The effect of transferring weekend physical therapy services from the acute to sub-acute setting in patients following hip and knee arthroplasty: a quasi-experimental study.

BACKGROUND: Weekend physical therapy services in the acute and/or sub-acute setting may optimize postoperative recovery following hip and knee arthroplasty, though evidence supporting these services is limited. PURPOSE: To explore the change in patient and service outcomes of transferring a weekend physical therapy service from the acute to the sub-acute setting following hip and knee arthroplasty. METHODS: This was a quasi-experimental research design nested within two stepped-wedge cluster randomized controlled trials. Acute weekend physical therapy services were sequentially discontinued and reallocated to the sub-acute setting in a random order from one ward at a time within the broader trial. Patient and service outcomes for participants 6 weeks following hip and knee arthroplasty (N = 247) were compared during 6 months of acute weekend physical therapy services (Phase 1, n = 117) followed by 6 months of sub-acute services (Phase 2, n = 130). Intention-to-treat statistical analyses were conducted. RESULTS: The intervention had a negligible effect on medium-term outcomes. The only statistically significant difference observed was slightly higher ratings of "worst pain experienced over the past week" [coefficient 0.865 (0.123 to 1.606), p = .022] during Phase 2. No interaction effects were observed despite a 2.4-day reduction in length of stay amongst complex patients during Phase 2 (18.28 and 15.86 days in Phase 1 and 2, respectively). CONCLUSIONS: No comparative advantage or disadvantage was observed by reallocating a weekend physical therapy budget from the acute to sub-acute setting following hip and knee arthroplasty. Further research investigating the cost-effectiveness of these services in the sub-acute setting may be warranted for complex patients.

Neural network models accurately predict discharge disposition after revision total knee arthroplasty?

PURPOSE: Based on the rising incidence of revision total knee arthroplasty (TKA), bundled payment models may be applied to revision TKA in the near future. Facility discharge represents a significant cost factor for those bundled payment models; however, accurately predicting discharge disposition remains a clinical challenge. The purpose of this study was to develop and validate artificial intelligence algorithms to predict discharge disposition following revision total knee arthroplasty. METHODS: A retrospective review of electronic patient records was conducted to identify patients who underwent revision total knee arthroplasty. Discharge disposition was defined as either home discharge or non-home discharge, which included rehabilitation and skilled nursing facilities. Four artificial intelligence algorithms were developed to predict this outcome and were assessed by discrimination, calibration and decision curve analysis. RESULTS: A total of 2228 patients underwent revision TKA, of which 1405 patients (63.1%) were discharged home, whereas 823 patients (36.9%) were discharged to a non-home facility. The strongest predictors for non-home discharge following revision TKA were American Society of Anesthesiologist (ASA) score, Medicare insurance type and revision surgery for peri-prosthetic joint infection, non-white ethnicity and social status (living alone). The best performing artificial intelligence algorithm was the neural network model which achieved excellent performance across discrimination (AUC = 0.87), calibration and decision curve analysis. CONCLUSION: This study developed four artificial intelligence algorithms for the prediction of non-home discharge disposition for patients following revision total knee arthroplasty. The study findings show excellent performance on discrimination, calibration and decision curve analysis for all four candidate algorithms. Therefore, these models have the potential to guide preoperative patient counselling and improve the value (clinical and functional outcomes divided by costs) of revision total knee arthroplasty patients. LEVEL OF EVIDENCE: IV.

Poor Recovery of Activities-of-Daily-Living Function Is Associated With Higher Rates of Postsurgical Hospitalization After Total Joint Arthroplasty.

OBJECTIVE: Medicare beneficiaries are increasingly using home health (HH) as the first postacute care setting after hospital discharge following total joint arthroplasty (TJA). Yet, prior research has shown that changes in payment models for TJA may negatively influence functional outcomes for Medicare beneficiaries. The purpose of this study was to evaluate the impact of poor functional outcomes during an HH episode of care on hospitalization risk for older recipients of TJA. METHODS: For this study, 5822 Medicare beneficiaries who underwent elective TJA and subsequently participated in HH care following hospital discharge were identified using Medicare hospitalizations records and HH claims. Recovery of activities-of-daily-living (ADL) function was evaluated using patient assessment data completed at HH admission and discharge from the Medicare Outcomes and Assessment Information Set (OASIS). Hospitalization outcomes were captured from Medicare hospital claims. Cox proportional hazards regression was used to evaluate the hazard ratio for hospitalization after HH discharge. RESULTS: The 5822 Medicare beneficiaries who received a TJA and subsequently were discharged to HH were evaluated (n = 3989 [68.6%] following total knee replacement, n = 1883 [31.4%]) following total hip replacement). Nearly 9% (n = 534) of patients did not improve their ability to perform ADLs during the HH episode; this lack of improvement was associated with a more than 2-fold increase in hospital readmission rate following HH discharge (2.3% vs 4.9%). In adjusted models, there was a significant 77% increase (hazard ratio = 1.77; 95% CI = 1.14-2.74) in hospitalization risk during the 90-day postsurgical period. CONCLUSION: Poor recovery of ADL function in HH settings following TJA is strongly associated with elevated risk of future hospitalizations. IMPACT: Medicare beneficiaries who fail to make substantive improvements in basic ADL function during HH care episodes following TJA may need intensive monitoring from interdisciplinary team members across the continuum of care, especially during transitions from home care to outpatient care. LAY SUMMARY: An increasing number of patients receive home health care after joint replacement surgery, but outcomes after home health are unclear. These findings suggest that improvements in basic tasks such as walking or bathing are associated with a lower likelihood of hospitalization.

The Effect of a Discharge Disposition Algorithm on Patient Outcomes and Satisfaction.

Total joint arthroplasties are one of the most common procedures performed in the United States. As changes have occurred in the surgical techniques of these procedures, postoperative recovery time has decreased and patients have been able to safely transition to home rather than a post-acute care facility. The demand for total joint arthroplasty (TJA) is expected to grow 44% as the prevalence of lower extremity osteoarthritis continues to rise (Sher et al., 2017) because of an aging baby boomer population. In the next 20 years, it is expected that the demand for total hip arthroplasty will grow by 174% and demand for total knee arthroplasty will grow by as much as 670% (Napier et al., 2013). An area with high variability in the postoperative period is in postdischarge rehabilitation. Post-acute inpatient care can account for up to 36% of the bundled costs of a TJA. There is a lack of evidence that patients recover better or have decreased complications by transitioning to an inpatient rehabilitation setting compared with transitioning to home. The aims of this literature search were to (a) identify the safest discharge disposition for patients following TJA; (b) determine the rate of complications and readmissions among those discharged to skilled nursing facility, inpatient rehabilitation unit, and home; and (c) explore how specified care pathways affect patient expectations and outcomes. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, ProQuest, and Cochrane were searched using the following key terms: discharge disposition, total joint arthroplasty, joint replacement, hip arthroplasty, knee arthroplasty, care pathway, discharge outcomes and readmissions, discharge protocols, and discharge algorithms. Five key themes emerged. Patients with significant comorbidities may require longer length of stay in the hospital or potentially discharge to a facility, discharge to facility associated with high rate of complications, setting patient expectations increases likelihood of discharge home, discharge to inpatient facilities does not improve outcomes, and discharge to any post-acute care facility is more expensive than discharge to home. This review identified themes in postoperative care of TJA patients that can be utilized to create a discharge disposition algorithm using best practices to stratify patients into the appropriate discharge disposition while setting appropriate expectations for patients undergoing these procedures to ensure high levels of patient satisfaction following these procedures.

Relationship Between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery After Hip Replacement.

OBJECTIVE: To determine whether patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016. DESIGN: Pre (January 1, 2015-June 30, 2016) vs post (July 1, 2016-December 31, 2017) design. SETTING: Skilled nursing facilities (n=12,829). PARTICIPANTS: Medicare fee-for-service beneficiaries (N=106,832) discharged from acute hospitals to SNF after hip replacement between January 1, 2015 and December 31, 2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 5- and 14-day minimum data set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10 days and any improvement between the 5- and 14-day assessments. RESULTS: The average adjusted change per 10 days for the quality measure total score for patients admitted before July 2016 and after July 2016 was 1.00 points (standard error, 0010) and 1.06 points (standard error, 0.010), respectively (P<.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (standard error, 0.06) had any improvement in the quality measure total score compared with 45.5% (standard error, 0.23) of patients admitted after July 2016 (P<.01). This was a relative increase of 2.5%. The adjusted change per 10 days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016. CONCLUSIONS: Patients admitted to a SNF after a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.

Association of Occupational and Physical Therapy With Duration of Prescription Opioid Use After Hip or Knee Arthroplasty: A Retrospective Cohort Study of Medicare Enrollees.

OBJECTIVE: To establish whether nonpharmacologic interventions, such as occupational and physical therapy, were associated with a shorter duration of prescription opioid use after hip or knee arthroplasty. DESIGN: This retrospective cohort study used data from a national 5% Medicare sample database between January 1, 2010 and December 31, 2015. SETTING: Home health or outpatient. PARTICIPANTS: Adults 66 years or older with an inpatient total hip (n=4272) or knee (n=9796) arthroplasty (N=14,068). INTERVENTIONS: We dichotomized patients according to whether they had received any nonpharmacologic pain intervention within 1 year after hospital discharge (eg, occupational or physical therapy evaluation). Using Cox proportional hazards, we treated exposure to nonpharmacologic interventions as time dependent to determine if skilled therapy was associated with duration of opioid use. MAIN OUTCOME MEASURES: Duration of prescription opioid use. RESULTS: Median time to begin nonpharmacologic interventions was 91 days (95% confidence interval [CI], 74-118d) for hip and 27 days (95% CI, 27-28d) for knee arthroplasty. Median time to discontinue prescription opioids was 16 days (hip: 95% CI, 15-16d) and 30 days (knee: 95% CI, 29-31d). Nonpharmacologic interventions delivered with home health increased the likelihood of discontinuing opioids after hip (hazard ratio [HR], 1.15; 95% CI, 1.01-1.30) and knee (HR, 1.10; 95% CI, 1.03-1.17) arthroplasty. A sensitivity analysis found these estimates to be robust and conservative. CONCLUSIONS: Occupational and physical therapy with home health was associated with a shorter duration of prescription opioid use after hip and knee arthroplasty. Occupational and physical therapy can address pain and sociobehavioral factors associated with postsurgical opioid use.

Community Deprivation Index and Discharge Destination After Elective Hip Replacement.

OBJECTIVE: To examine how the deprivation level of the community in which one lives influences discharge disposition and the odds of 90-day readmission after elective total hip arthroplasty (THA). METHODS: We performed a retrospective cohort study on 84,931 patients who underwent elective THA in the Pennsylvania Health Care Cost Containment Council database from 2012 to 2016. We used adjusted binary logistic regression models to test the association between community Area Deprivation Index (ADI) level and patient discharge destination as well as 90-day readmission. We included an interaction term for community ADI level and patient race in our models to assess the simultaneous effect of both on the outcomes. RESULTS: After adjusting for patient- and facility-level characteristics, we found that patients from high ADI level communities (most disadvantaged), compared to patients from low ADI level communities (least disadvantaged), were more likely to be discharged to an institution as opposed to home for postoperative care and rehabilitation (age <65 years adjusted odds ratio [ORadj ] 1.47; age ≥65 years ORadj 1.31; both P < 0.001). The interaction effect of patient race and ADI level on discharge destination was statistically significant in those patients age ≥65 years, but not in patients age <65 years. The association with ADI level on 90-day readmission was not statistically significant. CONCLUSION: In this statewide sample of patients who underwent elective THA, the level of deprivation of the community in which patients reside influences their discharge disposition, but not their odds of 90-day readmission to an acute-care facility.

Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission.

BACKGROUND: Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments. METHODS: We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests. RESULTS: Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use. CONCLUSION: Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.

Is retrospective assessment of health-related quality of life valid?

BACKGROUND: Health-related quality of life (HRQoL) is a commonly used health outcome. For many acute conditions (e.g. fractures), retrospective measurement of HRQoL is necessary to establish pre-morbid health status. However, the validity of retrospective measurement of HRQoL following an intervening significant health event has not been established. The aim of this study was to test the validity of retrospective measurement (recall) of HRQoL by using a test-retest design to measure reliability and agreement between prospective and retrospective patient-reported HRQoL before and after an intervening health event (elective orthopaedic surgery). METHOD: Participants were recruited from the pre-admission clinic of a metropolitan hospital. Participants were assessed for their HRQoL using the EQ-5D-5L at two time-points; prospectively at 2 weeks prior to their date of surgery and then retrospectively (recalling their pre-operative health) following elective hip or knee joint replacement surgery. Prospective measurements were compared with retrospective measurements for the five domain scores (nominal data) using intra-class correlation and for the EQ-Index score and EQ-Visual Analogue Scale (VAS) score (continuous data), using Pearson's correlation. Agreement was tested in continuous variables using Lin's coefficient of concordance (pc) and Bland-Altman plots. RESULTS: One hundred seventy-four patients consented to participate. Eighty-eight paired prospective and retrospective scores were collected and there was a median between-test period of 15 days. At a group level, the prospective measurements were similar to the retrospective measurements; the modes and means of the five domain scores were not different and the mean differences (MD) between the scores for EQ-Index (MD = 0.02, on a scale of 0-1) and EQ-VAS (MD = 0.53, on a scale of 1-100) were negligible. However, the correlation of paired scores was varied; the range of domain score correlations was 0.52 to 0.74, the concordance was substantial for the EQ-Index scores (pc = 0.76, 95% CI = 0.66, 0.84) and moderate for the EQ-VAS scores (pc = 0.46, 95% CI = 0.28, 0.61). CONCLUSION: Agreement between prospective and retrospective measurements was high at a group level and moderate to substantial at an individual level. Retrospective measurement of HRQoL using the EQ-5D-5L in an orthopaedic clinical context is a valid alternative to using reference data to estimate baseline or pre-morbid health status.

Predictive ability of the American Society of Anaesthesiologists physical status classification system on health-related quality of life of patients after total hip replacement: comparisons across eight EQ-5D-3L value sets.

BACKGROUND: American Society of Anaesthesiologists (ASA) physical status classification system and its association with postoperative outcomes has been studied in different diseases. However, there is a paucity of studies on the relationship between ASA class and postoperative health-related quality of life (HRQoL) outcomes following total hip replacement (THR). The aim of this study was to assess the discriminative abilities of EQ-5D-3L value sets from Sweden, Germany, Denmark and the United Kingdom in relation to ASA classes and these value sets' abilities to show the predictive performance of ASA classes on HRQoL among THR patients in Sweden. METHODS: A longitudinal study was conducted using data of patients in the Swedish Hip Arthroplasty Register who underwent THR between 2008 and 2016. We included 69,290 pre- and 1-year postoperative records and 21,305 6-year postoperative records. The study examined three experience-based EQ-5D-3L value sets (the Swedish VAS and TTO and the German VAS) and five hypothetical value sets (TTO from Germany and VAS and TTO value sets from Denmark and the UK each). Using linear models, the abilities of the value sets to discriminate among ASA classes and to show the predictive performance of ASA classes on HRQoL score were assessed. RESULTS: All value sets differentiated among ASA classes and showed the predictive effect of ASA classes on HRQoL. ASA classes were found to predict HRQoL consistently for all value sets investigated, with small variations in prediction error among the models. CONCLUSION: ASA classes of patients undergoing THR predicted HRQoL scores significantly and consistently, indicating their importance in tailoring care for patients.

Clinical and cost-effectiveness of physiotherapy interventions following total hip replacement: a systematic review and meta-analysis.

To examine the reported clinical and cost-effectiveness of physiotherapy interventions following total hip replacement (THR). A systematic review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). MEDLINE, CINAHL, AMED, Scopus, DARE, HTA, and NHS EED databases were searched for studies on clinical and cost-effectiveness of physiotherapy in adults with THR published up to March 2020. Studies meeting the inclusion criteria were identified and key data were extracted. Risk of bias was assessed using the Cochrane Risk of Bias Tool and a Consolidated Health Economic Evaluation Reporting Standards (CHEERS). Data were summarised and combined using random-effect meta-analysis. A total of 1263 studies related to the aim of the review were identified, from which 20 studies met the inclusion criteria and were included in the review. These studies were conducted in Australia (n = 3), Brazil (n = 1), United States of America (USA) (n = 2), France (n = 2), Italy (n = 2), Germany (n = 3), Ireland (n = 1), Norway (n = 2), Canada (n = 1), Japan (n = 1), Denmark (n = 1), and United Kingdom (UK) (n = 1). The duration of follow-up of the included studies was ranged from 2 weeks to 12 months. Physiotherapy interventions were found to be clinically effective for functional performance, hip muscle strength, pain, and range of motion flexion. From the National Health Service perspective, an accelerated physiotherapy programme following THR was cost-effective. The findings of the review suggest that physiotherapy interventions were clinically effective for people with THR. However, questions remain on the pooled cost-effectiveness of physiotherapy interventions, and further research is required to examine this in patients with THR. Future studies are required to examine the cost-effectiveness of these interventions from patients, caregivers, and societal perspectives.Registration Prospero (ID: CRD42018096524).

The use of digitally collected patient-reported outcome measures for newly operated patients with total knee and hip replacements to improve post-treatment recovery: study protocol for a randomized controlled trial.

BACKGROUND: The number of total knee replacements (TKRs) and total hip replacements (THRs) has been increasing noticeably in high-income countries, such as Germany. In particular, the number of revisions is expected to rise because of higher life expectancy and procedures performed on younger patients, impacting the budgets of health-care systems. Quality transparency is the basis of holistic patient pathway optimization. Nevertheless, a nation-wide cross-sectoral assessment of quality from a patient perspective does not yet exist. Several studies have shown that the use of patient-reported outcome measures (PROMs) is effective for measuring quality and monitoring post-treatment recovery. For the first time in Germany, we test whether early detection of critical recovery paths using PROMs after TKR/THR improves the quality of care in a cost-effective way and can be recommended for implementation into standard care. METHODS/DESIGN: The study is a two-arm multi-center patient-level randomized controlled trial. Patients from nine hospitals are included in the study. Patient-centered questionnaires are employed to regularly measure digitized PROMs of TKR/THR patients from the time of hospital admission until 12 months post-discharge. An expert consortium has defined PROM alert thresholds at 1, 3, and 6 months to signal critical recovery paths after TKR/THR. An algorithm alerts study assistants if patients are not recovering in line with expected recovery paths. The study assistants contact patients and their physicians to investigate and, if needed, adjust the post-treatment protocol. When sickness funds' claims data are added, the cost-effectiveness of the intervention can be analyzed. DISCUSSION: The study is expected to deliver an important contribution to test PROMs as an intervention tool and examine the determinants of high-quality endoprosthetic care. Depending on a positive and cost-effective impact, the goal is to transfer the study design into standard care. During the trial design phase, several insights have been discovered, and there were opportunities for efficient digital monitoring limited by existing legacy care models. Digitalization in hospital processes and the implementation of digital tools still represent challenges for hospital personnel and patients. Furthermore, data privacy regulations and the separation between the in- and outpatient sector are roadblocks to effectively monitor and assess quality along the full patient pathway. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00019916. Registered November 26, 2019 - retrospectively registered.

Rapid recovery following hip and knee arthroplasty using local infiltration analgesia: length of stay, rehabilitation protocol and cost savings.

BACKGROUND: We implemented local infiltration analgesia (LIA) as a technique of providing post-operative pain management and early mobilization after arthroplasty surgery and have progressively found patients able to go home earlier. This study compares the national data on hip and knee arthroplasty provided by the Royal Australasian College of Surgeons and Medibank Private with our outcomes using LIA and rapid recovery. METHODS: Prospective study of one surgeon including 200 knees, and 165 hips in the two years till June 2016. Variables included in comparison to the two groups were: length of stay, percentage of patients transferred to rehabilitation or intensive care unit (ICU), readmitted within 30 days and average separation cost. RESULTS: Hip replacement median length of stay in our series was two nights versus five nights, inpatient rehabilitation 7% versus 36%, ICU admission zero versus 4%, and readmissions 3.9% versus 6.0%, the average hospital separation cost in our series was $17 813 versus $26 734. Knee replacement median length of stay in our study was one night versus five nights, ICU 0.5% versus 3%, rehabilitation 4.5% versus 43%, and readmission 6% versus 7%, the average hospital separation cost in our group was $16 437 versus $27 505. CONCLUSION: The comprehensive approach of LIA and rapid recovery enables patients to have shorter hospitalization, lower rehabilitation incidence and a resultant reduction in health expenditure.

Costs and Outcomes of Medicare Advantage and Traditional Medicare Beneficiaries After Total Hip and Knee Arthroplasty.

INTRODUCTION: Medicare Advantage (MA) has increased popularity among eligible participants by providing additional benefits from a private insurer, but these plans are omitted from several government cost savings programs, including bundled payment models. The purpose of this study was to determine whether 90-day episode-of-care (EOC) costs and outcomes were different for patients with MA plans undergoing total joint arthroplasty compared with traditional Medicare patients. METHODS: We reviewed claims data for a consecutive series of patients undergoing primary total hip and knee arthroplasty from 2015 to 2018 at our institution with traditional Medicare coverage or MA through a single private insurer. Demographics, comorbidities, 90-day costs, readmissions, complications, and discharge disposition were compared between the groups. A multivariate regression analysis was performed to determine the independent effect of insurance status on EOC costs and outcomes. RESULTS: Of the 10,869 patients in the study, 1,076 (9.9%) were covered under an MA plan. MA patients were more likely to be discharged to a rehabilitation facility (19% versus 14%, P < 0.0001). No significant differences were observed in length of stay (1.88 versus 1.88 days, P = 0.1439), complications (3.9% versus 3.5%, P = 0.4554), or readmissions (5.9% versus 4.9%, P = 0.1893). EOC costs were significantly higher for the MA group ($21,347 versus $19,551, P < 0.0001). DISCUSSION: Patients with MA have higher total EOC costs than traditional Medicare beneficiaries with comparable short-term outcomes after total hip and knee arthroplasty. Further study is needed to determine whether alternative payment models in MA patients can improve care and reduce costs.

Home health monitoring around the time of surgery: qualitative study of patients' experiences before and after joint replacement.

OBJECTIVES: Hip and knee replacements are common major elective surgical interventions with over 200 000 performed annually in the UK. Not all patients achieve optimal outcomes or experience problems or delays in recovery. The number of patients needing these operations is set to increase, and routine clinical monitoring is time-consuming and resource-consuming for patients and healthcare providers; therefore, innovative evaluation of surgical outcomes is needed. The aim of this qualitative study was to capture the patient experience of living with a novel home monitoring sensing system during the period around joint replacement. SETTING: One secondary care hospital in the South West, UK. PARTICIPANTS: 13 patients (8 female, 63-89 years) undergoing total hip or knee replacement enrolled into the study. DESIGN: Qualitative study with thematic analysis. The system remained in situ for up to 12 weeks after their surgery and comprised a group of low-powered sensors monitoring the environment (temperature, light and humidity) and activity of people within the home. Patients were interviewed at two timepoints: before and after surgery. Interviews explored views about living with the technology, its acceptability, as well as attitudes towards health technology. RESULTS: Three main themes emerged: installation of home-sensing technology on the journey to surgery, the home space and defining unobtrusiveness and pivotal role of social support networks. CONCLUSIONS: Patients who agreed to the technology found living with it acceptable. A home-sensing system that monitors the environment and activity of the people in the home could provide an innovative way of assessing patients' surgical outcomes. At a time characterised by reduced mobility, functional limitations and increased pain, patients in this study relied on informal and formal supportive networks to help maintain the system through the busy trajectory of the perioperative period.

Comparison of Payment Margins Between the Bundled Payments for Care Improvement Initiative and the Comprehensive Care for Joint Replacement Model Shows a Marked Reduction for a Successful Program.

BACKGROUND: The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative. METHODS: The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed. RESULTS: The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%. CONCLUSIONS: These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs.

INTRODUCTION: An attractive option to reduce hospital length of stay (LOS) after hip or knee joint replacement (THA, TKA) is to follow the Enhanced Recovery After Surgery principles (ERAS) to improve patient experience to a level where they will feel confident to leave for home earlier. The objective of this study was to evaluate the implementation of short-stay protocol following the ERAS principles. HYPOTHESIS: We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital LOS and reduced direct health care costs compared to our standard procedure. MATERIAL AND METHODS: We compared the complications rated according to Clavien-Dindo scale, hospital LOS and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. RESULTS: Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital LOS for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p<0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489 CAD per THA and 4158 CAD per TKA. DISCUSSION: In many short-stay protocols, focus has shifted from ERAS goals of a reduction in complications and improved recuperation to use length of stay as the main factor of success. Implementation of an ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital LOS, but also in improved patient care and reduced direct health care costs. LEVEL OF EVIDENCE: Level II.

[Clinical Study of Enhanced Recovery after Surgery in Peri-operative Management of Total Hip Arthroplasty].

OBJECTIVE: To evaluate the clinical effect and rehabilitation benefit of enhanced recovery after surgery (ERAS) model in perioperative management of total hip arthroplasty (THA). METHODS: A retrospective study were conducted in THA patients from the database of big data Research Center of Biomedicine, West China Hospital of Sichuan University from 2013 to 2016. The differences of rehabilitation quality, rehabilitation efficiency and hospitalization cost between ERAS model (ERAS group) and traditional model (traditional group) were compared. RESULTS: 915 THA patients were included in the study, of which 497 patients were given ERAS peri-operative management and 418 patients in the traditional group. The rate of overall complications in the ERAS group was significantly lower than that in the traditional group (4.8% vs. 8.6%, P < 0.05), with lower rate of deep venous thrombosis (0.8% vs. 3.1%) and pulmonary infection (0.6% vs. 2.4%) in the ERAS group. Compared with the traditional group, the average length of stay in hospital was shorter in the ERAS group 〔(7.6±2.0) d vs. (10.9±2.9) d, P=0.039〕, as well as postoperative length of stay in hospital 〔(5.6±0.9) d vs. (8.6±2.0) d, P=0.028)〕. And the ERAS model reduced the total hospitalization cost by 4.8% to 7.1% (P < 0.05), of which the drug cost decreased by 17.2% to 24.9% (P < 0.05). CONCLUSIONS: ERAS model in THA is safe and effective. It can reduce hospitalization cost and help to control medical cost.

Assessment of functional recovery after total hip and knee arthroplasty: An observational study of 95 patients.

BACKGROUND: A significant proportion of patients experience functional limitations following total hip and knee arthroplasty (THA and TKA). The purpose of this study was to investigate prospectively the patient-reported and objectively assessed functional recovery following THA and TKA. METHODS: Patients were recruited at a regional Danish hospital, using a prospective, observational hypothesis-generating cohort design. Primary outcome measures were performance-based function (30-s chair-stand test) and self-reported physical function measured by the Hip Disability and Osteoarthritis Outcome Score (HOOS) for those who had undergone THA, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) for those who had undergone TKA. In addition, patient expectations, the "forgotten joint" scale and pain catastrophizing were measured. Outcome measures were collected at baseline (preoperatively) and at follow-up (4 months postoperatively). RESULTS: A total of 95 patients (59 who had undergone THA and 36 who had undergone TKA) were recruited. Performance-based function improved only slightly, with a mean difference of 2.9 (95% confidence interval [CI] 1.9, 4.0) for THAs and 1.6 (95% CI 0.4, 2.8) for TKAs. Self-reported physical function improved significantly, with a mean difference of 37.9 (95% CI 31.5, 44.3) for THAs and 28.6 (95% CI 22.7, 34.4) for TKAs. However, dividing the cohort into "improved" and "non-improved" groups based on changes in performance-based function, no clinically relevant predictors for poor performance-based outcome could be found. CONCLUSIONS: Self-reported outcome measures improved significantly following THA and TKA, whereas performance-based function improved only slightly by the 4-month follow-up. The subgroup that did not improve in performance-based function still reported significant improvements in self-reported outcome measures, demonstrating the difficulty in predicting optimal rehabilitation strategies after THA and TKA.

Use of Observation Status Versus Readmission in Elective Total Knee and Hip Arthroplasty Returns to Hospital: A Single-Institution Perspective.

BACKGROUND: The Affordable Care Act's Readmission Reduction Program (RRP) and ongoing transparency efforts to promote consumer-driven competition place significant institutional focus on improving 30-day readmission rates. It remains unclear whether the reduction in readmission rates subsequent to the RRP occurred due to improved quality and/or partly due to increased use of observation status in conditions that may have been classified as readmissions prior to the RRP. We hypothesize that a significant percentage of our institution's 30-day readmissions after elective total knee and hip arthroplasty (TKA/THA) overestimate the needs, duration, and complexity of the hospital-based intervention and inaccurately reflect the quality of service provided. METHODS: We performed a retrospective review of prospectively collected quality control data for 30-day returns to hospital after elective TKA/THA at our institution over a 2-year period. After stratification of the readmissions to under 48-hour and over 48-hour length of stay, we calculated the financial implications to our institution if the under 48-hour length of stay admissions were reclassified as an observation by applying discharge-weighted and payment-weighted analyses to the 2017 RRP report. We then calculated the out-of-pocket expenses for the under 48-hour Medicare subpopulation. RESULTS: We found that 16.7% of the 30-day readmissions after elective TKA/THA required a length of stay under 48 hours. If the short length of stay TKA/THA readmissions were reclassified as observations, our institution's 2018 RRP penalty would have been reduced to 39% or $334,512.28. However, this reclassification would result in an increase in out-of-pocket expenses by $540.25 (range $291.56-$1105.08) per patient. CONCLUSION: A subpopulation of 30-day readmissions does not require a level of care consistent with inpatient admission services. Classification of this short length of stay subpopulation as an observation vs an admission per Centers for Medicare and Medicaid Services guidelines would have removed our institution from the TKA/THA-specific RRP penalty. However, this would result in the unintended consequence of shifting costs, particularly self-administered drug costs, to patients.