Primary total hip arthroplasty complications and costs in liver transplant recipients: a matched analysis using a national database.

BACKGROUND: The number of liver transplant recipients (LTR) is worldwide increasing and, as the survival is improving as well, there is an increasing number of patients needing total hip arthroplasty (THA). There might be increased risks for this specific group of patients and due to their comorbidities costs might be higher too. Using a big national database outcome and cost of THA should be compared between liver transplant recipients and the general population. METHODS: The study was performed using a collection of Medicare, Medicaid, and private insurance claims. Length of stay (LOS), 30-day readmissions, complications rates up to 5 years, and 90-day total cost of care between liver transplant recipients and matched non-transplant patients should be compared. All primary THAs from 2010 to 2019 were identified. 513 patients with a liver transplant before their THA were matched to 10,759 patients without a history of solid organ transplant at a 1:20 ratio based on age, sex, Charlson Comorbidity Index, obesity, and diabetes status. RESULTS: LTR had a longer average LOS (4.2 vs. 3.4 days, p < 0.001). There was no difference in the thirty-day readmissions (5.7% vs. 4.1%, p = 0.117) and 90-day dislocation rates (2.9% vs. 2.4%, p = 0.600). Total costs in the first ninety days after THA were not different between the LTR and controls (p = 0.756). CONCLUSIONS: These findings suggest that complications and costs are no major point of concern in patients with liver transplant that are operated with THA.

National Trends for Reverse Shoulder Arthroplasty After the Affordable Care Act: An Analysis From 2011 to 2015.

Few studies have investigated nationwide patient trends and health care costs for reverse shoulder arthroplasty (RSA) after 2014. This study uses a large validated nationwide database to retrospectively assess changes in patient and hospital demographic features, hospital costs, and hospital charges for inpatient RSA procedures before and after implementation of the Affordable Care Act. The National Inpatient Sample database was used to identify all patients who underwent RSA between January 2011 and December 2015, yielding 163,171 patients (63.4% female; mean age, 72 years). Categorical data were assessed with chi-square/Fisher's exact test, and continuous data were assessed with analysis of variance. There was an increased proportion of RSA recipients identifying as Hispanic (4.1% to 4.8%) and Native American (0.1% to 0.4%; P<.0001). The proportion of patients who had Medicaid (1.4% to 2.4%) and private insurance (15.1% to 16.6%) increased as well (P<.0001). A decrease in mean hospital costs occurred between 2011 and 2015 (-$256; P=.002), whereas an increase occurred in hospital charges (+$6,314; P<.001). These findings provide insight on RSA use and patient demographic trends in the United States. Additionally, these results help to capture the effects of extended health coverage and new reimbursement models on hospital costs and charges. [Orthopedics. 2022;45(2):97-102.].

Access to Total Knee Arthroplasty Among Patients With Low Incomes Has Not Increased Under Global Budget Revenue.

In 2014, Maryland implemented an experimental reimbursement model, Global Budget Revenue (GBR). This model provided hospitals with a capitated annual budget each fiscal year to use toward all services, regardless of payer. Goals of GBR include reductions in cost, improvements in care quality, and increased access for patients to high-volume procedures, such as total knee arthroplasty (TKA). We assessed demographics and outcomes among patients with low incomes and patients of racial minority groups in Maryland who underwent TKA before and after GBR implementation. Patients undergoing TKAs from 2011 to 2016 were queried from the Maryland State Inpatient Database, resulting in 71,066 patients. There were 13,722 patients with low incomes and 19,846 patients of racial minority groups. The chi-square test was used for sex, income, insurance, Charlson Comorbidity Index, and morbid obesity, with the Student's t test being reserved for age before and after GBR. The proportion of patients with low incomes decreased the year before GBR but increased with GBR and maintained (P<.001). The proportion of patients of racial minority groups increased the year before GBR implementation, decreased slightly, and then maintained (P<.001). Mean cost decreased for both cohorts of patients (both P<.001). Discharges to home increased for both cohorts (P<.001), while length of stay decreased (both P<.001). Global Budget Revenue decreased cost while improving outcomes for TKA patients post-GBR. Patients with low incomes have not increased their use of TKA, contrary to patients of racial minority groups. This suggests that barriers remain. Further follow-up of GBR performance in subsequent years will increase understanding of the sustainability of this trend and the degree to which any increase in access is dependent on the implementation of the Affordable Care Act. [Orthopedics. 2022;45(1):e11-e16.].

Complications Associated With Same-Day Bilateral Total Knee Arthroplasties.

Same-day bilateral total knee arthroplasties (SBTKAs) are associated with shorter rehabilitation and lower cost. However, controversy surrounding the safety of SBTKAs exists. Recent studies are lacking to determine whether patient selection has brought SBTKA in line with unilateral total knee arthroplasty (UTKA). Therefore, the authors evaluated and compared patient characteristics, hospital characteristics, and inpatient course between UTKA and SBTKA from 2009 to 2016. The National Inpatient Sample was queried from 2009 to 2016 for UTKA and SBTKA patients. Of the 5,329,466 patients identified, 5,084,328 (95.4%) patients received UTKAs and 245,138 (4.6%) patients underwent SBTKAs. Incidence, rate, patient and hospital characteristics, health status, length of stay (LOS), discharge disposition, hospital charges, hospital costs, and complications were analyzed and statistically compared. The incidence (-1.4%) and rate (15.8%) of SBTKAs decreased (both P<.001). The SBTKA cohort had more patients who were younger, male, White, obese, healthier, and using private insurance (P<.001 for all). The SBTKA cohort had longer LOS, a higher proportion of discharges to skilled nursing facilities, higher cost and charges, and more complications, including deep venous thromboses/pulmonary emboli (DVT/PE) and transfusions (P<.001 for all). Conversely, SBTKA was associated with fewer myocardial infarctions (P<.001). Although improved from previous literature, SBTKA is still associated with longer LOS, higher cost and charges, and more complications, including DVT/PE and transfusions, although with a lower rate of myocardial infarction. However, studies are needed to determine whether the risk of 1 SBTKA outweighs the cumulative risk of staged UTKAs. [Orthopedics. 2021;44(3):e407-e413.].

Closing the Socioeconomic Gap in Massachusetts: Trends in Total Hip Arthroplasty From 2013 to 2015.

To extend insurance coverage to all residents, Massachusetts legislation expanded Medicaid eligibility and added new private insurance categories. To date, no one has analyzed the effect of these changes and compared recent trends in total hip arthroplasty (THA) utilization. Therefore, this study sought to update the current trends of THA utilization in Massachusetts from 2013 to 2015. The Massachusetts State Inpatient Database was queried for all patients who underwent primary THA between 2013 and 2015, and 30,308 patients were identified. Analyzed variables included age, sex, race, Charlson Comorbidity Index, median household income, primary payer, discharge disposition, length of stay, hospital charges, hospital costs, and complications. Categorical and continuous variables were assessed using chi-square analyses and analyses of variance, respectively. Between 2013 and 2015, annual THAs increased from 9361 to 10,562. Race did not vary significantly (P=.447), although an increase in patients using Medicaid and a decrease in patients using other insurance was observed (P<.001). Patients with an income quartile of 1 increased, whereas the number of THA patients in quartile 3 decreased (P<.001). There was a decrease in both hospital charges (P<.001) and costs (P<.001). Mean length of stay decreased (P<.001), and the number of patients with complications decreased (P<.001). Massachusetts has been successful in increasing access to THA procedures for low-income patients and increasing the number of patients who use Medicaid for THAs. The current delivery of health care in Massachusetts has shown improvement for its residents, serving as an example that other states can learn from. [Orthopedics. 2021;44(2):e167-e172.].

Maryland's Global Budget Revenue Model: How Do Costs and Readmission Rates Fare for Patients Undergoing Total Knee Arthroplasty?

In 2014, Maryland implemented the Global Budget Revenue (GBR) model for cost reduction and quality improvement. This study evaluated GBR's effect on demographics and outcomes for patients who underwent primary total knee arthroplasty (TKA) by comparing Maryland to the United States (U.S.). We identified primary TKA patients in Maryland's State Inpatient Database (n = 71,022) and the National Inpatient Sample (n = 4,045,245) between 2011 and 2016 utilizing International Classification of Disease (ICD)-9 and ICD-10 diagnosis codes. Multiple regression was used for difference-in-difference (DID) analyses to compare the intervention cohort (Maryland) to the nonintervention cohort (U.S.) between the pre-GBR (2011-2013) and post-GBR (2014-2016) periods. After GBR implementation, there were proportionally less white, obese, morbidly obese, Medicare, and Medicaid patients with proportionally more routine discharge patients in Maryland and the U.S. (all p < 0.001). There were proportionally less home health care (HHC) patients in Maryland, but more in the U.S. (both p < 0.001). The mean lengths of stay (LOS), costs, and complications decreased for both cohorts, while charges increased for the U.S. (all p < 0.001). The DID analysis suggested Maryland saw more Asian and Medicaid patients and less obese and morbidly obese patients under GBR. The DID assessments also found decreased LOS, costs, and charges (p < 0.001 for all) for patients under GBR. As other states such as Pennsylvania and Vermont explore hospital budgets, Maryland may provide a more viable model for future health care policies that incorporate global budgets.

Osteoarthritis and Osteonecrosis in Total Hip Arthroplasty: 90-Day Postoperative Costs and Outcomes.

BACKGROUND: Two common diagnoses for patients undergoing total hip arthroplasty (THA) are osteoarthritis (OA) and osteonecrosis (ON), pathologically different diseases that affect postoperative complication rates. The underlying pathology of ON may predispose patients to a higher rate of certain complications. Previous research has linked ON with higher mortality and revisions, but a comparison of costs and complication rates may help elucidate further risks. This study reports 90-day costs, lengths of stay (LOS), readmission rates, and complication rates between patients undergoing THA for OA and ON. METHODS: The Nationwide Readmissions Database was retrospectively reviewed for primary THAs, with 90-day readmissions assessed from the index procedure. Patients diagnosed with OA (n = 1,577,991) and ON (n = 55,034) were identified. Costs, LOS, and any readmission within 90 days for complications were recorded and analyzed with the chi-square and t-tests. RESULTS: Patients with ON had higher 90-day costs ($20,110.80 vs. 22,462.79, P < .01) and longer average LOS (3.48 vs. 4.49 days, P < .01). Readmission rates within 90 days of index THA were significantly higher among patients with ON (7.7% vs. 13.1%, P < .01). Patients with OA had a lower incidence of 90-day overall complications (4.1 vs. 6.4%, P < .01). CONCLUSIONS: Patients undergoing THA for ON incur higher readmission-related costs and complication rates. Understanding the predisposing factors for increased complications in ON may improve patient outcomes.

Same-Day Bilateral Total Knee Arthroplasty: Incidence and Perioperative Outcome Trends from 2009 to 2016.

BACKGROUND: Same-day bilateral total knee arthroplasty (BiTKA) is a controversial topic in orthopedics, prompting a consensus statement to be released by national experts. To date, no studies have evaluated the trends of this method since these recommendations. This study utilized a national database to evaluate: 1) incidence; 2) patient characteristics; 3) hospital characteristics; and 4) inpatient course for same-day BiTKAs in the United States from 2009 to 2016. METHOD: The National Inpatient Sample database was queried for individuals undergoing same-day BiTKAs, yielding 245,138 patients. Patient demographics included age, sex, race, obesity status and Charlson Comorbidity Index (CCI) score. Hospital characteristics consisted of location/teaching status, geographic region, charges, and costs. Inpatient course included length of stay, discharge disposition, and complications. RESULTS: Same-day BiTKA incidence decreased from 5.6% to 4.0% over the study (p < 0.001). Decreases in patient age and female proportion (p < 0.001 for both) were seen, while African American and Hispanic patients increased (p < 0.001), as did obese patient proportions (p < 0.001). Patients with CCI scores of 2 increased, while those with ≥3 decreased (p < 0.001). Hospital charges increased, while costs decreased (p < 0.001 for both). Length of stay following same-day BiTKA decreased (p < 0.001) and routine home discharges increased (p < 0.001). Most inpatient complications decreased, although the percentage of mechanical complications and respiratory failures increased (p < 0.01 for all). CONCLUSIONS: During the study period, younger patients with fewer comorbidities underwent BiTKAs, which likely resulted from improved patient assessment and management. Future investigations should include an evaluation of long-term complications and outcomes in certain patient populations for this procedure.

Factors associated with non-home discharge after total knee arthroplasty: Potential for cost savings?

INTRODUCTION: Increasing demand for total knee arthroplasties (TKA) has been targeted by legislation to minimize costs and maximize outcomes. Home discharges reduce costs, and it is important to determine patient variables associated with this discharge disposition. We explored non-modifiable and modifiable factors associated with non-home discharges to determine what patient specific factors require attention. METHODS: This retrospective study included 171,903 National Surgical Quality Improvement Program (NSQIP) patients between 2011 and 2016. Patient specific variables and discharge destinations included home, short-term nursing facilities (SNF), not home, and rehabilitation. Chi-squared analyses and analyses of variance (ANOVA) were conducted for categorical and continuous data, respectively. Multinomial regression model was utilized to assess associations between discharge destination and patient specific variables. RESULTS: Every year increase above the mean age (66 years) was associated with a nine percent (p < .001) and six percent (p < .001) increased odds for discharge to SNF or rehabilitation, respectively, compared to home discharges. Every 10% increase in BMI from the mean was associated with a 10% increase in discharge to both SNF and rehabilitation (p < .001 for both). CONCLUSION: With increasing demands for TKAs and expenditures to Medicare, evaluating factors that impact patient discharge can help optimize costs and outcomes of TKA procedures. Arthroplasty surgeons can benefit by recognizing these correlations and exploring reductions to non-home discharges through pre-operative patient optimization. Future studies should evaluate the economic cost potential associated with optimizing routine home discharge in TKA patients. LEVEL OF EVIDENCE: IV.

Obesity in Total Hip Arthroplasty: Demographic Disparities and Outcome Incongruities.

Introduction As morbid obesity disproportionately affects minorities and those of lower socioeconomic status, body mass index (BMI) restrictions on total hip arthroplasty (THA) may harm populations already facing disparities in care. Therefore, this study analyzed demographics and outcomes in morbidly obese primary THA patients. Methods The National Inpatient Sample was queried for THAs performed between 2009 and 2016. Of 2,676,086 patients identified, 453,250 had a BMI over 25 kg/m2. Patients were stratified by BMI into overweight (BMI=25.0-29.9 kg/m2), non-morbidly obese (BMI=30.0-40.0 kg/m2), and morbidly obese (BMI>40.1 kg/m2). Patient demographics (age, sex, race, insurance, income, and Charlson Comorbidity Index) and outcomes (length of stay [LOS], mortality, disposition, complications, charges, and costs) were assessed. Categorical and continuous data were analyzed with chi-square analyses and one-way analyses of variance, respectively. Results The number of overweight, non-morbidly obese, and morbidly obese patients increased by 299.0%, 109.3%, and 90.9%, respectively, between 2009 and 2016 (p<0.001). Morbidly obese patients were younger than non-morbidly obese and overweight patients (p<0.001) and had a higher proportion of females (p<0.001) and black patients (p<0.001). Morbidly obese patients most frequently used Medicaid and private insurance (p<0.001). Morbidly obese patients demonstrated a longer LOS, a higher mortality rate, a lower rate of home discharges and the most complications (all, p<0.001).  Conclusion These results reflect the worsening obesity epidemic and may be useful in counseling preoperative weight loss to morbidly obese patients to reduce mortality and complications.

The Affordable Care Act and Global Budget Revenue: The Impact on Total Hip Arthroplasties.

BACKGROUND: Maryland possesses a unique, population-based alternative payment model named Global Budget Revenue (GBR). This study evaluated the effects of GBR on demographics and outcomes for patients who underwent primary total hip arthroplasty (THA) by comparing Maryland to the United States (U.S.). METHODS: We identified primary THA patients in the Maryland State Inpatient Database (n = 35,925) and the National Inpatient Sample (n = 2,155,703) between 2011 and 2016 utilizing International Classification of Diseases 9 and 10 diagnosis codes. Qualitative analysis was used to report trends. Multiple regressions were used for difference-in-difference (DID) analyses to compare Maryland to the U.S. between pre-GBR (2011-2013) and post-GBR (2014-2016) periods. RESULTS: After GBR implementation, there were proportionally more patients who were obese (Maryland: +5.1% vs U.S.: +3.0%), used Medicare (+1.6% vs +0.7%), used Medicaid (+2.4% vs +1.3%) while less used private insurance (-4.2% vs -1.8%) (all P < .001). There were proportionally less home health care patients in Maryland, but more in the U.S. (-3.5% vs +1.6%; both P < .001). The mean costs decreased for both cohorts (-$1780.80 vs -$209.40; both P < .001). The DID found Maryland saw more Medicaid and less private insurance patients under GBR (both P ≤ .001). Maryland saw more obese patients than would be expected (P = .001). The DID also found decreased costs for patients under GBR (P < .001 for both). CONCLUSION: Maryland has benefitted from GBR with decreased cost and an increase in Medicaid patients. Maryland may provide a viable model for future healthcare policies that incorporate global budgets.

Maryland's Global Budget Revenue model associated with lower inpatient costs and 30-day readmissions in patients undergoing total hip arthroplasty.

BACKGROUND: Maryland implemented the Global Budget Revenue (GBR) to reduce hospital costs, improve quality, and decrease readmissions. Studies assessing its impact on inpatient total hip arthroplasty (THA) procedures are lacking. This study compared before and after GBR changes in 1) patient characteristics; 2) discharge dispositions and lengths of stay (LOS); 3) costs and charges of inpatient stays; and 4) 30-day readmission rates (RR) for THA recipients. METHODS: The Maryland State Inpatient Database was queried for patients who underwent THA between 2010 and 2016 utilizing the ICD-9 and ICD-10 procedure codes (n = 43,251). Pre- and post-GBR periods were grouped as 2010 to 2013 and 2014 to 2016, respectively. Chi-square analyses were used to analyze patient characteristics. Student's t-tests were utilized to compare ages, LOS, costs, charges, and RR. RESULTS: There were no differences in the proportion of minorities undergoing THA between the pre- and post-GBR periods (18.3% vs 19.4% African American, 1.2% vs 1.3% Hispanic; P = .056). The number of THA patients with Medicaid insurances increased during post-GBR (4.0% vs 6.7%; P < .001). There was an increased rate of home discharges during post-GBR (33.1% vs 40.9%; P < .001). We found lower LOS (-0.50 days; 95% CI: -0.458 to -0.533; P < .001), mean inpatient costs (-$1417.44; 95% CI -$1143.76 to -$1150.32; P < .001), and mean inpatient charges (-$2196.50; 95% CI: -$1980.10 to -$2412.90; P < .001) during the post-GBR period. There were lower 30-day RR during the post-GBR period (-0.9%; P < .001). CONCLUSIONS: Our findings suggest favorable preliminary results for patients undergoing THA under the GBR model.