthopedists must take steps to mitigate this potentially devastating complication.

Presentation of Knee Osteoarthritis in the Emergency Department: A Problem Worth Mentioning?

INTRODUCTION: Osteoarthritis (OA) of the knee is a progressive debilitating disease affecting more than 27 million Americans. Treatment is often aimed at reducing pain and slowing disease progression. However, patients with significant barriers to healthcare may elect to visit the emergency department (ED) due to OA-related knee pain. The purpose of this study is to provide a detailed analysis of 1) patient demographics; 2) payor type; 3) charges; and 4) discharge status of patients presenting to the emergency department with a primary diagnosis of knee OA. MATERIALS AND METHODS: The Nationwide Emergency Department Sample from 2009 to 2013 was queried for all patients who presented to the ED with a primary diagnosis of knee OA (ICD-9 CM=715.96) and did not have a concomitant major injury. This yielded 215,253 patients. An analysis of variance (ANOVA) test with a post-hoc Turkey-Kramer test was conducted to assess mean differences of continuous data over time. All categorical data was analyzed using chi-square analysis. RESULTS: The incidence of ED visits dropped significantly between the years 2009 and 2010 (68,661 to 36,846) and plateaued between the years 2010 and 2013. Patients had a mean age of 59.9 years and were primarily women (67.3%). The majority of patients were at the lowest 50% income bracket (68.8%). The Southern US census region had the highest number of ED visits (n=91,995; 42.7%), and Medicare was the primary payor in most cases (n=87,323; 40.7%). The mean charge for ED visits from 2009 to 2013 was $1,368.39, and there was a statistically significant increase in ED-related charges between 2009 and 2013 (p<0.001). The majority of discharges from the ED were routine (n=202,247; 93.8%). CONCLUSION: While the early management of knee osteoarthritis is largely successful at delaying the need for surgery, there are still many patients who do not receive adequate care and present to the emergency room for non-emergent evaluation. This, along with rising charges for ED visits, is likely increasing resource consumption and the financial impact on the healthcare system. Future efforts should focus on improving access to care for patients with knee OA before it develops into an overwhelming burden.

An Assessment of the Comprehensiveness of Various Hip Outcome Scores.

INTRODUCTION: Evaluating outcomes following total hip arthroplasty (THA) has been essential for improving satisfaction and quality of care. However, finding systems that fully encompass these outcomes poses a challenge for physicians, and often still do not provide an adequate picture of a patient's recovery. Therefore, we evaluated different scoring systems to determine the most efficient method of assessing the outcomes of patients undergoing THA. MATERIALS AND METHODS: We evaluated all hip scoring systems currently available in the literature and identified the parameters assessed in the questionnaires. The parameters were then subdivided into subjective, objective, rehabilitative, and quality of life outcome measures. We identified the most commonly referenced questionnaires and assessed multiple permutations of these with other scoring systems to determine the combinations that would most efficiently and comprehensively evaluate the outcomes of patients undergoing THA. RESULTS: The 42 identified scoring systems covered the following parameters: 4 subjective, 5 objective, 17 rehabilitative, and 18 quality of life. The Harris Hip Score (HHS) was the most cited system (5,613), but the Hip Disability and Osteoarthritis Outcome Score (HOOS) had the greatest coverage of all the parameters (49%). On combinatorial analysis, the 2-, 3-, and 4-item permutations that had the greatest coverage were HOOS and 36-Item Short-Form Health Survey (SF-36) (59%), HOOS, SF-36, and Larson (75%), and HOOS, SF-36, Larson, and Lower Extremity Functional Scale (LEFS) (80%). CONCLUSION: Physicians and researchers have attempted to fully assess the outcomes of patients undergoing THA. Utilizing existing scoring systems in particular combinations may allow us to form an ideal questionnaire that provides sufficient coverage of parameters, thus providing a more comprehensive way to cost-effectively evaluate outcomes. Further analysis is required to determine whether or not these permutations provide a sufficient evaluation in a clinical setting.

Liposomal Bupivacaine in Total Knee Arthroplasty for Better Postoperative Analgesic Outcome and Economic Benefits.

When orthopedists consider which analgesia to use after total knee arthroplasty (TKA), the primary objective is to relieve pain with fewer adverse side effects. Over the last decade, substantial efforts have been made to improve pain control following TKA, but it is still very challenging to obtain optimal control. Current modalities in use, such as opioids, epidurals, and nerve blocks, provide substantial pain relief, but they are associated with substantial side effects and serious complications. Recently, bupivacaine, a commonly used nonopioid analgesic, has been formulated into an aqueous suspension of multivesicular liposomes that provide long-lasting analgesia, while avoiding significant adverse effects of opioids. The purpose of this review is to analyze the use of traditional postsurgical pain management and the potential contribution of a long-acting liposomal formulation of bupivacaine as part of the analgesic regimen in TKA, including its mode of action, injection technique, efficacy on pain, and health care costs.

A Comprehensive Assessment of Various Outcome Scores to Evaluate Total Hip Arthroplasties.

INTRODUCTION: Many scoring systems have been developed that serve to evaluate outcomes following total hip arthroplasty (THA). However, most systems focus on specific aspects of a patient's recovery rather than investigating a broad spectrum of parameters, which prevent physicians from obtaining a sufficient impression of a patient's recovery. Therefore, we evaluated existing scoring systems to assess the outcome categories included and parameters of interest. MATERIALS AND METHODS: We examined all hip scoring systems currently available in the literature. The outcomes measured in each scoring system were sub-classified into one of four categories; subjective, objective, rehabilitative, and quality of life. We determined the number of scoring systems that incorporated each of these four categories and we assessed the most common parameters in each. The categories and individual parameters were assigned a relative weighted mean score based on how often they were incorporated, in an effort to determine their importance. RESULTS: We identified 42 hip scoring systems consisting of 44 individual parameters, which were divided into the above four categories. Of the relevant scoring systems, 74% included subjective parameters, 31% included objective parameters, 90% included rehabilitative parameters, and 62% included quality of life parameters. The most commonly assessed subjective parameters include pain, stiffness, and general hip difficulty. The most commonly assessed objective parameters include general/combined ROM, flexion/extension, and abduction/adduction. The most commonly assessed rehabilitative parameters include the ability to walk, the ability to climb stairs, and the ability to reach to the floor. The most commonly assessed quality of life measures include the ability to use a car, performance of light domestic duties, and performance of heavy domestic duties. The category of rehabilitative practices carried the greatest weighted mean (49%) in hip scoring systems, followed by subjective (40%), quality of life (6%), and objective (5%). With regard to individual hip outcome parameters, pain carried the greatest weighted mean (23%), followed by the ability to walk and the ability to perform general activities (11% each). CONCLUSION: Patient outcomes can be evaluated by the use of scoring systems in an effort to determine the effectiveness of THA in regaining function and improving quality of life. Determining the frequency and importance of parameters in current scoring systems may allow for a more accurate and purposeful assessment of post-operative function and patient satisfaction. Understanding what is evaluated in existing scoring systems may shed light on the future development of a comprehensive outcome questionnaire.

Decreased Opioid Utilization and Cost at One Year in Chronic Low Back Pain Patients Treated with Transcutaneous Electric Nerve Stimulation (TENS).

INTRODUCTION: Chronic low back pain (CLBP) may be treated without opioids through the use of transcutaneous electrical nerve stimulation (TENS). However, no study has evaluated its clinical effect and economic impact as measured by opioid utilization and costs. The purpose of this study was to evaluate patients who were given TENS for CLBP compared to a matched group without TENS at one-year follow-up, to determine differences between opioid consumption. MATERIALS AND METHODS: Opioid utilization and costs in patients who did and did not receive TENS were extracted from a Medicare supplemental administrative claims database. Patients were selected if they had at least two ICD-9-CM coded claims for low back pain in a three-month period and were then propensity score matched at a 1:1 ratio between patients who received TENS and those who did not. There were 22,913 patients in each group who had a minimum follow-up of one year. There were no significant demographic or comorbidity differences with the exception that TENS patients had more episodes of back pain. RESULTS: Significantly fewer patients in the TENS group required opioids at final follow-up (57.7 vs. 60.3%). TENS patients also had significantly fewer annual per-patient opioid costs compared to non-TENS patients ($169 vs. $192). There were significantly lower event rates in TENS patients compared to non-TENS patients when measured by opioid utilization (characterized by frequency of prescription refills) (3.82 vs. 4.08, respectively) or pharmacy utilization (31.67 vs. 32.25). The TENS group also demonstrated a significantly lower cost of these utilization events ($44 vs. $49) and avoided more opioid events (20.4 events fewer per 100 patients annually). DISCUSSION: Treatment of CLBP with TENS demonstrated significantly fewer patients requiring opioids, fewer events where a patient required an opioid prescription, and lower per-patient costs. Since TENS is both non-invasive and a non-narcotic, it may potentially allow physicians to be more aggressive in treating CLBP patients.