Inflation-Adjusted Medicare Reimbursement for Revision Hip Arthroplasty: Study Showing Significant Decrease from 2002 to 2019.

BACKGROUND: Investigations into reimbursement trends for primary and revision arthroplasty procedures have demonstrated a steady decline over the past several years. Revision total hip arthroplasty (rTHA) due to infection (rTHA-I) has been associated with higher resource utilization and complexity, but long-term inflation-adjusted data have yet to be compared between rTHA-I and rTHA due to aseptic complications (rTHA-A). The present study was performed to analyze temporal reimbursement trends regarding rTHA-I procedures compared with those for rTHA-A procedures. METHODS: The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements associated with 1-stage and 2-stage rTHA-I as well as 1-stage rTHA-A procedures from 2002 to 2019. Current Procedural Terminology (CPT) codes for rTHA were grouped according to the American Academy of Orthopaedic Surgeons coding reference guide. Monetary values were adjusted for inflation using the consumer price index (U.S. Bureau of Labor Statistics; reported as 2019 U.S. dollars) and used to calculate the cumulative and average annual percent changes in reimbursement. RESULTS: Following inflation adjustment, the physician fee reimbursement for rTHA-A decreased by a mean [and standard deviation] of 27.26% ± 3.57% (from $2,209.11 in 2002 to $1,603.20 in 2019) for femoral component revision, 27.41% ± 3.57% (from $2,130.55 to $1,542.91) for acetabular component revision, and 27.50% ± 2.56% (from $2,775.53 to $2,007.61) for both-component revision. Similarly, for a 2-stage rTHA-I, the mean reimbursement declined by 18.74% ± 3.87% (from $2,063.36 in 2002 to $1,673.36 in 2019) and 24.45% ± 3.69% (from $2,328.79 to $1,755.45) for the explantation and reimplantation stages, respectively. The total decline in physician fee reimbursement for rTHA-I ($1,020.64 ± $233.72) was significantly greater than that for rTHA-A ($580.72 ± $107.22; p < 0.00001). CONCLUSIONS: Our study demonstrated a consistent devaluation of both rTHA-I and rTHA-A procedures from 2002 to 2019, with a larger deficit seen for rTHA-I. A continuation of this trend could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level. LEVEL OF EVIDENCE: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

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

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

Pre-operative optimisation for hip and knee arthroplasty: Minimise risk and maximise recovery.

BACKGROUND: Osteoarthritis of the hip and knee is a common cause of pain and reduced mobility. Arthroplasty reliably improves quality of life for most patients when non-operative measures have failed. However, hip and knee arthroplasties are major operations that carry significant risks, including the need for revision surgery. OBJECTIVE: The purpose of this article is to discuss pre-operative patient optimisation prior to arthroplasty to minimise risks and maximise recovery. DISCUSSION: Recent literature has identified a number of modifiable factors that increase the risk of post-operative complications following arthroplasty. These include obesity, diabetes, tobacco use, opioid use, anaemia, malnutrition, poor dentition and vitamin D deficiency. Addressing these factors prior to arthroplasty may reduce the risk of adverse outcomes. Pre-operative education and exercise, termed prehabilitation, has an important role in optimising patient outcomes following hip and knee arthroplasty. Participation in a prehabilitation program prior to arthroplasty is recommended.

Projections of Primary TKA and THA in Germany From 2016 Through 2040.

BACKGROUND: Future projections for both TKA and THA in the United States and other countries forecast a further increase of already high numbers of joint replacements. The consensus is that in industrialized countries, this increase is driven by demographic changes with more elderly people being less willing to accept activity limitations. Unlike the United States, Germany and many other countries face a population decline driven by low fertility rates, longer life expectancy, and immigration rates that cannot compensate for population aging. Many developing countries are likely to follow that example in the short or medium term amid global aging. Due to growing healthcare expenditures in a declining and aging population with a smaller available work force, reliable predictions of procedure volume by age groups are requisite for health and fiscal policy makers to maintain high standards in arthroplasty for the future population.Questions/purposes (1) By how much is the usage of primary TKA and THA in Germany expected to increase from 2016 through 2040? (2) How is arthroplasty usage in Germany expected to vary as a function of patient age during this time span? METHODS: The annual number of primary TKAs and THAs were calculated based on population projections and estimates of future healthcare expenditures as a percent of the gross domestic product (GDP) in Germany. For this purpose, a Poisson regression analysis using age, gender, state, healthcare expenditure, and calendar year as covariates was performed. The dependent variable was the historical number of primary TKAs and THAs performed as compiled by the German federal office of statistics for the years 2005 through 2016. RESULTS: Through 2040, the incidence rate for both TKA and THA will continue to increase annually. For TKA, the incidence rate is expected to increase from 245 TKAs per 100,000 inhabitants to 379 (297-484) (55%, 95% CI 21 to 98). The incidence rate of THAs is anticipated to increase from 338 to 437 (357-535) per 100,000 inhabitants (29% [95% CI 6 to 58]) between 2016 and 2040. The total number of TKAs is expected to increase by 45% (95% CI 14 to 8), from 168,772 procedures in 2016 to 244,714 (95% CI 191,920 to 312,551) in 2040. During the same period, the number of primary THAs is expected to increase by 23% (95% CI 0 to 50), from 229,726 to 282,034 (95% CI 230,473 to 345,228). Through 2040, the greatest increase in TKAs is predicted to occur in patients aged 40 to 69 years (40- to 49-year-old patients: 269% (95% CI 179 to 390); 50- to 59-year-old patients: 94% (95% CI 48 to 141); 60- to 69-year-old patients: 43% (95% CI 13 to 82). The largest increase in THAs is expected in the elderly (80- to 89-year-old patients (71% [95% CI 40 to 110]). CONCLUSIONS: Although the total number of TKAs and THAs is projected to increase in Germany between now and 2040, the increase will be smaller than that previously forecast for the United States, due in large part to the German population decreasing over that time, while the American population increases. Much of the projected increase in Germany will be from the use of TKA in younger patients and from the use of THA in elderly patients. Knowledge of these trends may help planning by surgeons, hospitals, stakeholders, and policy makers in countries similar to Germany, where high incidence rates of arthroplasty, aging populations, and overall decreasing populations are present. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Trends in the utilisation rates and acute hospital capacity needs for total hip replacements: results of an analysis of administrative data.

Total hip replacement surgery is the mainstay of treatment for end-stage hip arthritis. In 2014, there were 28227 procedures (incidence rate 252/100000 population). Using administrative data, we projected the future volume of total hip replacement procedures and incidence rates using two models. The constant rate model fixes utilisation rates at 2014 levels and adjusts for demographic changes. Projections indicate 32248 admissions by 2025 or an annual growth of 1.22% (incidence rate 273). The time trend model additionally projects the evolution in age-specific utilisation rates. 34895 admissions are projected by 2025 or an annual growth of 1.95% (incidence rate 296). The projections show a shift in performing procedures at younger age. Forecasts of length of stay indicate a substantial shortening. By 2025, the required number of hospital beds will be halved. Despite more procedures, capacity can be reduced, leading to organisational change (e.g. elective orthopaedic clinics) and more labour intensive stays.

Effects of an aging population on hospital costs related to elective hip replacements.

OBJECTIVES: Elective hip replacement is a common procedure for elderly people with osteoarthrosis. With more elderly people in the future, the demand for hip replacements will increase and put additional constraints on hospital services. The objective was to explore the future need for hip replacements and related costs and to investigate if anticipated future efficiency gains might alleviate the strain of increased demand. STUDY DESIGN: Registry-based modelling study. METHODS: Data were obtained from the Irish Central Statistics Office and the national Hospital Inpatient Enquiry system for 2011-2017. We estimated the future demand for hip replacements each year until 2051 and analysed changes in hip replacement rates and the average length of stay. These assumptions were used in our projections. RESULTS: Assuming no change in procedure rates, the annual cost of providing elective hip replacements is expected to increase by 1060 (30%) episodes in 2026 which implies a cost increment of €16M (33%) (vs 2017-level). If the historical increase in the procedure rate is assumed, the cost will increase by €33M (67%). If the observed reduction in length of stay can be maintained, costs will reduce by €14M (29.0%). Such a cost saving may alleviate the effect of the demographic changes and observed increases in procedure rates. CONCLUSIONS: Steady-state assumptions are unrealistic and efficiency gains can alleviate future pressure from population growth. However, this analysis has not addressed the present insufficient capacity of public hospitals to meet population needs, as judged by waiting lists and transfers to private hospitals.

Comparison of Hospital Readmission After Total Hip and Total Knee Arthroplasty vs Spinal Surgery After Implementation of the Hospital Readmissions Reduction Program.

Importance: The Hospital Readmissions Reduction Program (HRRP) was recently expanded to penalize excessive readmissions after total hip arthroplasty (THA) and total knee arthroplasty (TKA). These are the first surgical procedures to be included in the HRRP. Objective: To determine whether the HRRP was associated with a greater decrease in readmissions after targeted procedures (THA and TKA) compared with similar nontargeted procedures (lumbar spine fusion and laminectomy). Design, Setting, and Participants: A retrospective cohort study was conducted of patients 50 years or older among all payers in the Nationwide Readmissions Database who underwent THA, TKA, lumbar spine fusion, or laminectomy between January 1, 2010, and September 30, 2015. Multivariable logistic regression and interrupted time-series models were used to calculate and compare 30-day readmission trends in 3 periods associated with the HRRP: preimplementation (January 2010-September 2012), implementation (October 2012-September 2014), and penalty (October 2014-September 2015). Statistical analysis was performed from January 1, 2010, to September 30, 2015. Exposures: Announcement and implementation of the HRRP. Main Outcomes and Measures: Readmission within 30 days after hospitalization for THA, TKA, lumbar spine fusion, or laminectomy surgery. Results: The study included 6 687 077 (58.3% women and 41.7% men; mean age, 66.7 years; 95% CI, 66.7-66.8 years) weighted hospitalizations for THA, TKA, lumbar spine fusion, and laminectomy surgery: 4 765 466 hospitalizations for targeted conditions and 1 921 611 for nontargeted conditions. After passage of the Patient Protection and Affordable Care Act, the risk-adjusted rates of readmission after all procedures decreased in a similar fashion. Implementation of the HRRP was associated with a 0.018% per month decrease in the rate of readmission (95% CI, -0.025% to -0.010%) after targeted procedures, which was not observed after nontargeted procedures (slope per month, -0.003%; 95% CI, -0.016% to 0.010%). Penalties were not associated with a greater decrease in readmission for either targeted or nontargeted procedures. Conclusions and Relevance: These results appear to be consistent with hospitals responding to the future possibility of penalties by reducing readmissions after surgical procedures targeted by the HRRP.

Outpatient Joint Arthroplasty-Patient Selection: Update on the Outpatient Arthroplasty Risk Assessment Score.

BACKGROUND: The Outpatient Arthroplasty Risk Assessment (OARA) score was designed to identify patients medically appropriate for same- and next-day discharge after surgery. The purpose of this study was to update and confirm the greater predictive utility of the OARA score in relation to American Society of Anesthesiologists Physical Status (ASA-PS) classification for same-day discharge and to identify the optimal preoperative OARA score for safe patient selection for outpatient surgery. METHODS: The perioperative medical records of 2051 primary total joint arthroplasties performed by a single surgeon at an academic tertiary care hospital were retrospectively reviewed. Six statistical measures were calculated to examine OARA score performance in binary classification of successful same-day discharge and preoperative OARA scores equal to 0 to 59 points (yes vs no) vs 0 to 79 points (yes vs no). RESULTS: Mean OARA scores increased more sharply in magnitude with increasing length of stay, providing superior discrimination than the ASA-PS classification with respect to same-day discharge. Preoperative OARA scores up to 79 points approached the desired 100% for positive predictive value (98.8%) and specificity (99.3%) and 0% for false positive rates (0.7%). CONCLUSION: The OARA score was designed to err in the direction of medical safety, and OARA scores between 0 and 79 are conservatively highly effective for identifying patients who can safely elect to undergo outpatient total joint arthroplasty. The ASA-PS classification does not provide sufficient discrimination for safely selecting patients for outpatient arthroplasty.

The projected burden of primary total knee and hip replacement for osteoarthritis in Australia to the year 2030.

BACKGROUND: Comprehensive national joint replacement registries with well-validated data offer unique opportunities for examining the potential future burden of hip and knee osteoarthritis (OA) at a population level. This study aimed to forecast the burden of primary total knee (TKR) and hip replacements (THR) performed for OA in Australia to the year 2030, and to model the impact of contrasting obesity scenarios on TKR burden. METHODS: De-identified TKR and THR data for 2003-2013 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population projections and obesity trends were obtained from the Australian Bureau of Statistics, with public and private hospital costs sourced from the National Hospital Cost Data Collection. Procedure rates were projected according to two scenarios: (1) constant rate of surgery from 2013 onwards; and (2) continued growth in surgery rates based on 2003-2013 growth. Sensitivity analyses were used to estimate future TKR burden if: (1) obesity rates continued to increase linearly; or (2) 1-5% of the overweight or obese population attained a normal body mass index. RESULTS: Based on recent growth, the incidence of TKR and THR for OA is estimated to rise by 276% and 208%, respectively, by 2030. The total cost to the healthcare system would be $AUD5.32 billion, of which $AUD3.54 billion relates to the private sector. Projected growth in obesity rates would result in 24,707 additional TKRs totalling $AUD521 million. A population-level reduction in obesity could result in up to 8062 fewer procedures and cost savings of up to $AUD170 million. CONCLUSIONS: If surgery trends for OA continue, Australia faces an unsustainable joint replacement burden by 2030, with significant healthcare budget and health workforce implications. Strategies to reduce national obesity could produce important TKR savings.

Certificate-of-Need State Laws and Total Hip Arthroplasty.

BACKGROUND: Many states have certificate-of-need (CON) programs requiring governmental approval to open or expand healthcare services, with the goal of limiting cost and coordinating utilization of healthcare resources. The purpose of the present study was to evaluate the associations between these state-level CON regulations and total hip arthroplasty (THA). METHODS: States were designated as CON or non-CON based on existing laws. The 100% Medicare Standard Analytic Files from 2005 to 2014 were used to compare THA procedure volumes, charges, reimbursements, and distribution of procedures based on facility volumes between the CON and non-CON states. Adverse postoperative outcomes were also analyzed. RESULTS: The per capita incidence of THA was higher in non-CON states than CON states at each time period and overall (P < .0001). However, the rate of change in THA incidence over the time period was higher in CON states (1.0 per 10,000 per year) compared to non-CON states (0.68 per 10,000 per year) although not statistically significant. Length of stay was higher and a higher percentage of patients received care in high-volume hospitals in CON states (both P < .0001). No meaningful differences in postoperative complications were found. CONCLUSION: CON laws did not appear to have limited the growth in incidence of THA nor improved quality of care or outcomes during the study time period. It does appear that CON laws are associated with increased concentration of THA procedures at higher volume facilities. Given the inherent potential confounding population and geographic factors, additional research is needed to confirm these findings.

Ten-year epidemiological study in an orthopaedic and trauma surgery centre: Are there risks involved in increasing scheduled arthroplasty volume without increasing resources?

BACKGROUND: Current trends in patient management include decreasing hospital stay lengths and reductions in available material and human resources. A shortening of hospital stays in university hospitals has been documented over the last decade. However, to our knowledge, no study has assessed possible relationships linking shorter stays to staffing levels or complication rates. The objectives of this study were: 1) to assess changes in case volume in a university orthopaedics and trauma surgery department between 2006 and 2016, 2) and to look for correlations linking these changes to staffing levels and the rates of significant complications, including the number of hip dislocations after total hip arthroplasty (THA) and the number of infections and complications resulting in malpractice litigation after hip, knee, or shoulder arthroplasty. HYPOTHESIS: The case volume increased during the study period, whereas resources remained unchanged or decreased. MATERIAL AND METHODS: A retrospective study was performed using the electronic database of an orthopaedics and trauma surgery department. Data collected between 2006 and 2016 were analysed. Mean hospital stay length, patient age, and surgical volume were recorded, and changes over time in case volume for trauma surgery and scheduled arthroplasties were evaluated. Changes in staffing levels and rates of complications (dislocation after THA and infections and complications resulting in malpractice litigation) between 2006 and 2016 were assessed. Only arthroplasty procedures performed in the department were considered for the study of complications and litigation. RESULTS: Between 2006 and 2016, mean hospital stay decreased from 8.7±10.8 days (range, 0-141 days) in to 7.0±9.4 days (range, 0-150 days). Mean patient age increased from 54.4±21.2 years (range, 11.7-100.9 years) in 2006 to 59.3±20.9 years (range, 13.2-103.1 years) in 2016. The total number of procedures rose from 2158 in 2006 to 3100 in 2016 (+43.6%). The number of THAs increased by 16.2% and the number of total knee arthroplasties by 96.7%. The number of operations for trauma increased from 725 in 2006 to 1135 in 2016 (+56.0%). During the study period, the number of hospital beds declined from 70 to 55. No increase was seen in the frequencies of dislocation after THA (3/284 [1.4%] in 2006 and 4/330 [1.2%] in 2016) or prosthetic joint infection (5/439 [1.1%] in 2006 and 6/657 [0.9%] in 2016). In contrast, malpractice suits filed by patients after arthroplasty increased from 1/439 (0.2%) in 2006 to 8/657 (1.2%) in 2016. CONCLUSION: Over the last decade, trauma and arthroplasty surgical volumes increased substantially, whereas staffing levels remained unchanged and number of beds diminished. The frequency of significant complications such as dislocation after THA did not increase. In contrast, a marked rise was seen in malpractice litigation. However, the increased volume with unchanged resources found in this study should be interpreted in the light of the marked increase in patient dependency and of our role as a referral centre managing patients with complications after surgery performed at other institutions. LEVEL OF EVIDENCE: IV, retrospective observational study.

Trends in Total Hip Arthroplasty Under the Patient Protection and Affordable Care Act: A National Database Analysis Between 2008 and 2015.

The Patient Protection and Affordable Care Act expanded health coverage for low-earning individuals and families. With more Americans having access to care, the use of elective procedures, such as total hip arthroplasty (THA), was expected to increase. Therefore, the aim of this study was to evaluate trends in THA before and after the initiation of the Patient Protection and Affordable Care Act regarding race, age, body mass index, and sex between 2008 and 2015. The National Surgical Quality Improvement Program database was queried for all individuals who had undergone primary THA between 2008 and 2015. This yielded a total of 104,209 patients. Descriptive statistics were used to analyze patient-level data. A Cochran-Armitage test assessed trends in categorical data points over time. Analysis indicated an increased percentage of blacks or African Americans undergoing THA (7.8% vs 9.2%, P<.001), followed by Native Americans or Pacific Islanders (0.0% vs 0.4%, P<.001), American Indians or Alaskan Natives (0.3% vs 0.5%, P=.016), and Asians (1.4% vs 1.5%, P=.002). An increased percentage of patients 55 to 80 years old received THAs (68.6% vs 74.1%, P<.001). The percentage of patients with a body mass index of 25.0 to 29.9 kg/m2, 30.0 to 34.9 kg/m2, and 35.0 to 39.9 kg/m2 increased (32.9% vs 33.1%, 24.2% vs 25.6%, 12.6% vs 13.3%, respectively, P<.001 for all). These findings may provide insight on the changing patient characteristics for orthopedic surgeons performing THA. Furthermore, these findings may inform health policy makers interested in increasing access to procedures underutilized by specific patient populations and the creation of strategies to meet increased demand. [Orthopedics. 2018; 41(4):e534-e540.].

Time Trends in Characteristics of Patients Undergoing Primary Total Hip and Knee Arthroplasty in California, 2007-2010.

BACKGROUND: As the number of total hip and knee arthroplasty cases increases, it is important to understand the burden of factors that impact patient outcomes of these procedures. This article examined the time trends in key demographics, clinical characteristics, comorbidity burden (Deyo-Charlson Comorbidity Index [CCI]), and presence of depression in patients undergoing primary total hip arthroplasty and total knee arthroplasty using population-based, all-payer inpatient database, California Healthcare Cost and Utilization Project, from 2007 to 2010. METHODS: Chi-square tests and analysis of variance were used. Multivariate logistic regression analyses were also performed to compare the prevalence of depression in 2007 to later years. RESULTS: In the primary total hip arthroplasty cohort, the prevalence of depression significantly increased by 20%, mean age decreased by 0.4 years, mean length of stay (LOS) decreased by 0.5 days, and having a CCI score of ≥3 increased by 30% (P value < .001 for all) over the study period. Similarly, in the primary total knee arthroplasty cohort, the prevalence of depression increased by 23%, the mean age decreased by 0.4 years, mean LOS decreased by 0.4 days, and the prevalence of CCI score of ≥3 increased by 35% (P value < .001 for all). CONCLUSION: Despite the younger age of the joint arthroplasty population over time, we found increased prevalence of depression and comorbidity scores but shorter LOS. Further study is needed to determine the impact of the changing demographics of the total joint population and the best strategies to optimize their outcome with these procedures.

Trends and Economic Impact of Hip and Knee Arthroplasty in Central Europe: Findings from the Austrian National Database.

Arthroplasty registers were originally established in Scandinavia to receive clinically relevant information from pooled data, to improve quality and reduce revision surgeries, with socioeconomic benefit. In Austria, where the highest rate of total knee arthroplasties (TKA) per inhabitant of all OECD countries was reached in 2014, arthroplasties are centrally reported since 2009. Study purpose was to perform the first analysis of the Austrian database, aiming to obtain data on trends in arthroplasty in Austria over time in relation to demographic development. Between 2009 and 2015 an almost continuous increase of total hip arthroplasties (THA; 18.052) by 14% and TKA (17.324) by 13% were observed, representing 210 THA and 202 TKA per 100k inhabitants in 2015. A similar increase was found for revision surgeries, with 1.290 re-implanted THA (7.1% of all THA) and 919 re-implanted TKA (5.3% of all TKA) in 2015. Implantation of mega or tumor prosthesis for the knee and hip joint remained constant and was mainly performed in two university hospitals. Patellar resurfacing decreased by 31.6%. Demographic development will further increase the number of primary and revision surgeries. Inclusion of more detailed information on used and revised components was established and will improve efficacy in quality control.

Trends in Medicare Reimbursement for Orthopedic Procedures: 2000 to 2016.

Understanding trends in reimbursement is critical to the financial sustainability of orthopedic practices. Little research has examined physician fee trends over time for orthopedic procedures. This study evaluated trends in Medicare reimbursements for orthopedic surgical procedures. The Medicare Physician Fee Schedule was examined for Current Procedural Terminology code values for the most common orthopedic and nonorthopedic procedures between 2000 and 2016. Prices were adjusted for inflation to 2016-dollar values. To assess mean growth rate for each procedure and subspecialty, compound annual growth rates were calculated. Year-to-year dollar amount changes were calculated for each procedure and subspecialty. Reimbursement trends for individual procedures and across subspecialties were compared. Between 2000 and 2016, annual reimbursements decreased for all orthopedic procedures examined except removal of orthopedic implant. The orthopedic procedures with the greatest mean annual decreases in reimbursement were shoulder arthroscopy/decompression, total knee replacement, and total hip replacement. The orthopedic procedures with the least annual reimbursement decreases were carpal tunnel release and repair of ankle fracture. Rate of Medicare procedure reimbursement change varied between subspecialties. Trauma had the smallest decrease in annual change compared with spine, sports, and hand. Annual reimbursement decreased at a significantly greater rate for adult reconstruction procedures than for any of the other subspecialties. These findings indicate that reimbursement for procedures has steadily decreased, with the most rapid decrease seen in adult reconstruction. [Orthopedics. 2018; 41(2):95-102.].

Technology-Assisted Hip and Knee Arthroplasties: An Analysis of Utilization Trends.

BACKGROUND: Robotic and computer navigation technology is available to surgeons for use in hip and knee arthroplasties to increase the precision of component placement. However, they do add significant costs to these procedures, and the long-term clinical outcomes and value of technology assistance for joint replacement remain unclear. METHODS: We identified 321,522 patients in Medicare Severity Diagnosis Related Groups 469 and 470 who underwent primary total hip arthroplasty (N = 133,472) or primary total or unicompartmental knee arthroplasty (N = 188,050) between 2008 and 2015 in the New York Statewide Planning and Research Cooperative System (SPARCS). RESULTS: Among all total joint arthroplasties performed during this period, technology assistance was used in 5.1% of cases. Technology assistance was more common for knee (7.3%) than hip (1.9%) arthroplasty (P < .001). The proportion of cases using technology assistance grew each year, increasing from 2.8% (knee 4.3% and hip 0.5%) in 2008 to 8.6% (knee 11.6% and hip 5.2%) in 2015 (P trend <.001). The proportion of hospitals and surgeons using robotic assistance also increased during the study period, increasing from 16.2% of hospitals and 6.2% of surgeons in 2008 to 29.2% of hospitals and 17.1% of surgeons in 2015 (P trend <.001 for both). Technology was more likely to be used for patients with private insurance (5.9%) compared with Medicare (4.7%, P < .001) or Medicaid (2.2%, P < .001), and for patients at high-volume (6.9%, P < .001) or very high-volume (6.1%, P < .001) as compared with low-volume (2.7%) hospitals. CONCLUSION: Technology assistance has become increasingly used by orthopedic surgeons for hip and knee arthroplasties, however, adoption has not been uniform.

Supervised neuromuscular exercise prior to hip and knee replacement: 12-month clinical effect and cost-utility analysis alongside a randomised controlled trial.

BACKGROUND: There are indications of beneficial short-term effect of pre-operative exercise in reducing pain and improving activity of daily living after total hip replacement (THR) and total knee replacement (TKR) surgery. Though, information from studies conducting longer follow-ups and economic evaluations of exercise prior to THR and TKR is needed. The aim of the study was to analyse 12-month clinical effect and cost-utility of supervised neuromuscular exercise prior to THR and TKR surgery. METHODS: The study was conducted alongside a randomised controlled trial including 165 patients scheduled for standard THR or TKR at a hospital located in a rural area of Denmark. The patients were randomised to replacement surgery with or without an 8-week preoperative supervised neuromuscular exercise program (Clinical Trials registration no.: NCT01003756). Clinical effect was measured with Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee injury and Osteoarthritis Outcome Score (KOOS). Quality adjusted life years (QALYs) were based on EQ-5D-3L and Danish preference weights. Resource use was extracted from national registries and valued using standard tariffs (2012-EUR). Incremental net benefit was analysed to estimate the probability for the intervention being cost effective for a range of threshold values. A health care sector perspective was applied. RESULTS: HOOS/KOOS quality of life [8.25 (95% CI, 0.42 to 16.10)] and QALYs [0.04 (95% CI, 0.01 to 0.07)] were statistically significantly improved. Effect-sizes ranged between 0.09-0.59 for HOOS/KOOS subscales. Despite including an intervention cost of €326 per patient, there was no difference in total cost between groups [€132 (95% CI -3942 to 3679)]. At a threshold of €40,000, preoperative exercise was found to be cost effective at 84% probability. CONCLUSION: Preoperative supervised neuromuscular exercise for 8 weeks was found to be cost-effective in patients scheduled for THR and TKR surgery at conventional thresholds for willingness to pay. One-year clinical effects were small to moderate and favoured the intervention group, but only statistically significant for quality of life measures. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT01003756 ) October 28, 2009.

Equity of publicly-funded hip and knee joint replacement surgery in New Zealand: results from a national observational study.

AIM: This study examines equity in the provision of publicly-funded hip and knee total joint replacement (TJR) surgery in New Zealand between 2006 and 2013 to: 1) investigate national rates by demographic characteristics; 2) describe changes in national rates over time; and 3) compare rates of provision between District Health Boards (DHBs). METHODS: Hospital discharge data for people aged 20 years or over who had at least one hip or knee TJR between 2006 and 2013 was obtained from the Ministry of Health's National Minimum Dataset. RESULTS: Higher TJR rates were observed among those aged 75-84 years, females, those of Maori ethnicity, those not living in rural or main urban areas and those in the most deprived socio-economic groups. TJRs increased from 7,053 in 2006 to 8,429 in 2013, however the rate was highest in 2007. In 2012-13, age-ethnicity-standardised rates varied between DHBs from 196 to 419/100,000 person years, with larger DHBs having lower rates than smaller DHBs. CONCLUSION: There was evidence of geographic inequity in TJR provision across New Zealand. Despite increased numbers of procedures, rates of publicly-funded TJR surgery are barely keeping up with population increases. Reasons behind differences in provision should be examined.

National Trends in Primary Total Hip Arthroplasty in Extremely Young Patients: A Focus on Bearing Surface Usage From 2009 to 2012.

BACKGROUND: The ideal bearing surface for primary total hip arthroplasty (THA) in young patients remains a debate. Data on recent national trends are lacking. The purpose of this study is to provide an analysis on the national epidemiologic trends of bearing surface usage in patients aged ≤30 years undergoing THA from 2009 through 2012. METHODS: Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2009 to 2012, 9265 THA discharges (4210 coded by bearing surface) were identified in patients aged ≤30 years. Prevalence of surface type was analyzed along with patient and hospital demographic data. Statistical analysis was performed using SAS (SAS version 9.1; SAS, Inc, Cary, NC). Significance was set at P < .05. RESULTS: Ceramic-on-polyethylene (CoP) bearing surfaces were most commonly used, representing 35.6% of cases, followed by metal-on-polyethylene (MoP; 28.0%), metal-on-metal (MoM; 19.3%), and ceramic-on-ceramic (CoC; 17.0%) bearing surfaces. Hard-on-hard bearing surfaces (MoM and CoC) represented only 36.4% of cases, a significant decrease from previously reported findings (2006-2009) where hard-on-hard bearing surfaces were the majority (62.2%; P < .05). Hard-on-hard bearing surface usage decreased from 2009 to 2012 (MoM: 29.7% to 10.2%; CoC: 20.0% to 14.7%), whereas hard-on-soft bearing surface usage (MoP and CoP) increased. CoP bearing surfaces saw the most significant increase from 25.7% in 2009 to 48.2% in 2012. A cost analysis revealed that CoP discharges were associated with higher hospital charges than other surface types, with an average charge of $66,457 (P < .05). CONCLUSION: Use of hard-on-hard surfaces has decreased significantly in this population, whereas CoP and MoP surfaces have become increasingly common. Determining the optimal bearing surface for extremely young patients continues to be a challenge for orthopedic surgeons as they weigh the risks and benefits of each.

The Effects of Hospital Closure on the Local Utilization of Total Joint Replacement The Queens Experience.

Since 2000, 31 hospitals have closed in New York State. This has primarily been due to the financial difficulties endured by these institutions, many of which were located in areas inhabited predominantly by patients of lower socioeconomic status. Additionally, recommendations by the NYS Depart- ment of Health (Berger Commission) cited excess hospital capacity as a driver for the struggles of the healthcare delivery system in New York, forcing financially stable in - stitutions to close their doors as well. Data has shown that outcomes are improved when complex procedures, such as joint arthroplasty, are performed at high volume hospitals. However, for patients in the outer boroughs of NYC, travel to these specialized centers may be too expensive and physi- cally difficult for poor patients with severe osteoarthritis. Using the SPARCS database, we identified a temporary decrease in utilization of lower extremity total joint replace - ment in the areas immediately adjacent to closed hospitals. This does not appear to have a lasting effect as illustrated by quick return back to pre-closure trends and further in- crease when compared with regional trends. This effect is more pronounced in urban areas where public transportation and traffic are more of an issue for patients, making it more difficult to travel with the goal of seeking care elsewhere.