Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Primary Hip and Knee Arthroplasty as Reported by American Board of Orthopedic Surgery Part II Candidates.

BACKGROUND: Many strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS: The American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used. RESULTS: In total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients. CONCLUSION: It was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE: Therapeutic Level III. DISCLAIMER: All views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.

Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications.

BACKGROUND: Despite increasing implementation of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), there are little data on its financial implications. We analyzed hospital cost and reimbursement data within the context of insurance provider type and postoperative complications. METHODS: Clinicopathologic variables, hospital costs, and reimbursement for all patients undergoing CRS/HIPEC at a single institution from 2009 to 2013 were analyzed. RESULTS: A total of 64 patients underwent CRS/HIPEC. Median PCI score was 19, and average operative time was 550 min. Tumor histology included appendiceal (n = 40; 62 %), colorectal (n = 16; 25 %), goblet cell (n = 5; 8 %), and mesothelioma (n = 3; 5 %). Median length-of-stay was 13 days. Complications occurred in 42 patients (66 %), including 13 (20 %) with major (Clavien grade III-IV) complications. Payer mix included 42 private insurance and 22 Medicare/Medicaid. Financial data was available for 56 patients: average total hospital cost was $49,248 and reimbursement was $63,771, for a hospital profit of $14,523/patient. Despite similar costs between Medicare/Medicaid and private-insurance patients, Medicare/Medicaid reimbursed much less ($30,713 vs $80,747; p < 0.001), resulting in a net loss of $17,342 per patient. For private-insured patients, major complications were associated with increased cost and increased reimbursement, resulting in a net profit of $36,285, compared with a net loss of $54,274 in Medicare/Medicaid patients. CONCLUSIONS: CRS/HIPEC is profitable in privately insured patients, even for those with major complications, but loses money in patients with Medicare/Medicaid. Under a future bundled-reimbursement system, complications will be negatively associated with profit. With these impending changes, hospitals must place emphasis on value, recalculate the reimbursement necessary for financial viability, and focus on decreasing costs and minimizing complications.