Does Medicare Insurance Mitigate Racial/Ethnic Disparities in Access to Lumbar Spinal Surgery When Compared to Commercial Insurance?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Compare disparities in lumbar surgical care utilization in Commercially insured versus Medicare patients. SUMMARY OF BACKGROUND DATA: While disparities in spinal surgery have been previously described, less evidence exists on effective strategies to mitigate them. Theoretically, universal health care coverage under Medicare should improve health care access. MATERIALS AND METHODS: Utilizing National Inpatient Sample data (2003-2018), we included inpatient lumbar discectomy or laminectomy/fusion cases in black, white, or Hispanic patients aged 18-74 years, with Commercial or Medicare insurance. A multivariable Poisson distribution model determined race/ethnicity subgroup-specific rate ratios (RRs) of patients undergoing lumbar surgery compared to their respective population distribution (using US Census data) based on race/ethnicity, region, gender, primary payor, and age (Commercially insured age subgroups: 18-39, 40-54, and 55-64 y; Medicare age subgroup: 65-74 y). RESULTS: Of the 2,310,956 lumbar spine procedures included, 88.9%, 6.1%, and 5.0% represented white, black, and Hispanic patients, respectively. Among Commercially insured patients, black and Hispanic (compared to white) patients had lower rates of surgical care utilization; however, these disparities decreased with increasing age: black (RR=0.37, 95% CI: 0.37-0.38) and Hispanic patients (RR=0.53, 95% CI: 0.52-0.54) aged 18-39 years versus black (RR=0.72, 95% CI: 0.71-0.73) and Hispanic patients (RR=0.64, 95% CI: 0.63-0.65) aged 55-64 years. Racial/ethnic disparities persisted in Medicare patients, especially when compared to the neighboring age subgroup that was Commercially insured: black (RR=0.61, 95% CI: 0.60-0.62) and Hispanic patients (RR=0.61, 95% CI: 0.60-0.61) under Medicare. CONCLUSIONS: Disparities in surgical care utilization among black and Hispanic patients persist regardless of health care coverage, and an expansion of Medicare eligibility alone may not comprehensively address health care disparities. LEVEL OF EVIDENCE: Level III.

Assessment of Risk Factors and Rate of Conversion to Total Hip Arthroplasty Within 2 Years After Hip Arthroscopy Utilizing a Large Database of Commercially Insured Patients in the United States.

Background: The conversion rate of hip arthroscopy (HA) to total hip arthroplasty (THA) has been reported to be as high as 10%. Despite identifying factors that increase the risk of conversion, current studies do not stratify patients by type of arthroscopic procedure. Purpose/Hypothesis: To analyze the rate and predictors of conversion to THA within 2 years after HA. It was hypothesized that osteoarthritis (OA) and increased patient age would negatively affect the survivorship of HA. Study Design: Cohort study; Evidence level, 3. Methods: The IBM MarketScan database was utilized to identify patients who underwent HA and converted to THA within 2 years at inpatient and outpatient facilities between 2013 and 2017. Patients were split into 3 procedure cohorts as follows: (1) femoroacetabular osteoplasty (FAO), which included treatment for femoroacetabular impingement; (2) isolated debridement; and (3) isolated labral repair. Cohort characteristics were compared using standardized differences. Conversion rates between the 3 cohorts were compared using chi-square tests. The relationship between age and conversion was assessed using linear regression. Predictors of conversion were analyzed using multivariable logistic regression. The median time to conversion was estimated using Kaplan-Meier tests. Results: A total of 5048 patients were identified, and the rates of conversion to THA were 12.86% for isolated debridement, 8.67% for isolated labral repair, and 6.76% for FAO (standardized difference, 0.138). The isolated labral repair cohort had the shortest median time to conversion (isolated labral repair, 10.88 months; isolated debridement, 10.98 months; and FAO, 11.9 months [P = .034). For patients >50 years, isolated debridement had the highest rate of conversion at 18.8%. The conversion rate increased linearly with age. Factors that increased the odds of conversion to THA were OA, having an isolated debridement procedure, and older patient age (P < .05). Conclusion: Older patients and those with preexisting OA of the hip were at a significantly increased risk of failing HA and requiring a total hip replacement within 2 years of the index procedure. Younger patients were at low risk of requiring a conversion procedure no matter which arthroscopic procedure was performed.

Impact of Surgeon Case Volume on Outcomes After Reverse Total Shoulder Arthroplasty.

INTRODUCTION: Despite a rapid increase in utilization of reverse total shoulder arthroplasty (rTSA), volume-outcome studies focusing on surgeon volume are lacking. Surgeon-specific volume-outcome studies may inform policymakers and provide insight into learning curves and measures of efficiency with greater case volume. METHODS: This retrospective cohort study with longitudinal data included all rTSA cases as recorded in the Centers for Medicare & Medicaid Services Limited Data Set (2016 to 2018). The main effect was surgeon volume; this was categorized using two measures of surgeon volume: (1) rTSA case volume and (2) rTSA + TSA case volume. Volume cutoff values were calculated by applying a stratum-specific likelihood ratio analysis. RESULTS: Among 90,318 rTSA cases performed by 7,097 surgeons, we found a mean annual rTSA surgeon volume of 6 ± 10 and a mean rTSA + TSA volume of 9 ± 14. Regression models using surgeon-specific rTSA volume revealed that surgery from low (<29 cases) compared with medium (29 to 96 cases) rTSA-volume surgeons was associated with a significantly higher 90-day all-cause readmission (odds ratio [OR], 1.17; confidence interval [CI], 1.10 to 1.25; P < 0.0001), higher 90-day readmission rates because of an infection (OR, 1.46; CI, 1.16 to 1.83; P = 0.0013) or dislocation (OR, 1.43; CI, 1.19 to 1.72; P = 0.0001), increased 90-day postoperative cost (+11.3% CI, 4.2% to 19.0%; P = 0.0016), and a higher transfusion rate (OR, 2.06; CI, 1.70 to 2.50; P < 0.0001). Similar patterns existed when using categorizations based on rTSA + TSA case volume. CONCLUSION: Surgeon-specific volume-outcome relationships exist in this rTSA cohort, and we were able to identify thresholds that may identify low and medium/high volume surgeons. Observed volume-outcome relationships were independent of the definition of surgeon volume applied: either by focusing on the number of rTSAs performed per surgeon or anatomic TSAs performed. LEVEL OF EVIDENCE: III.

Risk of Infection After Total Knee or Hip Arthroplasty After Receipt of Multiple Corticosteroid or Hyaluronic Acid Injections.

BACKGROUND: Few studies have assessed the relationship between the quantity of preoperative corticosteroid injections (CSIs) or hyaluronic acid injections (HAIs) and postoperative infection risk after total knee or hip arthroplasty (TKA, THA). We aimed to (1) determine whether the number of injections administered before TKA/THA procedures is associated with postoperative infections and (2) establish whether infection risk varies by injection type. METHODS: This retrospective cohort study included 230,487 THAs and 371,511 TKAs from the 2017 to 2018 Medicare Limited Data Set. The quantity of CSI or HAI, defined as receiving either CSI or HAI ≤2 years before TKA/THA, was identified and categorized as 0, 1, 2, or >2. The primary outcome was 90-day postoperative infection. Multivariable regression models measured the association between the number of injections and 90-day postoperative infection. Odds ratios and 95% confidence intervals were reported. RESULTS: The percentage of THA patients receiving 1, 2, and >2 preoperative CSIs was 6.1%, 1.6%, and 0.8%, respectively. Receiving >2 CSIs within 2 years before THA was associated with higher odds of 90-day postoperative infection (odds ratios = 1.74, 95% CI = 1.11 to 2.74, P = 0.02). The percentage of TKA patients receiving 1, 2, and >2 CSIs was 3.0%, 1.2%, and 1.1%, respectively. For HAIs in TKA patients, percentage receiving injections was 98.3%, 0.6%, 0.2%, and 0.9%, respectively. Quantity of CSIs or HAIs administered was not associated with postoperative infection among TKA patients. CONCLUSION: Patients receiving >2 injections before THA had higher odds of 90-day postoperative infection. This finding was not observed in TKA patients. These results suggest that the use of >2 injections within 2 years of THA should be avoided.

Hip Arthroscopy Trends: Increasing Patient Out-of-Pocket Costs, Lower Surgeon Reimbursement, and Cost Reduction With Utilization of Ambulatory Surgery Centers.

PURPOSE: To (1) report on trends in immediate procedure reimbursement, patient out-of-pocket expenditures, and surgeon reimbursement in hip arthroscopy (2) compare trends in ambulatory surgery centers (ASC) versus outpatient hospitals (OH) utilization; (3) quantify the cost differences (if any) associated with ASC versus OH settings; and 4) determine the factors that predict ASC utilization for hip arthroscopy. METHODS: The cohort for this descriptive epidemiology study was any patient over 18 years identified in the IBM MarketScan Commercial Claims Encounter database who underwent an outpatient hip arthroscopy, identified by Current Procedural Terminology codes, in the United States from 2013 to 2017. Immediate procedure reimbursement, patient out-of-pocket expenditure, and surgeon reimbursement were calculated, and a multivariable model was used to determine the influence of specific factors on these outcome variables. Statistically significant P values were less than .05, and significant standardized differences were more than 0.1. RESULTS: The cohort included 20,335 patients. An increasing trend in ASC utilization was observed (P = .001), and ASC utilization for hip arthroscopy was 32.4% in 2017. Patient out-of-pocket expenditures for femoroacetabular impingement surgery increased 24.3% over the study period (P = .003), which was higher than the rate for immediate procedure reimbursement (4.2%; P = .007). ASCs were associated with $3,310 (28.8%; P = .001) reduction in immediate procedure reimbursement and $47 (6.2%; P = .001) reduction in patient out-of-pocket expenditure per hip arthroscopy. CONCLUSIONS: ASCs provide a significant cost difference for hip arthroscopy. Although there is an increasing trend toward ASC utilization, it remains relatively low at 32.4% in 2017. Thus, there are opportunities for expanded ASC utilization, which is associated with significant immediate procedure reimbursement difference of $3,310 and patient out-of-pocket expenditure difference of $47 per hip arthroscopy case, ultimately benefiting healthcare systems, surgeons, and patients alike. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Ambulatory Surgery Centers Significantly Decrease Total Health Care Expenditures in Primary Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described. PURPOSE: To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017. STUDY DESIGN: Descriptive epidemiology study. METHODS: For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement. RESULTS: There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all). CONCLUSION: Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.

Racial Differences in Manipulation Under Anesthesia Rates Following Total Knee Arthroplasty.

BACKGROUND: Despite the extensive literature on racial disparities in care and outcomes after total knee arthroplasty (TKA), data on manipulation under anesthesia (MUA) is lacking. We aimed to determine (1) the relationship between race and rate of (and time to) MUA after TKA, and (2) annual trends in racial differences in MUA from 2013 to 2018. METHODS: This retrospective cohort study (using 2013-2018 Medicare Limited Data Set claims data) included 836,054 primary TKA patients. The primary outcome was MUA <1 year after TKA; time from TKA to MUA in days was also recorded. A mixed-effects multivariable model measured the association between race (White, Black, Other) and odds of MUA. Odds ratios (OR) and 95% confidence intervals (CI) were reported. A Cochran Armitage Trend test was conducted to assess MUA trends over time, stratified by race. RESULTS: MUA after TKA occurred in 1.7%, 3.2% and 2.1% of White, Black, and Other race categories, respectively (SMD = 0.07). After adjustment for covariates, (Black vs White) patients had increased odds of requiring an MUA after TKA: odds ratio (OR) 1.97, 95% confidence intervals (CI) 1.86-2.10, P < .0001. Moreover, White (compared to Black) patients had significantly shorter time to MUA after TKA: 60 days (interquartile range [IQR] 46-88) versus 64 days (interquartile range [IQR] 47-96); P < .0001. These disparities persisted from 2013 through 2018. CONCLUSION: Continued racial differences exist for rates and timing of MUA following TKA signifying the continued need for efforts aimed toward understanding and eliminating inequalities that exist in total joint arthroplasty (TJA) care.

Evaluating Resource Utilization for In-Person and Virtual Joint Classes in Total Joint Arthroplasty: An Analysis of Attendance Patterns at a Large Metropolitan Health System.

BACKGROUND: Provider-run "joint classes" educate total joint arthroplasty (TJA) patients on how to best prepare for surgery and maximize recovery. There is no research on potential healthcare inequities in the context of joint classes or on the impact of the recent shift toward telehealth due to coronavirus disease 2019 (COVID-19). Using data from a large metropolitan health system, we aimed to (1) identify demographic patterns in prepandemic joint class attendance and (2) understand the impact of telehealth on attendance. METHODS: We included data on 3,090 TJA patients from three centers, each with a separately operated joint class. Attendance patterns were assessed prepandemic and after the resumption of elective surgeries when classes transitioned to telehealth. Statistical testing included standardized differences (SD > 0.1 indicates significance) and a multivariate linear regression. RESULTS: The in-person and telehealth attendance rates were 69.9% and 69.2%, respectively. Joint class attendance was significantly higher for non-White, Hispanic, non-English primary language, Medicaid, and Medicare patients (all SD > 0.1). Age was a determinant of attendance for telehealth (SD > 0.1) but not for in-person (SD = 0.04). Contrastingly, physical distance from hospital was significant for in-person (SD > 0.1) but not for telehealth (SD = 0.06). On a multivariate analysis, distance from hospital (P < .05) and telehealth (P < .0001) were predictors of failed class attendance. CONCLUSION: This work highlights the relative importance of joint classes in specific subgroups of patients. Although telehealth attendance was lower, telehealth alleviated barriers to access related to physical distance but increased barriers for older patients. These results can guide providers on preoperative education and the implementation of telehealth.

Economic impact of Comorbidities in Total Ankle Arthroplasty and Ankle Arthrodesis.

BACKGROUND: The demand for total ankle arthroplasty (TAA) and ankle arthrodesis surgery is increasing. Findings from other orthopaedic populations suggest an increasing comorbidity burden among those planned for surgery, however, data on TAA and ankle arthrodesis is limited. The goal of this study is to study the comorbidity burden for TAA and ankle arthrodesis. HYPOTHESIS: Comorbidity burden is associated with higher resource utilization for both TAA and ankle arthrodesis. PATIENTS AND METHODS: This retrospective cohort study utilized data from the nationwide Premier Healthcare Database (2006-2016) which contains inpatient claims on n=10,085 ankle arthrodesis and n=4,977 TAA procedures. Patients were categorized into Deyo-Charlson comorbidity index (DCCI) groups. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization, discharge to a skilled nursing facility (SNF), and 30-day readmission. Mixed-effects models estimated associations between DCCI and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI). RESULTS: In the TAA group, 67.9% of patients were in DCCI category 0 while 22.4%, 6.6%, and 3.1% were in the 1, 2, and >2 DCCI categories, respectively. This was 61.3%, 18.1%, 9.8% and 10.9% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus, and chronic pulmonary disease. Particularly in the ankle arthrodesis group, the proportion of patients with comorbidities has increased over time. After adjustment for relevant covariates, patients in the DCCI group >2 (compared to '0') were associated with stepwise effects of up to 77.1% (CI 70.9%; 83.6%) longer length of stay and up to 48.5% (CI 44.0%; 53.2%) higher cost of hospitalization. DISCUSSIONS: Comorbidity burden is increasing among patients undergoing ankle arthrodesis where it is associated with significantly increased resource utilization. Our data demonstrate the potential impact of patient selection, which may be crucial in optimizing preoperative status. LEVEL OF EVIDENCE: III.

Trends in Periprosthetic Knee Infection and Associated Costs: A Population-Based Study Using National Data.

Given increasing demand for primary knee arthroplasties, revision surgery is also expected to increase, with periprosthetic joint infection (PJI) a main driver of costs. Recent data on national trends is lacking. We aimed to assess trends in PJI in total knee arthroplasty revisions and hospitalization costs. From the National Inpatient Sample (2003-2016), we extracted data on total knee arthroplasty revisions (n = 782,449). We assessed trends in PJI prevalence and (inflation-adjusted) hospitalization costs (total as well as per-day costs) for all revisions and stratified by hospital teaching status (rural/urban by teaching status), hospital bed size (≤299, 300-499, and ≥500 beds), and hospital region (Northeast, Midwest, South, and West). The Cochran-Armitage trend test (PJI prevalence) and linear regression determined significance of trends. PJI prevalence overall was 25.5% (n = 199,818) with a minor increasing trend: 25.3% (n = 7,828) in 2003 to 28.9% (n = 19,275) in 2016; p < 0.0001. Median total hospitalization costs for PJI decreased slightly ($23,247 in 2003-$20,273 in 2016; p < 0.0001) while median per-day costs slightly increased ($3,452 in 2003-$3,727 in 2016; p < 0.0001), likely as a function of decreasing length of stay. With small differences between hospitals, the lowest and highest PJI prevalences were seen in small (≤299 beds; 22.9%) and urban teaching hospitals (27.3%), respectively. In stratification analyses, an increasing trend in PJI prevalence was particularly seen in larger (≥500 beds) hospitals (24.4% in 2003-30.7% in 2016; p < 0.0001), while a decreasing trend was seen in small-sized hospitals. Overall, PJI in knee arthroplasty revisions appears to be slightly increasing. Moreover, increasing trends in large hospitals and decreasing trends in small-sized hospitals suggest a shift in patients from small to large volume hospitals. Decreasing trends in total costs, alongside increasing trends in per-day costs, suggest a strong impact of length of stay trends and a more efficient approach to PJI over the years (in terms of shorter length of stay).

Impact of Increasing Comorbidity Burden on Resource Utilization in Patients With Proximal Humerus Fractures.

INTRODUCTION: Proximal humerus fractures (PHF) are a common upper extremity fracture in the elderly cohort. An aging and more comorbid cohort, along with recent trends of increased operative intervention, suggests that there could be an increase in resource utilization caring for these patients. We sought to quantify these trends and quantify the impact that comorbidity burden has on resource utilization. METHODS: Data on 83,975 patients with PHFs were included from the Premier Healthcare Claims database (2006 to 2016) and stratified by Deyo-Charlson index. Multivariable models assessed associations between Deyo-Charlson comorbidities and resource utilization (length and cost of hospitalization, and opioid utilization in oral morphine equivalents [OME]) for five treatment modalities: (1) open reduction internal fixation (ORIF), (2) closed reduction internal fixation (CRIF), (3) hemiarthroplasty, (4) reverse total shoulder arthroplasty, and (5) nonsurgical treatment (NST). We report a percentage change in resource utilization associated with an increasing comorbidity burden. RESULTS: Overall distribution of treatment modalities was (proportion in percent/median length of stay/cost/opioid utilization): ORIF (19.1%/2 days/$11,183/210 OME), CRIF (1.1%/4 days/$11,139/220 OME), hemiarthroplasty (10.7%/3 days/$17,255/275 OME), reverse total shoulder arthroplasty (6.4%/3 days/$21,486/230 OME), and NST (62.7%/0 days/$1,269/30 OME). Patients with an increased comorbidity burden showed a pattern of (1) more pronounced relative increases in length of stay among those treated operatively (65.0% for patients with a Deyo-Charlson index >2), whereas (2) increases in cost of hospitalization (60.1%) and opioid utilization (37.0%) were more pronounced in the NST group. DISCUSSION: In patients with PHFs, increased comorbidity burden coincides with substantial increases in resource utilization in patients receiving surgical and NSTs. Combined with known increases in operative intervention, trends in increased comorbidity burden may have profound effects on the cohort level and resource utilization for those with PHFs, especially because the use of bundled payment strategies for fractures increases. LEVEL OF EVIDENCE: Level III.

Poor Access to Opioid Addiction Care for Total Joint Arthroplasty Patients.

INTRODUCTION: The United States is experiencing an opioid epidemic, and orthopedists prescribe a large proportion of these drugs. Patients often become dependent on painkillers and face barriers to treatment. Given that many joint arthroplasty patients are enrolled in Medicare, we aimed to examine the ease of orthopedic patients with various insurance types to access addiction and pain specialists. METHODS: Using three web-based directories, we identified addiction specialists within a 5-mile radius of our hospital. We contacted these practices and inquired as to whether they treated addiction, types of insurance they accepted, and appointment availability. RESULTS: We identified 190 addiction and pain management specialists and were able to reach 134/190 (70.5%). Nine (6.7%) of the 134 reachable physicians accepted Medicare or Medicaid, which is nine (4.7%) of the 190 physicians initially located. The average wait time to an appointment was 4.2 days, and a significant difference in wait time existed across insurance types (p = 0.0284). DISCUSSION: Orthopedic patients face many barriers to receiving treatment for painkiller addiction. Wait time to see an addiction specialist also varied based on insurance type. Online directories may not be useful for certain patient populations to identify physicians. Orthopedic surgeons should partner with addiction and pain specialists to help alleviate the barriers that patients face.

Cost of Care for Patients With Pre-Existing Comorbidities Undergoing Total Joint Arthroplasty: A Retrospective Cohort Study Evaluating Disease-Specific Perioperative Care.

BACKGROUND: Investigations suggest a relationship between increased resource utilization with disease burden and advanced age. However, it remains unknown the degree increased resource utilization is associated with pre-existing conditions, before complications occur. METHODS: This retrospective study identified total hip/knee arthroplasty cases in the Premier Database from 2006 to 2016 (N = 1,613,744), with hospitalization cost as the primary outcome. With a variable combining the conditions and complication, generalized linear models measured associations between condition/complication interaction groups and hospitalization cost. Estimates of percent cost increase by variable were obtained. RESULTS: Across all conditions, an increase in cost ranging from 0.38% to 4.28% was found in the absence of a complication. The "Condition = No, Complication = Yes" group was associated with a range of 11.50%-12.40% increase in average hospitalization cost, and the range was 14.43%-30.85% for the "Condition = Yes, Complication = Yes" group. CONCLUSION: We found that having a high-risk condition without a complication accounted only for a modest hospitalization cost increase.

Impact of obstructive sleep apnea on perioperative complications among patients undergoing hysterectomy: a population-based analysis.

INTRODUCTION: Although obstructive sleep apnea (OSA) is a known risk factor for perioperative complications in various patient cohorts data is lacking for patients undergoing hysterectomies, one of the most frequently performed surgeries among women. Using national data we therefore aimed to assess the risk in this patient group. MATERIALS AND METHODS: We extracted data on patients who underwent a hysterectomy between 2006 and 2014 from a large nationwide database (n = 459,508). OSA patients (identified by ICD-9 CM codes) were compared to non-OSA patients regarding perioperative outcomes: cardiac, central-nervous, gastrointestinal, genitourinary, renal, respiratory, and thromboembolic complications; as well as opioid prescription, need for blood transfusion, cost of hospitalization, length of stay and ICU admission. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Overall, 2.67% (n = 11,936) of patients were identified as having OSA. Compared to non-OSA patients, OSA was particularly associated with higher odds for renal (OR 1.98; 95% CI 1.70-2.32) and respiratory complications (OR 3.25; 95% CI 2.97-3.56), and ICU admission (OR 2.28; 95% CI 1.77-2.94). Further, while significant, OSA was associated with modestly increased cost of hospitalization (+6.24%; P < 0.0001) and length of stay (+2.58%; P < 0.0001). CONCLUSIONS: In patients undergoing hysterectomies, OSA was associated with substantially increased risk of complications and modestly increased resource utilization. Further research is needed to assess currently used perioperative care strategies for OSA patients undergoing hysterectomies, with the goal to improve outcomes.

Surgeon Type and Outcomes After Inpatient Ankle Arthrodesis and Total Ankle Arthroplasty: A Retrospective Cohort Study Using the Nationwide Premier Healthcare Claims Database.

BACKGROUND: Two main treatments for end-stage ankle arthritis are ankle arthrodesis and total ankle arthroplasty (TAA). While both procedures can be performed either by a foot and ankle orthopaedic surgeon or a podiatrist (when within a particular state's scope of practice), studies comparing the surgical outcomes of the 2 surgeon types are lacking. Therefore, in this study, we compared outcomes by surgeon type for TAA and for ankle arthrodesis. METHODS: This retrospective cohort study utilized data from the nationwide Premier Healthcare claims database (2011 to 2016) regarding TAA (n = 3,674) and ankle arthrodesis (n = 4,980) procedures. Multivariable models estimated associations between surgeon type (podiatrist versus orthopaedic foot and ankle surgeon) and opioid utilization (in oral morphine equivalents [OMEs]), length of stay, and cost of hospitalization. We report percent change (compared with reference) and 95% confidence intervals (CIs). RESULTS: Overall, 76.5% (n = 2,812) and 18.8% (n = 690) of TAA procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 4.7% (n = 172). For ankle arthrodesis, 75.3% (n = 3,752) and 18.3% (n = 912) of the procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 6.3% (n = 316). The proportion of TAA and ankle arthrodesis procedures performed by podiatrists increased over time, from 12.8% and 13.6% in 2011 to 24.6% and 26.0% in 2016, respectively. When adjusting for relevant covariates, procedures performed by podiatrists (compared with orthopaedic foot and ankle surgeons) were associated with increased length of stay: for TAA, +16.7% (95% CI, 7.6% to 26.5%; median, 2 days in both groups) and for ankle arthrodesis, +14.2% (95% CI, 7.9% to 20.9%; median, 3 compared with 2 days) (p < 0.05 for both). In addition, ankle arthrodesis performed by podiatrists was associated with increased cost of hospitalization: +28.5% (95% CI, 22.1% to 35.2%; median, $19,236 compared with $13,433) (p < 0.05). Differences in opioid utilization were nonsignificant in the main analysis: +10.9% (95% CI, -3.1% to 26.8%; median, 345 compared with 250 OMEs) and +2.8% (95% CI, -5.9% to 12.4%; median, 351 compared with 315 OMEs) for TAA and ankle arthrodesis, respectively. CONCLUSIONS: An increasing trend in the proportion of procedures performed by podiatrists was coupled with apparent increases in length of stay and cost compared with procedures performed by orthopaedic foot and ankle surgeons. Given the increasing demand for these procedures, factors associated with resource utilization, such as type of surgeon, may be increasingly important on the population level. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Management in Hepatic Resections: Comparative Effectiveness of Neuraxial Anesthesia and Disparity of Care Patterns.

BACKGROUND: Complication rates after hepatic resection can be affected by management decisions of the hospital care team and/or disparities in care. This is true in many other surgical populations, but little study has been done regarding patients undergoing hepatectomy. METHODS: Data from the claims-based national Premier Perspective database were used for 2006 to 2014. The analytical sample consisted of adults undergoing partial hepatectomy and total hepatic lobectomy with anesthesia care consisting of general anesthesia (GA) only or neuraxial and GA (n = 9442). The key independent variable was type of anesthesia that was categorized as GA versus GA + neuraxial. The outcomes examined were clinical complications and health care resource utilization. Unadjusted bivariate and adjusted multivariate analyses were conducted to examine the effects of the different types of anesthesia on clinical complications and health care resource utilization after controlling for patient- and hospital-level characteristics. RESULTS: Approximately 9% of patients were provided with GA + neuraxial anesthesia during hepatic resection. In multivariate analyses, no association was observed between types of anesthesia and clinical complications and/or health care utilization (eg, admission to intensive care unit). However, patients who received blood transfusions were significantly more likely to have complications and intensive care unit stays. In addition, certain disparities of care, including having surgery in a rural hospital, were associated with poorer outcomes. CONCLUSIONS: Neuraxial anesthesia utilization was not associated with improvement in clinical outcome or cost among patients undergoing hepatic resections when compared to patients receiving GA alone. Future research may focus on prospective data sources with more clinical information on such patients and examine the effects of GA + neuraxial anesthesia on various complications and health care resource utilization.

Impact of Intravenous Acetaminophen on Perioperative Opioid Utilization and Outcomes in Open Colectomies: A Claims Database Analysis.

BACKGROUND: The value of intravenous acetaminophen in postoperative pain management remains debated. The authors tested the hypothesis that intravenous acetaminophen use, in isolation and in comparison to oral, would be associated with decreased opioid utilization (clinically significant reduction defined as 25%) and opioid-related adverse effects in open colectomy patients. METHODS: Using national claims data from open colectomy patients (Premier Healthcare Database, Premier Healthcare Solutions, Inc., USA; 2011 to 2016; n = 181,640; 602 hospitals), we separately categorized oral and intravenous acetaminophen use: 1 (1,000 mg) or more than 1 dose on the day of surgery, postoperative day 1, or later. Multilevel models measured associations between intravenous or oral acetaminophen and (1) opioid utilization and (2) opioid-related adverse effects. Percent change and multiplicity-adjusted 99.5% CI are reported. RESULTS: Overall, 25.1% of patients received intravenous acetaminophen, of whom 48.0% (n = 21,878) received 1 dose on the day of surgery. In adjusted analyses, particularly more than 1 dose of intravenous acetaminophen (versus nonuse) on postoperative day 1 was associated with a -12.4% (99.5% CI, -15.2 to -9.4%) change in opioid utilization. In comparison, a stronger reduction was seen in those receiving more than 1 oral acetaminophen dose: -22.6% (99.5% CI, -26.2 to -18.9%). Unadjusted group medians were 550 and 490 oral morphine equivalents, respectively. Intravenous versus oral differences were less pronounced among those receiving more than 1 acetaminophen dose on the day of surgery: -8.0% (99.5% CI, -11.0 to -4.9%) median 499 oral morphine equivalents versus -8.7% (99.5% CI, -14.4 to -2.7%) median 445 oral morphine equivalents, respectively; all statistically significant, but none clinically significant. Comparable outcome patterns existed for opioid-related adverse effects. CONCLUSIONS: The demonstrated marginal effects do not support routine use of intravenous acetaminophen given alternative nonopioid analgesic options.

Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study.

BACKGROUND: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization. METHODS: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into "opioids only" and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported. RESULTS: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to "opioids only") experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a -18.5% decrease in opioid prescription (95% CI, -19.7% to -17.2%; 205 vs. 300 overall median oral morphine equivalents), and a -12.1% decrease (95% CI, -12.8% to -11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used. CONCLUSIONS: While the optimal multimodal regimen is still not known, the authors' findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

Trends in Periprosthetic Hip Infection and Associated Costs: A Population-Based Study Assessing the Impact of Hospital Factors Using National Data.

BACKGROUND: Periprosthetic joint infection (PJI) is an important cost driver in hip arthroplasty revisions, thus necessitating careful trend monitoring. Recent national trend data are lacking; we therefore assessed national PJI burden, trends in prevalence, and hospitalization costs. METHODS: We extracted data on hip arthroplasty revisions from the National Inpatient Sample (2003-2013; n = 465,209). Trends in PJI prevalence and hospitalization costs were (1) assessed for the full cohort and (2) stratified by hospital teaching status, hospital bed size (≤299, 300-499, and ≥500 beds), and hospital region (Northeast, Midwest, South, and West). The Cochran-Armitage trend test (PJI prevalence) and linear regression (hospitalization costs) determined significance of trends. Trends were adjusted for patient's age, gender, insurance type, race, Deyo-Charlson comorbidities, obesity, length of stay, and hospital characteristics. RESULTS: Overall, PJI prevalence was 15.0% (n = 70,011); adjusted prevalence increased from 13.1% in 2003 to 16.4% in 2013 (P < .0001), while adjusted median PJI hospitalization costs increased from $28,240 in 2003 to $31,529 in 2013 (P < .0001). Rural hospitals had the lowest PJI burden (12.5%; n = 4,525), while urban and teaching hospitals had the highest PJI burden (16.4%; n = 40,297). The stratified analyses, particularly in large hospitals (>500 beds), showed that PJI prevalence increased from 13.0% (2003) to 17.4% (2013; a 33.8% increase; P < .0001). Similarly, PJI revision hospitalization costs increased from a median of $27,490 (2003) to $31,312 (2013; a 14% increase; P < .0001). CONCLUSION: The burden of PJI in hip arthroplasty revision is increasing and-while additional research is needed-there appears to be a particular shift of revision burden to larger hospitals with increasing costs.

Intravenous Acetaminophen Does Not Reduce Inpatient Opioid Prescription or Opioid-Related Adverse Events Among Patients Undergoing Spine Surgery.

BACKGROUND: Having entered the US market relatively recently, the perioperative role of intravenous acetaminophen (ivAPAP) remains to be established for several surgeries. Using national data, we therefore assessed current utilization and whether it reduces inpatient opioid prescription and opioid-related side effects in a procedure with relatively high opioid utilization. METHODS: Patients undergoing a lumbar/lumbosacral spinal fusion (n = 117,269; 2011-2014) were retrospectively identified in a nationwide database and categorized by the amount and timing of ivAPAP administration (1 or >1 dose on postoperative day [POD] 0, 1, or 1+). Multivariable models measured associations between ivAPAP utilization categories and opioid prescription and perioperative complications; odds ratios (or % change) and 95% confidence intervals are reported. RESULTS: Overall, ivAPAP was used in 18.9% (n = 22,208) of cases of which 1 dose on POD 0 was the most common (73.6%; n = 16,335). After covariate adjustment, use of ivAPAP on POD 0 and 1 was associated with minimal changes in opioid prescription, length and cost of hospitalization particularly favoring >1 ivAPAP dose with a modestly (-5.2%, confidence interval, -7.2% to -3.1%; P < .0001) decreased length of stay. Use of ivAPAP did not coincide with a consistent pattern of significantly reduced odds for complications. In comparison, the most commonly used nonopioid analgesic, pregabalin/gabapentin, did demonstrate reduced opioid prescription combined with lower complication risk. CONCLUSIONS: We could not show that perioperative ivAPAP reduces inpatient opioid prescription with subsequent reduced odds for adverse outcomes. It remains to be determined if and under what circumstances ivAPAP has a meaningful clinical role in everyday practice.