Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.

Importance: The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective: To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants: This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results: The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance: Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Examination of total hip and knee arthroplasty tissues.

BACKGROUND: Many practices require tissues from hip and knee arthroplasty procedures to be sent for pathologic examination. These examinations rarely provide information beyond the clinical or radiologic diagnosis and rarely alter clinical management. We aimed to determine the rate at which histologic diagnoses based on gross assessment alone or gross plus microscopic assessment correspond with reported clinical diagnoses in patients undergoing total joint arthroplasties and whether the histologic diagnoses alter patient management. METHODS: We retrospectively reviewed arthroplasty cases performed at a high-volume teaching hospital in Manitoba, Canada. The clinical diagnosis was compared with the final pathology report based on gross examination, with or without histologic assessment. The results of the comparison were classified into 3 categories: concordant (same diagnosis), discrepant (different diagnoses without alterations in management) and discordant (different diagnoses resulting in management change). The overall provincial cost for pathologic examination was determined by multiplying the total examination cost by the estimated number of arthroplasty cases. RESULTS: There were 773 patients in our study sample. The concordant rate was 98.3% (95% confidence interval [CI] 97.1%-99.1%), the discrepant rate was 1.7% (95% CI 0.9%-2.9%) and the discordant rate was 0.0% (95% CI 0%-0.5%) for 773 cases. The pathology diagnosis did not alter patient management in any case. A total of 91.5% of specimens did not require full histologic review and received gross descriptions only. The discrepancy rate was higher in cases that included microscopic examination than in those that received only gross descriptions (15.2% v. 0.4%, p < 0.001). The overall provincial cost for pathologic examination was estimated at Can$304 556. CONCLUSION: Submitting routine tissue from arthroplasty procedures to pathology does not affect patient management and therefore provides no value for the health care resources expended in doing so.

CONTEXTE: Beaucoup d'établissements exigent que des tissus soient envoyés pour un examen anatomopathologique après une arthroplastie de la hanche et du genou. Ces examens n'apportent généralement pas d'information nouvelle quant au diagnostic clinique ou radiologique et modifient rarement la prise en charge. Notre objectif était de déterminer le pourcentage de correspondance entre les diagnostics histologiques fondés sur l'inspection grossière uniquement ou sur l'inspection grossière et l'examen au microscope, et les diagnostics cliniques des patients qui subissent des arthroplasties totales. Nous cherchions également à savoir si les diagnostics histologiques modifient la prise en charge. MÉTHODES: Nous avons procédé à une analyse rétrospective d'arthroplasties effectuées dans un grand hôpital universitaire du Manitoba, au Canada. Le diagnostic clinique était comparé au rapport final de pathologie fondé sur une inspection grossière, avec ou sans examen histologique. Les résultats de cette comparaison étaient classés en 3 catégories : concordance (même diagnostic), divergence (diagnostics différents, sans modification de la prise en charge) et discordance (diagnostics différents entraînant une modification de la prise en charge). Le coût global pour la province associé aux examens pathologiques a été établi en multipliant le coût total d'un examen par le nombre estimé de cas d'arthroplastie. RÉSULTATS: Notre échantillon comprenait 773 patients. Le taux de concordance était de 98,3 % (intervalle de confiance [IC] de 95 % 97,1 %­99,1 %), le taux de divergence était de 1,7 % (IC de 95 % 0,9 %­2,9 %) et le taux de discordance de 0,0 % (IC de 95 % 0 %­0,5 %). Dans tous les cas, le diagnostic pathologique n'a pas modifié la prise en charge. Au total, 91,5 % des spécimens ne nécessitaient pas d'examen histologique complet et n'ont fait l'objet que d'une inspection grossière. Le pourcentage d'anomalie était plus élevé pour les spécimens analysés au microscope que pour ceux ayant uniquement subi une inspection grossière (15,2 % c. 0,4 %, p < 0,001). Le coût total des examens pathologiques pour la province a été estimé à 304 556 $ CA. CONCLUSION: L'analyse pathologique systématique de tissus prélevés lors d'arthroplasties n'entraîne pas une modification de la prise en charge du patient; il n'y a donc pas de valeur associée aux ressources de santé utilisées pour ces examens.

Quality Measure Public Reporting Is Associated with Improved Outcomes Following Hip and Knee Replacement.

BACKGROUND: Given the inclusion of orthopaedic quality measures in the Centers for Medicare & Medicaid Services national hospital payment programs, the present study sought to assess whether the public reporting of total hip arthroplasty (THA) and total knee arthroplasty (TKA) risk-standardized readmission rates (RSRRs) and complication rates (RSCRs) was temporally associated with a decrease in the rates of these outcomes among Medicare beneficiaries. METHODS: Annual trends in national observed and hospital-level RSRRs and RSCRs were evaluated for patients who underwent hospital-based inpatient hip and/or knee replacement procedures from fiscal year 2010 to fiscal year 2016. Hospital-level rates were calculated with use of the same measures and methodology that were utilized in public reporting. Annual trends in the distribution of hospital-level outcomes were then examined with use of density plots. RESULTS: Complication and readmission rates and variation declined steadily from fiscal year 2010 to fiscal year 2016. Reductions of 33% and 25% were noted in hospital-level RSCRs and RSRRs, respectively. The interquartile range decreased by 18% (relative reduction) for RSCRs and by 34% (relative reduction) for RSRRs. The frequency of risk variables in the complication and readmission models did not systematically change over time, suggesting no evidence of widespread bias or up-coding. CONCLUSIONS: This study showed that hospital-level complication and readmission rates following THA and TKA and the variation in hospital-level performance declined during a period coinciding with the start of public reporting and financial incentives associated with measurement. The consistently decreasing trend in rates of and variation in outcomes suggests steady improvements and greater consistency among hospitals in clinical outcomes for THA and TKA patients in the 2016 fiscal year compared with the 2010 fiscal year. The interactions between public reporting, payment, and hospital coding practices are complex and require further study. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Resource evaluation framework for total knee arthroplasty.

PURPOSE: This article describes a framework for evaluating efficiency of OR procedures incorporating time measurement, personnel activity, and resource utilization using traditional industrial engineering tools of time study and work sampling. METHODS: The framework measures time using time studies of OR procedures and work sampling of personnel activities, ultimately classified as value-added or non-value-added. Statistical methods ensure that the collected samples meet adequate levels of confidence and accuracy. Resource utilization is captured through documentation of instrument trays used, defects in instruments, and trash weight and classification at the conclusion of surgeries. FINDINGS: A case study comprising 12 observations of total knee arthroplasty surgeries illustrates the use of the framework. The framework allows researchers to compare time, personnel, and resource utilization simultaneously within the OR setting. PRACTICAL IMPLICATIONS: The framework provides a holistic evaluation of methods, instrumentation and resources, and staffing levels and allows researchers to identify areas for efficiency improvement. ORIGINALITY/VALUE: The methods presented in this article are rooted in traditional industrial engineering work measurement methods but are applied to a healthcare setting in order to efficiently identify areas for improvement including time, personnel, and processes in operating rooms.

Spending And Quality After Three Years Of Medicare's Voluntary Bundled Payment For Joint Replacement Surgery.

Medicare has reinforced its commitment to voluntary bundled payment by building upon the Bundled Payments for Care Improvement (BPCI) initiative via an ongoing successor program, the BPCI Advanced Model. Although lower extremity joint replacement (LEJR) is the highest-volume episode in both BPCI and BPCI Advanced, there is a paucity of independent evidence about its long-term impact on outcomes and about whether improvements vary by timing of participation or arise from patient selection rather than changes in clinical practice. We found that over three years, compared to no participation, participation in BPCI was associated with a 1.6 percent differential decrease in average LEJR episode spending with no differential changes in quality, driven by early participants. Patient selection accounted for 27 percent of episode savings. Our findings have important policy implications in view of BPCI Advanced and its two participation waves.

Association of Mandatory Bundled Payments for Joint Replacement With Use of Postacute Care Among Medicare Advantage Enrollees.

Importance: In 2016, the Centers for Medicare & Medicaid Services introduced mandatory bundled payments for knee and hip replacement surgical procedures among traditional Medicare (TM) patients in randomly selected areas. The association of bundled payments with outcomes among patients enrolled in Medicare Advantage (MA) is not known. Objective: To determine the association of bundled payments for joint replacement surgical procedures with the use of postacute care (PAC) services among MA patients. Design, Setting, and Participants: This cohort study used difference-in-differences analysis to evaluate changes in PAC use among patients enrolled in Medicare who underwent joint replacement operations before and after the introduction of bundled payments (ie, from January 1, 2013, to September 30, 2017). A total of 75 metropolitan statistical areas were randomized to participate in the bundled payment program, with 121 areas serving as controls. Data were analyzed between September 15, 2018, and October 1, 2019. Exposure: Bundled payments for hip and knee joint replacement operations, in which hospitals received a single payment to cover all costs associated with a joint replacement and associated care for the 90 days after surgery. Main Outcomes and Measures: The primary outcomes were discharge to any institutional PAC setting and days spent in institutional PAC within 90 days after surgery. Secondary outcomes included discharge and days spent in specific PAC settings (ie, home health, skilled nursing facility, inpatient rehabilitation). Results: Of 1 536 387 individuals who underwent hip and knee join replacement surgery, 493 977 (32.2%) were enrolled in MA (mean [SD] age, 73.3 [8.4] years; 386 699 [63.5%] women; 55 078 [6.4%] black) and 1 042 410 (67.8%) were enrolled in TM (mean [SD] age, 73.3 [8.7] years, 829 014 [65.2%] women; 82 890 [9.4%] black). Among MA patients, bundled payments were associated with a reduction of 1.5 (95% CI, 1.0-2.0) percentage points in discharge to an institutional PAC setting (P < .001) and an estimated reduction of 0.3 (95% CI, 0.2-0.5) days spent in an institutional PAC setting (P < .001), a 5.6% relative reduction. Among TM patients, bundled payments were associated with a reduction of 2.6 (95% CI, 2.2-2.9) percentage points in institutional PAC discharge (P < .001) and a reduction of 0.8 (95% CI, 0.7-0.9) days spent in an institutional PAC setting (P < .001), a 2.5% relative reduction. These changes were larger in hospitals with greater proportions of TM patients. In hospitals with low concentrations of MA patients, time spent in institutional PAC settings decreased by 0.9 days among TM patients and 0.8 days among MA patients; in hospitals with high MA concentrations, time spent in institutional PAC settings decreased by 0.6 days for TM patients and 0.2 days for MA patients. Conclusions and Relevance: In this study, the first 18 months of the Centers for Medicare & Medicaid Services bundled payment program for joint replacement surgery were associated with reductions in the use of institutional PAC among MA patients. Past evaluations of bundled payments that focused on TM patients may not have measured the full consequences of this alternative payment model.

Patient Attitudes Toward Resident and Fellow Participation in Orthopedic Surgery.

BACKGROUND: Residents' and fellows' participation in orthopedic surgery is a potential source of anxiety and concern for patients. The purpose of this study was to determine patients' attitudes toward trainee involvement in orthopedic surgery, surgeons as educators, and disclosure of trainee involvement. METHODS: Three hundred two consecutive patients with preoperative and postoperative appointments at three arthroplasty practices in academic medical centers were surveyed with an anonymous, self-administered questionnaire. The questionnaire was developed in consultation with an expert in survey design. RESULTS: Two hundred thirty-four patients completed the questionnaire (response rate 77.5%). Respondents were 60.5% female, 79.6% white, 66.5% privately insured, and 82.8% had at least some college education. About 65.9% of the respondents felt that surgeons who teach are better surgeons. Nearly all felt residents and fellows should perform surgeries as part of their education (94.1% and 95.3%, respectively). However, 39.7% of the respondents were not satisfactory with a second-year resident assisting in their own surgery. Patients dissatisfied with their most recent orthopedic surgery were more likely to respond that they did not want residents helping with their surgery. Respondents agreed that resident or fellow involvement in surgery should be disclosed (92.2% and 90.1%, respectively). CONCLUSIONS: Insured and educated patients in the United States overwhelmingly desire disclosure of trainee involvement in their surgery. To address the need for orthopedic training in the context of a patient population that is not fully comfortable with trainee involvement in their own surgery, an open discussion between patients and surgeons regarding trainees' roles may be the best course of action.

Clinical Impact of Routine Complete Blood Counts Following Total Knee Arthroplasty.

BACKGROUND: Routine laboratory studies are generally obtained following total knee arthroplasty (TKA), and often continued daily until discharge. This study aims to investigate the utility and cost-effectiveness of complete blood count (CBC) tests following TKA. METHODS: Retrospective review identified 484 patients who underwent primary TKA under a tourniquet at a single institution. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were calculated for all variables. RESULTS: Twenty-five patients required transfusion following TKA (5.2%). Patients requiring transfusion had significantly lower preoperative hemoglobin compared to patients who did not require transfusion (11.47 vs 13.58 g/dL, P = .005). Risk of transfusion was 5.2 times higher in patients with preoperative anemia (95% confidence interval 2.90-9.35, P < .001). Without TXA, patients were 2.75 times more likely to receive transfusion (95% confidence interval 1.43-5.30, P < .001). An average of 2.9 CBC tests were collected per patient who did not receive medical intervention, costing a total of $144,773.80 in associated hospital charges ($316.10 per patient). CONCLUSION: Ensuring quality, cost-effective patient care following total joint arthroplasty is essential in the era of bundled payments. Routine postoperative CBCs do not add value for patients with normal preoperative hemoglobin who receive TXA during TKA performed under tourniquet. Patients who are anemic preoperatively or do not receive TXA should obtain a postoperative CBC test. Daily CBCs are unnecessary if the first postoperative CBC does not prompt intervention.

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.

Implementing a perioperative efficiency initiative for orthopedic surgery instrumentation at an academic center: A comparative before-and-after study.

Optimizing surgical instrumentation may contribute to value-based care, particularly in commonly performed procedures. We report our experience in implementing a perioperative efficiency program in 2 types of orthopedic surgery (primary total-knee arthroplasty, TKA, and total-hip arthroplasty, THA).A comparative before-and-after study with 2 participating surgeons, each performing both THA and TKA, was conducted. Our objective was to evaluate the effect of surgical tray optimization on operating and processing time, cost, and waste associated with preparation, delivery, and staging of sterile surgical instruments. The study was designed as a prospective quality improvement initiative with pre- and postimplementation operational measures and a provider satisfaction survey.A total of 96 procedures (38 preimplementation and 58 postimplementation) were assessed using time-stamped performance endpoints. The number and weight of trays and instruments processed were reduced substantially after the optimization intervention, particularly for TKA. Setup time was reduced by 23% (6 minutes, P = .01) for TKA procedures but did not differ for THA. The number of survey respondents was small, but satisfaction was high overall among personnel involved in implementation.Optimizing instrumentation trays for orthopedic procedures yielded reduction in processing time and cost. Future research should evaluate patient outcomes and incremental/additive impact on institutional quality measures.

Current Practice Patterns of Fellowship-Trained Arthroplasty Surgeons: Has the Influence of Fellowship Training Been Undervalued?

BACKGROUND: As the clinical and financial environments of total joint arthroplasty (TJA) have evolved over the last several decades so has the role of the surgeon in providing this care to patients. Our objective was to examine current practices and influential factors among fellowship-trained arthroplasty surgeons. METHODS: An electronic survey was sent to all surgeons who had completed one of the three high-volume adult reconstruction fellowships from the years 2007-2016. The survey consisted of 34 questions regarding current practice characteristics, case volumes for primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA), use of advanced technologies, choice of surgical approach and implant design, factors influencing their choices, and their involvement in implant selection and contract negotiations. RESULTS: Questionnaires were sent to 53 surgeons; 52 were completed. Sixty percent of respondents performed at least 100 TKAs and 84% performed at least 50 THAs annually. Ninety-four percent use a single company's implant for more than 90% of primary TKA and THA. Fellowship or residency experience was the most significant influence on TKA and THA implant selection for 62% and 45% of surgeons, respectively, while contracts of their current institution were the primary influence for 17% and 12%, respectively. Fifty-five percent of surgeons used some advanced technology of which 16% said this influenced their implant choice. Eighty-six percent perform the majority of cases at centers performing at least 200 TJAs per year, and 39% participate in implant contract negotiations. CONCLUSION: Despite changes in the economic environment of TJA, this study demonstrates that experience with a specific implant during training, particularly fellowship, is the most influential factor for implant selection among fellowship-trained arthroplasty surgeons.

Bundled Payment "Creep": Institutional Redesign for Primary Arthroplasty Positively Affects Revision Arthroplasty.

BACKGROUND: Revision total joint arthroplasty (TJA) is associated with increased readmissions, complications, and expense compared to primary TJA. Bundled payment methods have been used to improve value of care in primary TJA, but little is known of their impact in revision TJA patients. The purpose of this study is to evaluate the impact of a care redesign for a bundled payment model for primary TJA on quality metrics for revision patients, despite absence of a targeted intervention for revisions. METHODS: We compared quality metrics for all revision TJA patients including readmission rate, use of post-acute care facility after discharge, length of stay, and cost, between the year leading up to the redesign and the 2 years following its implementation. Changes in the primary TJA group over the same time period were also assessed for comparison. RESULTS: Despite a volume increase of 37% over the study period, readmissions declined from 8.9% to 5.8%. Use of post-acute care facilities decreased from 42% to 24%. Length of stay went from 4.84 to 3.92 days. Cost of the hospital episode declined by 5%. CONCLUSION: Our health system experienced a halo effect from our bundled payment-influenced care redesign, with revision TJA patients experiencing notable improvements in several quality metrics, though not as pronounced as in the primary TJA population. These changes benefitted the patients, the health system, and the payers. We attribute these positive changes to an altered institutional mindset, resulting from an invested and aligned care team, with active physician oversight over the care episode.

Quality Measures in Total Hip and Total Knee Arthroplasty.

INTRODUCTION: Total joint arthroplasty represents the largest expense for a single condition among Medicare beneficiaries. Payment models exist, such as bundled payments, where physicians and hospitals are reimbursed based on providing cost-efficient, high-quality care. There is a need to explicitly define "quality" relevant to hip and knee arthroplasty. Based on prior quality measure research, we hypothesized that less than 20% of developed quality measures are outcome measures. METHODS: This study systematically reviewed current and candidate quality measures relevant to total hip and knee arthroplasty using several quality measure databases and an Internet library search. RESULTS: We found a total of 35 quality measures and 81 candidate measures, most of which were process measures (N = 21, 60%), and represented the National Quality Strategy priorities of patient- and caregiver-centered experience and outcomes (31%), effective clinical care (28%), or patient safety (19%). CONCLUSION: Various stakeholders have developed quality measures in total joint arthroplasty, with increasing focus on developing outcome measures. The results of this review inform orthopaedic surgeons on quality measures that payers could use value-based payment models like the Merit-based Incentive Payment System and Comprehensive Care for Joint Replacement. LEVEL OF EVIDENCE: Level I, systematic review of level I evidence.

Value-based Total Hip and Knee Arthroplasty: A Framework for Understanding the Literature.

Since passage of the Patient Protection and Affordable Care Act of 2010, the current decade has witnessed an explosion of the value-based total hip and knee arthroplasty literature. Total hip arthroplasty and total knee arthroplasty are the most common inpatient surgeries for Medicare beneficiaries, and thus, it is no surprise that total joint arthroplasty is currently a prime target of efforts toward cost reduction and quality improvement. The purpose of this review was to provide a framework for understanding the rapidly growing quality and cost literature. Research efforts toward quality improvement are likely to be effective when they address the structure, process, and most importantly outcomes of total joint arthroplasty. Similarly, cost savings should be evaluated with an understanding of existing accounting methods, relationships to the entire cycle of osteoarthritis care, and the direct effect on the quality of care provided.

Mixed messages to consumers from Medicare: Hospital Compare grades versus value-based payment penalty.

OBJECTIVES: To (1) compare the 2015 hospital grades reported on Medicare's Hospital Compare website for heart failure (HF) and acute myocardial infarction (AMI) readmissions with the HF- and AMI-specific scores for excess readmissions used to assess Medicare readmission penalties and (2) assess how often hospitals were penalized for excess readmissions in only 1 or 2 conditions, given that hospitals received a penalty impacting all Medicare payments based on an overall readmission score calculated from 5 conditions (HF, AMI, pneumonia, chronic obstructive pulmonary disease, and total hip/knee arthroplasty). STUDY DESIGN: Retrospective secondary data analysis. METHODS: Descriptive analyses of hospital-specific, condition-specific grades and excess readmission scores and hospital-level penalties downloaded from Hospital Compare. RESULTS: Of the 2956 hospitals that had publicly reported HF grades on Hospital Compare, 91.9% (2717) were graded as "no different" than the national rate for HF readmissions, which included 48.6% that were scored as having excessive HF admissions, and 87% received an overall readmission penalty. Of 120 (4.1%) hospitals graded as "better" than the national rate for HF, none were scored as having excessive HF readmissions and 50% were penalized. AMI data yielded similar results. Among 2591 hospitals penalized for overall readmissions, 26.6% had only 1 condition with excess readmissions and 27.5% had 2 conditions. CONCLUSIONS: Many hospitals with an HF and AMI readmission grade of "no different" than the national rate on Hospital Compare received penalties for excessive readmissions under the Hospital Readmissions Reduction Program. The value signal to consumers and hospitals communicated by grades and penalties is therefore weakened because the methods applied to the same hospital data produce conflicting messages of "average grades" yet "bad enough for penalty."

Rapid Recovery Total Joint Arthroplasty is Safe, Efficient, and Cost-Effective in the Veterans Administration Setting.

BACKGROUND: Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting. METHODS: In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively. RESULTS: After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07). CONCLUSION: In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.

Maximizing Physician-Hospital Alignment: Lessons Learned From Effective Models of Joint Arthroplasty Care.

BACKGROUND: With recent healthcare reform efforts focusing on rewarding value instead of volume, it has become important for orthopedic surgeons to partner and align with their hospitals. We report our experience in aligning clinical and financial incentives with 6 health systems in our geographic area. METHODS: By managing the entire episode-of-care continuum for total hip and total knee arthroplasty patients, our standardized, evidence-based protocols have improved the quality of care for our joint arthroplasty patients. While most studies focus on cost through insurance claims data, we have been able to accurately determine the costs to our practice and each facility through time-driven activity-based costing. RESULTS: We have also achieved measureable claims and actual cost reduction by reducing unnecessary care, inappropriate variation in care, and avoidable complications through demand matching, risk stratification, and our nurse navigator program. Our joint ventures with our hospital partners in both specialty hospitals and our ambulatory surgery centers have also been critical to our success. CONCLUSION: Our experience demonstrates that large private practice groups can successfully align both clinical and financial incentives with healthcare systems to provide quality joint arthroplasty care at a lower cost.

Geographic variation in selected hospital procedures and services in the Israeli health care system.

BACKGROUND: Medical practice variation refers to differences in health service utilization among regions in the same country. It is used as a tool for studying health inequities. In 2011, the OECD launched a Medical Practice Variation Project which examines regional differences within countries and explores the sources of the inter-regional differences. The aim of this study is to examine the patterns and trends in geographic variation for selected health services in Israel. METHODS: The analysis is based on data from the National Hospital Discharges Database (NHDD) of the Israeli Ministry of Health. The eight procedures and services studied were: medical admissions (i.e. admissions without surgical procedures); hip fractures; caesarian sections; diagnostic cardiac catheterization; cardiac angioplasty (PTCA); cardiac bypass surgery (CABG); hysterectomy; and knee replacement surgery. The data are presented for the 7 districts in Israel, determined by address of residence. RESULTS: The procedures and services with the lowest variation across the seven districts were medical admissions (RR between regions-maximum/minimum 1.3) and hip fractures (RR 1.44), while the one with the highest variation was CABG (RR 1.98). The Israeli periphery, and the northern district in particular, had higher rates of medical admissions, knee replacement and cardiac procedures. When studying the trend over time, we found a decrease in use rates for most procedures, such as coronary bypass (R. 04) and CABG (R 0.8). Medical admissions decreased by 8%, with the highest decline (16%) observed in the central districts. CONCLUSIONS: This study provides Israeli policy makers with information which is vital for the strategic planning of service development, such as strengthening preventive medical services in the community, reducing cardiovascular risk factors in the periphery and expanding the national publication of clinical quality scores.

Assessment of patient-specific instrumentation precision through bone resection measurements.

PURPOSE: In the present study, the precision of two patient-specific instrumentation (PSI) systems for total knee arthroplasty (TKA) was evaluated by comparing bony resection thicknesses of the pre-operative PSI planning and intra-operative measurements by a vernier calliper. It was hypothesized that the data provided by pre-operative planning were accurate within ±2 mm of the bone resection thickness measured intra-operatively. METHODS: Forty-one patient-specific TKAs were examined: 25 performed with Visionaire® technology and 16 with OtisMed® system. PSI accuracy was analysed comparing the resected bone thicknesses in the femoral and tibial cuts with pre-operatively planned resections. To determine pre-operative planning precision, the thickness values reported by the PSI planning were subtracted from the values reported intra-operatively by the calliper. RESULTS: The mean absolute differences between pre-operatively planned resections and corresponding intra-operative thickness measurements ranged from a minimum of 2.6 mm (SD 0.8) to a maximum of 3.6 mm (SD 1.3) in all three anatomical planes in both groups. In every plane, the mean absolute discrepancies between planned resections and measured cuts differed significantly from zero (p < 0.0001). The proportion of differences within ±2 mm between intra-operative measured resections and planned PSI cuts occurred in more than 90 % of the cohort for femoral distal resections. Less precision was reported for the femoral posterior medial cuts (70.7 % within ±2 mm) and the tibial cuts (70.7 % on the medial, 75.6 % on the lateral side). Prosthetic component alignment on the coronal and transverse planes resulted in considerable deviations from the pre-operative planning. CONCLUSION: The two examined PSI technologies were accurate in femoral distal cuts, determining acceptable femoral component placement on the coronal plane. Posterior femoral and tibial cuts were less precise. Deviations from the pre-operative resection planning were reported in every plane. Inaccuracy was explained by ambiguous custom-made jigs placement on the bony surface. LEVEL OF EVIDENCE: III.