Effects of Hospital and Surgeon Volume on Patient Outcomes After Total Joint Arthroplasty: Reported From the American Joint Replacement Registry.

BACKGROUND: The purpose of this study was to evaluate outcomes and complications because it relates to surgeon and hospital volume for patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) using the American Joint Replacement Registry from 2012 to 2017. METHODS: A retrospective study was conducted on Medicare-eligible cases of primary elective THAs and TKAs reported to the American Joint Replacement Registry database and was linked with the available Centers of Medicaid and Medicare Services claims and the National Death Index data from 2012 to 2017. Surgeon and hospital volume were defined separately based on the median annual number of anatomic-specific total arthroplasty procedures performed on patients of any age per surgeon and per hospital. Values were aggregated into separate surgeon and hospital volume tertile groupings and combined to create pairwise comparison surgeon/hospital volume groupings for hip and knee. RESULTS: Adjusted multivariable logistic regression analysis found low surgeon/low hospital volume to have the greatest association with all-cause revisions after THA (odds ratio [OR], 1.63, 95% confidence interval [CI], 1.41-1.89, P < 0.0001) and TKA (OR, 1.72, 95% CI, 1.44-2.06, P < 0.0001), early revisions because of periprosthetic joint infection after THA (OR, 2.50, 95% CI, 1.53-3.15, P < 0.0001) and TKA (OR, 2.18, 95% CI, 1.64-2.89, P < 0.0001), risk of early THA instability and dislocation (OR, 2.47, 95% CI, 1.77-3.46, P < 0.0001), and 90-day mortality after THA (OR, 1.72, 95% CI, 1.27-2.35, P = 0.0005) and TKA (OR, 1.47, 95% CI, 1.15-1.86, P = 0.002). CONCLUSION: Our findings demonstrate considerably greater THA and TKA complications when performed at low-volume hospitals by low-volume surgeons. Given the data from previous literature including this study, a continued push through healthcare policies and healthcare systems is warranted to direct THA and TKA procedures to high-volume centers by high-volume surgeons because of the evident decrease in complications and considerable costs associated with all-cause revisions, periprosthetic joint infection, instability, and 90-day mortality. LEVEL OF EVIDENCE: III.

Personality Assessment and Emotional Intelligence in Orthopaedic Surgery Residency Selection and Training.

Orthopaedic surgery has increasingly emerged as one of the most popular and competitive of all medical specialties. The selection of the best applicants has become a more difficult process because the number of qualified medical students has concomitantly grown. Although there are standardized guidelines in residency selection, there are several intangible factors that determine an applicant's fit into a program. Personality assessments, such as the Neuroticism-Extraversion-Openness Personality Inventory and the Myers-Briggs Type Indicator, are proficiencies that have garnered significant interest to help fill this void. Understanding and measuring empirically supported measures of personality traits and styles of medical students and residents may be valuable to medical educators and program directors in a variety of applications such as residency selection, mentoring, and education. Similar to personality identification, emotional intelligence assessments, such as the Mayer-Salovey-Caruso Emotional Intelligence Test, can prove to be pivotal tools in residency education and training. Emotional intelligence has shown to align with current Accreditation Council for Graduate Medical Education residency standardized core competencies that emphasize aptitude in noncognitive characteristics.

2018 John Charnley Award: Analysis of US Hip Replacement Bundled Payments: Physician-initiated Episodes Outperform Hospital-initiated Episodes.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) initiative in 2013 to create incentives to improve outcomes and reduce costs in various clinical settings, including total hip arthroplasty (THA). This study seeks to quantify BPCI initiative outcomes for THA and to determine the optimal party (for example, hospital versus physician group practice [PGP]) to manage the program. QUESTIONS/PURPOSES: (1) Is BPCI associated with lower 90-day payments, readmissions, or mortality for elective THA? (2) Is there a difference in 90-day payments, readmissions, or mortality between episodes initiated by PGPs and episodes initiated by hospitals for elective THA? (3) Is BPCI associated with reduced total Elixhauser comorbidity index or age for elective THA? METHODS: We performed a retrospective analysis on the CMS Limited Data Set on all Medicare primary elective THAs without a major comorbidity performed in the United States (except Maryland) between January 2013 and March 2016, totaling more than USD 7.1 billion in expenditures. Episodes were grouped into hospital-run BPCI (n = 42,922), PGP-run BPCI (n = 44,662), and THA performed outside of BPCI (n = 284,002). All Medicare Part A payments were calculated over a 90-day period after surgery and adjusted for inflation and regional variation. For each episode, age, sex, race, geographic location, background trend, and Elixhauser comorbidities were determined to control for major confounding variables. Total payments, readmissions, and mortality were compared among the groups with logistic regression. RESULTS: When controlling for demographics, background trend, geographic variation, and total Elixhauser comorbidities in elective Diagnosis-Related Group 470 THA episodes, BPCI was associated with a 4.44% (95% confidence interval [CI], -4.58% to -4.30%; p < 0.001) payment decrease for all participants (USD 1244 decrease from a baseline of USD 18,802); additionally, odds ratios (ORs) for 90-day mortality and readmissions were unchanged. PGP groups showed a 4.81% decrease in payments (95% CI, -5.01% to -4.61%; p < 0.001) after enrolling in BPCI (USD 1335 decrease from a baseline of USD 17,841). Hospital groups showed a 4.04% decrease in payments (95% CI, -4.24% to 3.84%; p < 0.01) after enrolling in BPCI (USD 1138 decrease from a baseline of USD 19,799). The decrease in payments of PGP-run episodes was greater compared with hospital-run episodes. ORs for 90-day mortality and readmission remained unchanged after BPCI for PGP- and hospital-run BPCI programs. Patient age and mean Elixhauser comorbidity index did not change after BPCI for PGP-run, hospital-run, or overall BPCI episodes. CONCLUSIONS: Even when controlling for decreasing costs in traditional fee-for-service care, BPCI is associated with payment reduction with no change in adverse events, and this is not because of the selection of younger patients or those with fewer comorbidities. Furthermore, physician group practices were associated with greater payment reduction than hospital programs with no difference in readmission or mortality from baseline for either. Physicians may be a more logical group than hospitals to manage payment reduction in future healthcare reform. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Cost Savings in a Surgeon-Directed BPCI Program for Total Joint Arthroplasty.

BACKGROUND: There are few studies available on the savings generated and strategies employed for cost reduction in total joint arthroplasty. In this study, our organization-a group of private practices partnering with a consultant-aimed to analyze the impact of a preoperative protocol on overall cost savings. MATERIALS AND METHODS: Using administrative data from the Medicare Bundled Payments for Care Improvement (BPCI) initiative, 771 consecutive total joint arthroplasty patients from 2009-2014 were compared with 408 consecutive BPCI patients from 2014-2017. The 30-day episode and Medicare part B total cost of care was analyzed. This included inpatient and post-discharge expenditure, laboratory and imaging costs, physician and ER visits, and readmission. RESULTS: Average total episode cost declined by $3,174 or 13% from $23,925 to $20,752 (p<0.001) in the BPCI period. Readmission rate was unchanged (p=0.20), and there was a 48% reduction in the percent of patients presenting to the emergency room (p=.03). There was a decline of $2,647 (78%) in skilled nursing cost per case, which represented the majority of savings. Post-discharge imaging, laboratory test claims, postoperative emergency room visits, primary care physician (PCP) visits, and cost per episode all decreased. The decrease in PCP utilization did not result in increased medical complications or readmissions. CONCLUSION: Our preoperative patient-education protocol has decreased non-home discharge, unnecessary postoperative physician visits, and diagnostic testing resulting in an episode cost savings of 13%. With Advanced BPCI on the horizon, orthopedic surgeon control as the awardee of the bundle, combined with an increasing focus on patient education, will continue to lower costs and improve patient care.

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.