Pre-Operative Urodynamic Assessment Has Poor Predictive Value for Developing Post-Operative Urinary Retention.

BACKGROUND: Post-operative urinary retention (POUR) following primary total joint arthroplasty (TJA) has a reported prevalence up to 35%. Risk factors for POUR have included surrogate markers such as the presence or absence of urologic disease. Pre-operative dynamic measurement with post-void residual volumes (PVR) has not been investigated as a tool for assessing POUR risk. METHODS: All male TJA patients underwent an institutional pre-operative screen for POUR, including PVR measurements, patient-derived subjective urinary retention scores, and assessment of urologic disease. The prospectively collected data were retrospectively reviewed. Proportions were evaluated with the chi-squared test, while continuous variables were evaluated by logistic regression analysis. Receiver-operator characteristic curves were utilized to determine the efficacy of using urodynamic variables as a predictor of developing POUR. RESULTS: Two hundred fifty-two male patients were reviewed who had a mean age of 64.9 years and mean body mass index of 30.8 kg/m2. The overall rate of POUR was 5.1%. Patient urinary retention scores were not associated with POUR. Elevated pre-operative PVR (>10 cc) alone and in combination with a history of urologic disease was significantly associated with POUR. However, both had low positive predictive values (10.5% and 18.2%), despite high negative predictive values (99.2% and 97.9%). Utilization of PVR resulted in moderate sensitivity (91.6%) and low specificity (72.1%) with an area under the curve of 0.69. CONCLUSION: Urodynamic measurements and patient urinary retention scores, as part of an institutional pre-operative screening protocol, have limited value in determining which patients are at increased risk of POUR. The utility of obtaining these measurements pre-operatively is questionable.

Formal Physical Therapy Following Total Hip and Knee Arthroplasty Incurs Additional Cost Without Improving Outcomes.

BACKGROUND: Recent evidence has demonstrated that formal physical therapy (PT) may not be required for most patients undergoing total hip (THA) and knee (TKA) arthroplasty. This study compared the differences in costs and functional outcomes in patients receiving formal PT and those who did not follow primary THA and TKA. METHODS: We queried claims data from a single private insurer identifying patients who underwent primary THA or TKA from 2015 to 2017 in our practice. Demographics, comorbidities, number, and cost of PT visits in a 90-day episode of care were recorded. Outcomes were compared between patients using self-directed home exercises, home PT, outpatient PT, or both home and outpatient PT. A multivariate analysis was performed to identify significant predictors of outcomes. RESULTS: Of the 2971 patients included in analysis, patients using both services had higher 90-day PT costs (mean $2091, P < .001) than those using home PT alone ($1146), outpatient PT alone ($1356), or no formal PT ($0). Home PT had the greatest cost per visit for both private insurance patients ($177/visit) and Medicare Advantage patients ($157/visit), but patients using both home PT and outpatient PT services had the greatest overall PT cost, $2091 for private insurance and $1891 for Medicare Advantage. Patients who used home PT were at significantly higher risk of both complications (odds ratio = 3.21; 95% confidence interval, 2.1-4.9; P < .001) and readmissions (odds ratio = 3.4; 95% confidence interval, 2.1-5.5; P < .001). CONCLUSION: Participation in formal PT accounts for up to 8% of the episode of care following THA and TKA. The role of formal PT for most patients should take into account the cost-effectiveness of the intervention.

High-Quality Skilled Nursing Facilities Are Associated With Decreased Episode-of-Care Costs Following Total Hip and Knee Arthroplasty.

BACKGROUND: With the increasing popularity of alternative payment models following total hip (THA) and knee arthroplasty (TKA), efforts have focused on reducing post-acute care (PAC) costs, particularly patients discharged to skilled nursing facilities (SNFs). The purpose of this study is to determine if preferentially discharging patients to high-quality SNFs can reduce bundled payment costs for primary THA and TKA. METHODS: At our institution, a quality improvement initiative for SNFs was implemented at the start of 2017, preferentially discharging patients to internally credentialed facilities, designated by several quality measures. Claims data from Centers for Medicare and Medicaid Services were queried to identify patients discharged to SNF following primary total joint arthroplasty. We compared costs and outcomes between patients discharged to credentialed SNF sites and those discharged to other sites. RESULTS: Between 2015 and 2018, of a consecutive series of 8778 primary THA and TKA patients, 1284 (14.6%) were discharged to an SNF. Following initiation of the program, 498 patients were discharged to an SNF, 301 (60.4%) of which were sent to a credentialed facility. Patients at credentialed facilities had significantly lower SNF costs ($11,184 vs $8198, P < .0001), PAC costs ($18,952 vs $15,148, P < .0001), and episode-of-care costs ($34,557 vs $30,831, P < .0001), with no difference in readmissions (10% vs 12%, P = .33) or complications (8% vs 6%, P = .15). Controlling for confounding variables, being discharged to a credentialed facility decreased SNF costs by $1961 (P = .0020) and PAC costs by $3126 (P = .0031) per patient. CONCLUSION: Quality improvement efforts through partnership with selective SNFs can significantly decrease PAC costs for patients undergoing primary THA and TKA.

Reconstruction Plate-Based Antibiotic Cement Spacers: Clinical Outcomes and Description of Technique.

The standard of care for chronic deep peri-prosthetic hip infection is a two-stage exchange with placement of a temporary antibiotic cement spacer and treatment with intravenous antibiotics. Several commercially available cement spacer options exist. We report on a novel antibiotic spacer that may be an efficient, cost-effective alternative. Medical records of all patients treated for deep peri-prosthetic hip infection after total hip arthroplasty between 2004 and 2012 were reviewed. Each antibiotic spacer was constructed from a 12- to 16-hole recon plate bent to provide adequate soft tissue tension and a cement ball that matched the acetabulum. Premature failure of the plate and duration of implantation were measured. Failure was defined as fracture of the plate or dissociation of the cement head from the plate. Costs were compared with commercially available cement spacers. A total of 24 spacers were identified in 21 patients (mean age 68.9 years, mean body-mass index 26.4). The mean time between spacer placement and re-implantation was 6.4 months (range: 1.8-18 months). One patient had an indolent infection that was unresponsive to antibiotic therapy and required a hip disarticulation. At the time of reimplantation, 17 of 17 handmade spacers had no failures. Of the premade spacers, six of the seven had no failures. One premade spacer fractured at the femoral component trunion. The cost of the plate and antibiotic cement was $909-1000, approximately $5000 less than premade spacers. Antibiotic spacers can be readily constructed intraoperatively and offer good clinical outcomes with a low incidence of failure. This type of spacer saved $5000 per patient.

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.

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.

Can cementing technique reduce the cost of a primary total knee arthroplasty?

Studies on cost containment of total knee arthroplasty (TKA) have generated substantial interest over the past decade. Although multiple studies have evaluated the various intraoperative methods to control cost, no prior study has evaluated the economic impact and the clinical outcome based on amount of bone cement needed for a primary TKA. At a minimum of 3 years follow-up, we observed no difference in implant survivorship or Knee Society scores, but did observe substantial cost savings when one versus two packets of bone cement were used in combination with a hand mixing technique. By eliminating several extra cement mixing products, we achieved an approximately $1,000 cost saving per case with no difference in clinical outcomes at midterm follow-up.

Use of a bipolar sealer in total hip arthroplasty: medical resource use and costs using a hospital administrative database.

Perioperative blood loss during total hip arthroplasty (THA) increases patient morbidity, length of stay (LOS), medical resource use (MRU), and costs. Minimizing blood loss may reduce postoperative anemia, the need for blood transfusions, and the increased risk of infections and longer hospital stays associated with blood transfusions. Pharmacologic agents and bipolar sealer devices can minimize perioperative bleeding. A retrospective, comparative cohort study in the US hospital setting was conducted to assess MRU and associated costs and the incidence of transfusion and complications among patients undergoing THA with or without the use of a bipolar sealer. Using a nationwide all-payer hospital administrative database, THA procedures from January 1, 2008, to March 31, 2011, were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 81.51. The bipolar sealer cohort (n=2683) and matched control cohort (n=2683) had a mean age of 65 years from 38 hospitals. The 2 groups had similar incidences of pre-operative anemia and medical comorbidities. Patients in the bipolar sealer group required significantly fewer blood transfusions (21.3% vs 23.8%; P=.0286) and had significantly lower incidence of hematomas (0.2% vs 0.9%; P=.0015) and significantly shorter LOS (2.90 vs 3.31 days; P<.0001) overall. The bipolar sealer group had higher supply costs, which were offset by reduced hospital inpatient room and board and operating room costs; there was no significant difference in total hospital costs between the 2 groups ($18,937 vs $18,734; P=.56). A bipolar sealer decreases postoperative blood transfusions and LOS during primary THA without increasing total hospital costs.

Clinical and economic impact of TENS in patients with chronic low back pain: analysis of a nationwide database.

This study evaluated patients who were given transcutaneous electrical nerve stimulation (TENS) compared with a matched group without TENS prior to intervention and at 1-year follow-up. Patients who were treated with TENS had significantly fewer hospital and clinic visits, used less diagnostic imaging (31 vs 46 events per 100 patients), had fewer physical therapy visits (94 vs 107), and required less back surgery (7.5 vs 9.2 surgeries) than patients receiving other treatment modalities. Total annual costs for chronic low back pain patients without neurological involvement were lower in TENS patients ($17,957 vs $17,986 for non-TENS), even when the cost of the device was taken into account.

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.