Preoperative Symptoms of Depression are Associated With Worse Capability 6-weeks and 6-months After Total Hip Arthroplasty for Osteoarthritis.

BACKGROUND: Symptoms of depression have been associated with greater incapability following total hip arthroplasty (THA). A brief, 2-question, measure of symptoms of depression - the Patient Health Questionnaire-2 (PHQ-2) - may be sufficient to measure associations with the magnitude of incapability during recovery from THA. This study investigated whether preoperative symptoms of depression (measured with the PHQ-2) correlated with levels of incapability 6 weeks and 6 months after THA, accounting for demographic and clinical factors. METHODS: We performed a prospective cohort study across 5 centers and recruited 101 patients undergoing THA, of whom 90 (89%) completed follow-up. Patients completed demographics, a preoperative 2-item (PHQ-2) measure of symptoms of depression, and the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) at 6-weeks and 6-months postoperatively. Negative binomial regression models determined factors associated with HOOS JR at 6 weeks and 6 months, accounting for potential confounders. RESULTS: Accounting for potential confounding factors, we found that higher preoperative PHQ-2 scores (reflecting greater symptoms of depression) were associated with lower HOOS JR scores (reflecting a greater level of hip disability) at both 6 weeks (regression coefficient = -0.67, P < .001) and 6 months (regression coefficient = -1.9, P < .001) after THA. CONCLUSIONS: Symptoms of depression on a 2-question preoperative questionnaire are common, and greater symptoms of depression are associated with reduced capability within the first year following THA. These findings support the prioritization of routine mental health assessments before THA. Measuring mindset using relatively brief instruments will be important considering the current shift toward implementing self-reported measures of health status in clinical practice and incorporating them within alternative payment models.

A Model for Evaluating Total Costs of Care and Cost Savings of Specialty Condition-Based Care for Hip and Knee Osteoarthritis in an Integrated Practice Unit.

OBJECTIVES: The viability of specialty condition-based care via integrated practice units (IPUs) requires a comprehensive understanding of total costs of care. Our primary objective was to introduce a model to evaluate costs and potential costs savings using time-driven activity-based costing comparing IPU-based nonoperative management with traditional nonoperative management and IPU-based operative management with traditional operative management for hip and knee osteoarthritis (OA). Secondarily, we assess drivers of incremental cost differences between IPU-based care and traditional care. Finally, we model potential cost savings through diverting patients from traditional operative management to IPU-based nonoperative management. METHODS: We developed a model to evaluate costs using time-driven activity-based costing for hip and knee OA care pathways within a musculoskeletal IPU compared with traditional care. We identified differences in costs and drivers of cost differences and developed a model to demonstrate potential cost savings through diverting patients from operative intervention. RESULTS: Weighted average costs of IPU-based nonoperative management were lower than traditional nonoperative management and lower in IPU-based operative management than traditional operative management. Key drivers of incremental cost savings included care led by surgeons in partnership with associate providers, modified physical therapy programs with self-management, and judicious use of intra-articular injections. Substantial savings were modeled by diverting patients toward IPU-based nonoperative management. CONCLUSIONS: Costing models involving musculoskeletal IPUs demonstrate favorable costs and cost savings compared with traditional management of hip or knee OA. More effective team-based care and utilization of evidence-based nonoperative strategies can drive the financial viability of these innovative care models.

Association of Unmet Social Needs With Level of Capability in People With Persistent Knee Pain.

BACKGROUND: Musculoskeletal providers are increasingly recognizing the importance of social factors and their association with health outcomes as they aim to develop more comprehensive models of care delivery. Such factors may account for some of the unexplained variation between pathophysiology and level of pain intensity and incapability experienced by people with common conditions, such as persistent nontraumatic knee pain secondary to osteoarthritis (OA). Although the association of one's social position (for example, income, employment, or education) with levels of pain and capability are often assessed in OA research, the relationship between aspects of social context (or unmet social needs) and such symptomatic and functional outcomes in persistent knee pain are less clear. QUESTIONS/PURPOSES: (1) Are unmet social needs associated with the level of capability in patients experiencing persistently painful nontraumatic knee conditions, accounting for sociodemographic factors? (2) Do unmet health-related social needs correlate with self-reported quality of life? METHODS: We performed a prospective, cross-sectional study between January 2021 and August 2021 at a university academic medical center providing comprehensive care for patients with persistent lower extremity joint pain secondary to nontraumatic conditions such as age-related knee OA. A final 125 patients were included (mean age 62 ± 10 years, 65% [81 of 125] women, 47% [59 of 125] identifying as White race, 36% [45 of 125] as Hispanic or Latino, and 48% [60 of 125] with safety-net insurance or Medicaid). We measured patient-reported outcomes of knee capability (Knee injury and Osteoarthritis Outcome Score for Joint Replacement), quality of life (Patient-Reported Outcome Measure Information System [PROMIS] Global Physical Health and PROMIS Global Mental Health), and unmet social needs (Accountable Health Communities Health-Related Social Needs Survey, accounting for insufficiencies related to housing, food, transportation, utilities, and interpersonal violence), as well as demographic factors. RESULTS: After controlling for demographic factors such as insurance status, education attained, and household income, we found that reduced knee-specific capability was moderately associated with experiencing unmet social needs (including food insecurity, housing instability, transportation needs, utility needs, or interpersonal safety) (standardized beta regression coefficient [ß] = -4.8 [95% confidence interval -7.9 to -1.7]; p = 0.002 and substantially associated with unemployment (ß = -13 [95% CI -23 to -3.8]; p = 0.006); better knee-specific capability was substantially associated with having Medicare insurance (ß = 12 [95% CI 0.78 to 23]; p = 0.04). After accounting for factors such as insurance status, education attained, and household income, we found that older age was associated with better general mental health (ß = 0.20 [95% CI 0.0031 to 0.39]; p = 0.047) and with better physical health (ß = 0.004 [95% CI 0.0001 to 0.008]; p = 0.04), but effect sizes were small to negligible, respectively. CONCLUSION: There is an association of unmet social needs with level of capability and unemployment in patients with persistent nontraumatic knee pain. This finding signals a need for comprehensive care delivery for patients with persistent knee pain that screens for and responds to potentially modifiable social risk factors, including those based on one's social circumstances and context, to achieve better outcomes. LEVEL OF EVIDENCE: Level II, prognostic study.

Unhelpful Thoughts and Distress Regarding Symptoms Limit Accommodation of Musculoskeletal Pain.

BACKGROUND: Among people with musculoskeletal disorders, much of the variation in magnitude of incapability and pain intensity is accounted for by mental and social health opportunities rather than severity of pathology. Current questionnaires seem to combine distinct aspects of mental health such as unhelpful thoughts and distress regarding symptoms, and they can be long and burdensome. To identify personalized health strategies, it would be helpful to measure unhelpful thoughts and distress regarding symptoms at the point of care with just a few questions in a way that feels relevant to a person's health. QUESTIONS/PURPOSES: (1) Do questions that address unhelpful thoughts and distress regarding symptoms independently account for variation in accommodation of pain? (2) Which questions best measure unhelpful thoughts and distress regarding symptoms? METHODS: This is a cross-sectional questionnaire study of people seeking care regarding upper and lower extremity conditions from one of eight specialist clinicians (one upper extremity, one arthroplasty, and one sports surgeon and their three nurse practitioners and two physician assistants) in one urban office. Between June 2020 and September 2020, 171 new and returning patients were approached and agreed to participate, and 89% (153) of patients completed all questionnaires. The most common reason for noncompletion was the use of a pandemic strategy allowing people to use their phone to finish the questionnaire, with more people leaving before completion. Women and divorced, separated, or widowed people were more likely to not complete the survey, and we specifically account for sex and marital status as potential confounders in our multivariable analysis. Forty-eight percent (73 of 153) of participants were women, with a mean age 48 ± 16 years. Participants completed demographics and the validated questionnaires: Pain Catastrophizing Scale, Negative Pain Thoughts Questionnaire, Tampa Scale of Kinesiophobia, Intolerance of Uncertainty Scale, and Pain Self-Efficacy Questionnaire (a measure of accommodation to pain). In an exploratory factor analysis, we found that questions group together on four topics: (1) distress about symptoms (unhelpful feelings of worry and despair), (2) unhelpful thoughts about symptoms (such as worst-case thinking and pain indicating harm), (3) being able to plan, and (4) discomfort with uncertainty. We used a multivariable analysis, accounting for potential confounding demographics, to determine whether the identified question groupings account for variation in accommodation of pain-and thus are clinically relevant. Then, we used a confirmatory factor analysis to determine which questions best represent clinically relevant groupings of questions. RESULTS: After accounting for sex, marital status, work, and income, we found that distress and unhelpful thoughts about symptoms were independently associated with accommodation of pain, and together, they explained 60% of its variation (compared with 52% for distress alone and 40% for unhelpful thoughts alone). Variation in symptoms of distress was best measured by the question "I feel I can't stand it anymore" (76%). Variation in unhelpful thoughts was best addressed by the question "I wouldn't have this much pain if there wasn't something potentially dangerous going on in my body" (64%). CONCLUSION: We found that distress (unhelpful feelings) and unhelpful thoughts about symptoms are separate factors with important and comparable associations with accommodation to pain. It also appears that these two factors can be measured with just a few questions. Being attentive to the language people use and the language of influential questions might improve clinician identification of mental health opportunities in the form of distress and unhelpful thoughts about symptoms, which in turn might contribute to better accommodation and alleviation of symptoms. LEVEL OF EVIDENCE: Level II, prognostic study.

Are There Distinct Statistical Groupings of Mental Health Factors and Pathophysiology Severity Among People with Hip and Knee Osteoarthritis Presenting for Specialty Care?

BACKGROUND: There is mounting evidence that objective measures of pathophysiology do not correlate well with symptom intensity. A growing line of inquiry identifies statistical combinations (so-called "phenotypes") of various levels of distress and unhelpful thoughts that are associated with distinct levels of symptom intensity and magnitude of incapability. As a next step, it would be helpful to understand how distress and unhelpful thoughts interact with objective measures of pathologic conditions such as the radiologic severity of osteoarthritis. The ability to identify phenotypes of these factors that are associated with distinct levels of illness could contribute to improved personalized musculoskeletal care in a comprehensive, patient-centered model. QUESTIONS/PURPOSES: (1) When measures of mental health are paired with radiologic osteoarthritis severity, are there distinct phenotypes among adult patients with hip and knee osteoarthritis? (2) Is there a difference in the degree of capability and pain self-efficacy among the identified mental health and radiologic phenotypes? (3) When capability (Patient-reported Outcomes Measurement Information System Physical Function [PROMIS PF]) is paired with radiographic osteoarthritis severity, are there distinct phenotypes among patients with hip and knee osteoarthritis? (4) Is there a difference in mental health among patients with the identified capability and radiologic phenotypes? METHODS: We performed a secondary analysis of data from a study of 119 patients who presented for musculoskeletal specialty care for hip or knee osteoarthritis. Sixty-seven percent (80 of 119) of patients were women, with a mean age of 62 ± 10 years. Seventy-six percent (91 of 119) of patients had knee osteoarthritis, and 59% (70 of 119) had an advanced radiographic grade of osteoarthritis (Kellgren-Lawrence grade 3 or higher). This dataset is well-suited for our current experiment because the initial study had broad enrollment criteria, making these data applicable to a diverse population and because patients had sufficient variability in radiographic severity of osteoarthritis. All new and returning patients were screened for eligibility. We do not record the percentage of eligible patients who do not participate in cross-sectional surveys, but the rate is typically high (more than 80%). One hundred forty-eight eligible patients started the questionnaires, and 20% (29 of 148) of patients did not complete at least 60% of the questionnaires and were excluded, leaving 119 patients available for analysis. We measured psychologic distress (Patient Health Questionnaire-2 [PHQ-2] and Generalized Anxiety Disorder-2 questionnaire [GAD-2]), unhelpful thoughts about pain (Pain Catastrophizing Scale-4 [PCS-4]), self-efficacy when in pain (Pain Self-Efficacy Questionnaire-2), and capability (PROMIS PF). One of two arthroplasty fellowship-trained surgeons assigned the Kellgren-Lawrence grade of osteoarthritis based on radiographs in the original study. We used a cluster analysis to generate two sets of phenotypes: (1) measures of mental health (PHQ-2, GAD-2, PCS-4) paired with the Kellgren-Lawrence grade and (2) capability (PROMIS PF) paired with the Kellgren-Lawrence grade. We used one-way ANOVA and Kruskal-Wallis H tests to assess differences in capability and self-efficacy and mental health, respectively. RESULTS: When pairing measures of psychologic distress (PHQ-2 and GAD-2) and unhelpful thoughts (catastrophic thinking) with the grade of radiographic osteoarthritis, six distinct phenotypes arose. These groups differed in terms of capability and pain self-efficacy (for example, mild pathology/low distress versus average pathology/high distress [PROMIS PF, mean ± standard deviation]: 43 ± 6.3 versus 33 ± 4.8; p = 0.003). When pairing the degree of capability (PROMIS PF) with the Kellgren-Lawrence grade, four distinct phenotypes arose. Patients in three of these did not differ in terms of disease severity but had notable variation in the degree of limitations. Patients with these radiologic and capability phenotypes differed in terms of distress and unhelpful thoughts (for example, moderate pathology/low capability versus mild pathology/high capability [PHQ-2, median and interquartile range]: 3 [1 to 5] versus 0 [0 to 0]; p < 0.001). CONCLUSION: Statistical groupings ("phenotypes") that include both measures of pathology and mental health are associated with differences in symptom intensity and magnitude of incapability and have the potential to help musculoskeletal specialists discern mental and social health priorities. Future investigations may test whether illness phenotype-specific comprehensive biopsychosocial treatment strategies are more effective than treatment of pathology alone. LEVEL OF EVIDENCE: Level III, prognostic study.

Functional Outcomes of a Musculoskeletal Integrated Practice Providing Comprehensive Whole Person Care for Hip Osteoarthritis.

BACKGROUND: Outcomes of hip osteoarthritis (OA) management within integrated practice units (IPUs) are lacking. This study reports 6-month and 1-year patient-reported outcomes (PROs) of IPU care, the proportion of patients achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB) at 1 year, and baseline factors associated with the likelihood of achieving MCID and SCB. METHODS: We retrospectively evaluated 1009 new patients presenting to an IPU with hip OA between October 2017 and June 2020. Patients experienced multidisciplinary team-based management. Individuals with baseline and 6-month PROs or baseline and 1-year PROs (Hip Disability and Osteoarthritis Outcome Score Joint Replacement, HOOS JR) were included. We used anchor-based MCID and SCB thresholds and multivariable binary logistic regression models to identify baseline factors associated with achieving 1-year MCID and SCB. RESULTS: HOOS JR increased from baseline to 6 months (Δ = 19.1 ± 2.1, P = .065) and baseline to 1 year (Δ = 35.8 ± 2.9, P < .001). At 1 year, 72.7% (IPU only) and 88% (IPU-based total hip arthroplasty [THA]) achieved MCID (P < .001), and 62.3% (IPU only) and 88% (IPU-based THA) achieved SCB (P < .001). In multivariable regression, lower baseline HOOS JR scores (r = 0.96, P = .04), undergoing THA (r = 0.213, P < .001), and fewer symptoms of generalized anxiety (r = 0.932, P = .018) were independently associated with achieving MCID at 1 year. The same factors were independently associated with achieving SCB at 1 year. Lower baseline anxiety (Generalized Anxiety Disorder Questionnaire-7 item) and greater hip-related preoperative limitations result in greater likelihood of achieving MCID and SCB. CONCLUSION: Significant improvements in patient outcomes can be achieved by IPUs providing comprehensive care for hip OA including the management of psychological distress. Future prospective studies should compare the outcomes of IPUs with traditional care in managing diverse patient phenotypes.

Factors Associated with a Second Opioid Prescription Fill in Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) creates a relatively large degree of nociception, making it a good setting to study variation in pain intensity and pain alleviation. The purpose of this study is to investigate factors associated with a second prescription of opioid medications within 30 days of primary TKA. METHODS: Using an insurance database, we studied 1372 people over a 6-year period with no mental health comorbidities including substance misuse and no comorbid pain illness at the time of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA were sought among patient demographics and the overall prescription morphine milligram equivalents. Patient and prescription-related risk factors were evaluated utilizing logistic relative risk regression. We reserved a year of data, 222 people, to evaluate the performance of the derived model. RESULTS: More than half the patients filled a second prescription for opioids within 30 days of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA included age (P < .01), current smoker (P = .01), and the total morphine milligram equivalents of the initial prescription (P < .01). Applied to the 222 people we reserved for validation, the model was 81% sensitive and 14% specific for a second prescription within 30 days, with a positive predictive value of 74%, and a negative predictive value of 20%. CONCLUSION: People that are given more opioids tend to request more opioids, but our model had limited diagnostic performance characteristics indicating that we are not accounting for the key factors associated with a second opioid prescription. Future studies might address undiagnosed patient social and mental health opportunities, factors known to associate with pain intensity and satisfaction with pain alleviation. LEVEL OF EVIDENCE: Diagnostic Level III.

What Are the Uses and Limitations of Time-driven Activity-based Costing in Total Joint Replacement?

BACKGROUND: With increasing emphasis on value-based payment models for primary total joint arthroplasty (TJA), there is greater need for orthopaedic surgeons and hospitals to better understand the actual costs and resource use of TJA. Time-driven activity-based costing (TDABC) is a methodology for accurate cost estimation, but its application in the TJA care pathway across institutions/regions has not yet been analyzed. QUESTIONS/PURPOSES: In this systematic review of studies applying TDABC to primary TJA, we investigated the following: (1) Is there variation in TDABC methodology and cost estimates across institutions? (2) Is a standard set of direct and indirect costs included across studies? (3) Is there a difference in cost estimates derived from TDABC and traditional hospital cost-accounting approaches? and (4) How are institutions using TDABC (process and outputs) with respect to the TJA care pathway? METHODS: A comprehensive search strategy was developed that included the keywords "TDABC," "time-driven activity-based cost," "THA," "TKA," "THR," "TKR," and "TJR" in the PubMed/MEDLINE, EMBASE, Web of Science, Ovid SP, Scopus, and ScienceDirect databases for articles published between 2004 and 2018 as well as extensive hand searching and citation mining. Relevant studies (n = 15) were screened to include THA or TKA as the focus of the TDABC model, full-text articles, TDABC-based cost estimates for TJA, and studies written in English (n = 8). Due to the heterogeneity of outcomes/methodology in TDABC studies involving TJA, quality assessment was based on each study's adherence to the seven steps delineated by Kaplan et al. in their original publication introducing TDABC in health care. RESULTS: There was substantial variation in TDABC methodology (especially in scope), adherence to the seven steps of TDABC, and data collection. Only five of eight studies incorporated indirect costs into their TDABC calculation, with notable differences in which direct and indirect expenses were included. TDABC-based cost estimates for TJA ranged from USD 7081 to USD 29,557, with variation driven by the TJA timeframe and whether implant costs were included in the costing calculation. TDABC was most frequently used to compare against traditional hospital accounting methods (n = 4), to increase operational efficiency (n = 4), to reduce wasted resources (n = 3), and to mitigate risk (n = 3). CONCLUSIONS: TDABC-based cost estimates are more granular and useful in practice than those calculated via traditional hospital accounting; however, there is a lack of standardized principles to guide TDABC implementation (especially for indirect costs) due to institutional and regional differences in TDABC application. Although TDABC methodology will likely continue to vary somewhat between studies, standardized principles are needed to guide the definition, estimation, and reporting of costs to enable detailed examination of study methodology and inputs by readers. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Designing and Implementing Value-Based Care Delivery and Payment Models for Musculoskeletal Care.

Payors, purchasers, health care providers, and patients are increasingly focused on improving the value-defined as health outcomes that matter to patients per dollar expended-of health care delivered to patients. Orthopaedic providers are in a unique position to pioneer this transition given the introduction of alternative payment models as well as the longitudinal, multidisciplinary, and relatively homogenous nature of high-cost, high-burden orthopaedic conditions (eg, osteoarthritis). First, doing so requires identifying and objectively measuring outcomes that are important to patients (eg, quality of life, pain, functional status) over time. Second, it requires applying value-based principles by reorganizing delivery systems into integrated practice units-a team-based, multidisciplinary model-focused on delivering longitudinal care in a method that is tailored to each patient's values, goals, and disease state. Third, providers must understand the true cost of delivering such care through time-driven activity-based costing approaches. With this knowledge of outcomes and cost, providers and payors/purchasers will be adequately equipped to develop contracts that reward providers for delivering better value (across an orthopaedic patient population) while minimizing risk. The transition to value-based health care is feasible regardless of practice setting.

Skilled Nursing Facility Placement Process After Total Hip and Total Knee Arthroplasty: Revised Rating System and Opportunities for Intervention.

BACKGROUND: With the advent of bundled payment models, identifying high-performing skilled nursing facilities (SNFs) has become increasingly important. The goal of this study is to develop a rating system to rank SNFs within our health system and to use this system to improve the SNF discharge process at our institution. METHODS: All SNF-discharged primary total joint arthroplasty cases in 2017 at a multi-hospital academic health system were queried. Discharge patterns were assessed using heat map analysis. Regression analyses in conjunction with structured discussions with subject matter experts were used to identify measures of SNF efficiency and care quality. A revised rating system was developed and used to identify high-performing facilities within our health system. Opportunities to re-direct patients to higher performing facilities were identified. RESULTS: A revised rating system for SNFs was constructed based on risk-adjusted SNF length of stay, 30-day re-admission rate, and 30-day emergency department visit rate. As 82% of patients were discharged to SNFs in close proximity to their home, high-performing SNFs (according to the revised rating system) were identified by geographic region. Mapping of the discharge process revealed multiple opportunities where patients could be re-directed to a higher performing SNF in their area. Using conservative estimates (25% of discharges re-directed), this is expected to achieve a cost saving of $2,600,000 over a 5-year period, mainly through reductions in SNF length of stay. CONCLUSION: This study describes the development of a revised rating system for SNFs which, when implemented, is expected to achieve substantial cost savings over a 5-year period.

Preoperative Patient-Reported Outcomes and Clinical Characteristics as Predictors of 90-Day Cost/Utilization and Complications.

BACKGROUND: With the advent of mandatory bundle payments for total joint arthroplasty (TJA), assessing patients' risk for increased 90-day complications and resource utilization is crucial. This study assesses the degree to which preoperative patient-reported outcomes predict 90-day complications, episode costs, and utilization in TJA patients. METHODS: All TJA cases in 2017 at 2 high-volume hospitals were queried. Preoperative HOOS/KOOS JR (Hip Injury and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score) and Veterans RAND 12-item health survey (VR-12) were administered to patients preoperatively via e-collection platform. For patients enrolled in the Medicare bundle, cost data were extracted from claims. Bivariate and multivariate regression analyses were performed. RESULTS: In total, 2108 patients underwent TJA in 2017; 1182 (56%) were missing patient-reported outcome data and were excluded. The final study population included 926 patients, 199 (21%) of which had available cost data. Patients with high bundle costs tended to be older, suffer from vascular disease and anemia, and have higher Charlson scores (P < .05 for all). These patients also had lower baseline VR-12 Physical Component Summary Score (PCS; 24 vs 30, P ≤ .001) and higher rates of extended length of stay, skilled nursing facility discharge, 90-day complications, and 90-day readmission (P ≤ .04 for all). In multivariate analysis, higher baseline VR-12 PCS was protective against extended length of stay, skilled nursing facility discharge, >75th percentile bundle cost, and 90-day bundle cost exceeding target bundle price (P < .01 for all). Baseline VR-12 Mental Component Summary Score and HOOS/KOOS JR were not predictive of complications or bundle cost. CONCLUSION: Low baseline VR-12 PCS is predictive of high 90-day bundle costs. Baseline HOOS/KOOS JR scores were not predictive of utilization or cost. Neither VR-12 nor HOOS/KOOS JR was predictive of 90-day readmission or complications.

Are Medicare's Nursing Home Compare Ratings Accurate Predictors of 90-Day Complications, Readmission, and Bundle Cost for Patients Undergoing Primary Total Joint Arthroplasty?

BACKGROUND: Nursing Home Compare (NHC) ratings, created and maintained by Medicare, are used by both hospitals and consumers to aid in the skilled nursing facility (SNF) selection process. To date, no studies have linked NHC ratings to actual episode-based outcomes. The purpose of this study was to evaluate whether NHC ratings are valid predictors of 90-day complications, readmission, and bundle costs for patients discharged to an SNF after primary total joint arthroplasty (TJA). METHODS: All SNF-discharged primary TJA cases in 2017 at a multihospital academic health system were queried. Demographic, psychosocial, and clinical variables were manually extracted from the health record. Medicare NHC ratings were then collected for each SNF. For patients in the Medicare bundle, postacute and total bundle cost was extracted from claims. RESULTS: Four hundred eighty-eight patients were discharged to a total of 105 unique SNFs. In multivariate analysis, overall NHC rating was not predictive of 90-day readmission/major complications, >75th percentile postacute cost, or 90-day bundle cost exceeding the target price. SNF health inspection and quality measure ratings were also not predictive of 90-day readmission/major complications or bundle performance. A higher SNF staffing rating was independently associated with a decreased odds for >75th percentile 90-day postacute spend (odds ratio, 0.58; P = .01) and a 90-day bundle cost exceeding the target price (odds ratio = 0.69; P = .02) but was similarly not predictive of 90-day readmission/complications. CONCLUSION: Results of our study suggest that Medicare's NHC tool is not a useful predictor of 90-day costs, complications, or readmissions for SNFs within our health system.

Influence of Patient Activation, Pain Self-Efficacy, and Resilience on Pain Intensity and Magnitude of Limitations in Patients With Hip and Knee Arthritis.

Studying the relative impact of various measures of coping strategies can help determine which ones are most useful for patients with osteoarthritis (OA).This study prospectively enrolled 108 patients with hip or knee OA who were seeing an orthopedic surgeon before or after arthroplasty. Measures of coping strategies included the Patient Activation Measure (PAM), Pain Self-Efficacy Questionnaire (PSEQ-2), and the Brief Resilience Scale (BRS). The Hip Disability and Osteoarthritis Outcome Score, Junior (HOOS, JR), the Knee Injury and Osteoarthritis Outcome Score, Junior (KOOS, JR), and Numeric Rating Scale (NRS) were used to measure pain intensity. Pearson correlations measured the interrelationships of the outcome measures. The PSEQ-2 correlated significantly with the NRS, but the confidence intervals for the three instruments overlapped. The PAM and the PSEQ-2 correlated with the KOOS, JR. Only the PSEQ-2 was associated with variation in the NRS. The PAM, PSEQ-2, and BRS correlated with one another. While measures of self-efficacy, active involvement in care, and general resilience were correlated, the measure of pain self-efficacy had the strongest association with patient-reported outcomes. (Journal of Surgical Orthopaedic Advances 28(1):48-52, 2019).

Patient-Identified Barriers and Facilitators to Pre-Visit Patient-Reported Outcomes Measures Completion in Patients With Hip and Knee Pain.

BACKGROUND: Although patient-reported outcomes measures (PROMs) provide valuable health information and aid medical decision making for patients with hip and knee arthritis, survey completion rates remain low. The purpose of this study is to elucidate patient preferences regarding location of completion, delivery method, and barriers or facilitators to pre-visit completion. METHODS: Patients with hip and/or knee pain who were asked to complete pre-visit PROMs at 2 urban arthroplasty clinics were recruited. In-person, semi-structured, audio-recorded interviews were conducted, transcribed, and coded for thematic analysis. Codes were developed using a data-driven approach. RESULTS: We analyzed 51 interviews. The mean age was 57 years, 57% were women, and 45% had private or Medicare insurance. Prevalent themes regarding location preferences were convenience and communication preferences. Thirty-four patients stated a preference for completing pre-visit PROMs at home, 19 for in-office completion, and 10 stated no preference. Prevalent themes around delivery methods included technology access and familiarity. Of the 43 patients asked to select their preferred pre-visit PROM delivery method (phone call, email, text message, or postal mail), 31 (72%) preferred email or text messaging. Barriers to completing pre-visit PROMs were technological issues, recognizing the message was healthcare-related, and being too busy or forgetting. Twenty patients identified no barriers. CONCLUSION: Electronic PROM collection is favored by many patients, but alternative methods for patients without access to or familiarity with technology remain important. Clear recognition that the message is from a physician's office and physician communication of the utility of PROMs in clinical decision making may increase pre-visit completion.

Are Barbed Sutures Associated With 90-day Reoperation Rates After Primary TKA?

BACKGROUND: Studies have suggested that barbed sutures for wound closure in TKAs are an acceptable alternative to standard methods. However others have observed a higher risk of wound-related complications with barbed sutures. QUESTIONS/PURPOSES: (1) Do 90-day TKA reoperation rates differ between patients undergoing a barbed suture arthrotomy closure compared with a traditional interrupted closure? (2) Do the 90-day reoperation rates of wound-related, deep infection, and arthrotomy failure complications differ between barbed suture and traditional closures? METHODS: A retrospective analysis of a longitudinally maintained institutional primary TKA database was conducted on all TKAs performed between April 2011 and September 2015. We compared 884 primary TKAs, where the arthrotomy was closed with a barbed suture, with 1598 primary TKAs closed with the standard interrupted suture. After barbed sutures were introduced at our institution in 2012, the majority of surgeons gradually switched to barbed suture closures, with many using them exclusively by the end of the data collection period. We confirmed in-person followups and available data past 90 days for 97.4% (1556 of 1598) of the knees in patients with standard sutures and 94.8% (838 of 884) of the knees in patients with barbed sutures. Our primary endpoint was all-cause 90-day reoperation; our secondary endpoints considered: wound-related reoperation, as defined by previous studies; deep infection per Musculoskeletal Infection Society guidelines; and arthrotomy failure, defined intraoperatively as an opening or dehiscence through the previous arthrotomy closure. T tests and chi-square analyses were used to determine differences between the suture cohorts, and bivariate logistic regression was used to determine associations with our 90-day reoperation outcomes. RESULTS: With the numbers available, there was no association between suture type and 90-day all-cause reoperation (odds ratio [OR], 1.70; 95% CI, 0.82-3.53; p = 0.156). Suture type was not associated with wound-related reoperation (OR, 2.73; 95% CI, 0.97-7.69; p = 0.058). A 0.6% (five of 884) arthrotomy failure rate was observed in the barbed cohort while no (0 of 1598) arthrotomy failures were noted in the traditional group (p = 0.003). Deep infections were rare in both groups (two of 884 barbed sutures, 0 of 1598 standard sutures) and could not be compared. CONCLUSIONS: Although we saw no difference in overall and wound-related 90-day reoperation rates by suture type with the numbers available, we observed a higher frequency in our secondary question of arthrotomy failures when barbed sutures are used for arthrotomy closure during TKA. Given the widespread use of this closure technique, our preliminary pilot results warrant further investigation in larger multicenter cohorts. LEVEL OF EVIDENCE: Level III, therapeutic study.

Predictors of Same-Day Discharge in Primary Total Joint Arthroplasty Patients and Risk Factors for Post-Discharge Complications.

BACKGROUND: Same-day (<24 h) discharge total joint arthroplasty (TJA) may be a safe and effective option for certain patients with end-stage osteoarthritis. Given the growing pressure to improve quality and lower TJA episode costs, surgeons must identify which TJA patients can be appropriately discharged home quickly and safely. This study identifies characteristics associated with same-day discharge post-TJA as well as assesses risk factors for complications in this select patient population. METHODS: Bivariate and multivariate analyses were performed using perioperative variables from the 2011 to 2014 National Surgical Quality Improvement Program database. RESULTS: In total, 7474 primary TJAs among 120,847 TJA patients were discharged within 24 h post-surgery. These patients were more likely to be younger (<50 years), male sex, American Society of Anesthesiologists class 1 or 2, and less likely to be obese or taking steroids (P < .05 for all). They were also less likely to have co-morbidities. Rates of severe adverse event (SAE) or unplanned readmission post-discharge were 1.3% and 1.9%, respectively. Multivariate analysis identified age >80 (odds ratio [OR] 4.16, P = .001), smoking (OR 1.61, P = .03), bleeding-causing disorders (OR 2.56, P = .01), American Society of Anesthesiologists class 3 or 4 (OR 1.42, P < .05), and SAE pre-discharge (OR 13.13, P < .0001) as independent predictors for adverse events or readmission in this population. CONCLUSION: Patient characteristics, co-morbidities, and SAEs pre-discharge can be used to assess potential for discharge within 24 h. The results of our analysis may be used to develop risk stratification tools for identification of patients that are truly appropriate for same-day discharge TJA.

Health Utility of Early Hemiarthroplasty vs Delayed Total Hip Arthroplasty for Displaced Femoral Neck Fracture in Elderly Patients: A Markov Model.

BACKGROUND: Treatment for femoral neck fracture among patients aged 65 years or older varies, with many surgeons preferring hemiarthroplasty (HA) over total hip arthroplasty (THA). There is evidence that THA may lead to better functional outcomes, although it also carries greater risk of mortality and dislocation rates. METHODS: We created a Markov decision model to examine the expected health utility for older patients with femoral neck fracture treated with early HA (performed within 48 hours) vs delayed THA (performed after 48 hours). Model inputs were derived from the literature. Health utilities were derived from previously fit patients aged more than 60 years. Sensitivity analyses on mortality and dislocation rates were conducted to examine the effect of uncertainty in the model parameters. RESULTS: In the base case, the average cumulative utility over 2 years was 0.895 for HA and 0.994 for THA. In sensitivity analyses, THA was preferred over HA until THA 30-day and 1-year mortality rates were increased to 1.3× the base case rates. THA was preferred over HA until the health utility for HA reached 98% that of THA. THA remained the preferred strategy when increasing the cumulative incidence of dislocation among THA patients from a base case of 4.4% up to 26.1%. CONCLUSION: We found that delayed THA provides greater health utility than early HA for older patients with femoral neck fracture, despite the increased 30-day and 1-year mortality associated with delayed surgery. Future studies should examine the cost-effectiveness of THA for femoral neck fracture.

Do Aggregate Socioeconomic Status Factors Predict Outcomes for Total Knee Arthroplasty in a Rural Population?

BACKGROUND: We sought to determine whether several preoperative socioeconomic status (SES) variables meaningfully improve predictive models for primary total knee arthroplasty (TKA) length of stay (LOS), facility discharge, and clinically significant Veterans RAND-12 physical component score (PCS) improvement. METHODS: We prospectively collected clinical data on 2198 TKAs at a high-volume rural tertiary academic hospital from April 2011 through March 2016. SES variables included race and/or ethnicity, living alone, education, employment, and household income, along with numerous adjusting variables. We determined individual SES predictors and whether the inclusion of all SES variables contributed to each 10-fold cross-validated area under the model's area under the receiver operating characteristic (AUC). We also used 1000-fold bootstrapping methods to determine whether the SES and non-SES models were statistically different from each other. RESULTS: At least 1 SES predicted each outcome. Ethnic minority patients and those with incomes <$35,000 predicted longer LOS. Ethnic minority patients, the unemployed, and those living alone predicted facility discharge. Unemployed patients were less likely to achieve PCS improvement. Without the 5 SES variables, the AUC values of the LOS, discharge, and PCS models were 0.74 (95% confidence interval [CI] 0.72-0.77, "acceptable"); 0.86 (CI 0.84-0.87, "excellent"); and 0.80 (CI 0.78-0.82, "excellent"), respectively. Including the 5 SES variables, the 10-fold cross-validated and bootstrapped AUC values were 0.76 (CI 0.74-0.79); 0.87 (CI 0.85-0.88); and 0.81 (0.79-0.83), respectively. CONCLUSION: We developed validated predictive models for outcomes after TKA. Although inclusion of multiple SES variables provided statistical predictive value in our models, the amount of improvement may not be clinically meaningful.

Nonelective Primary Total Hip Arthroplasty: The Effect of Discharge Destination on Postdischarge Outcomes.

BACKGROUND: Medicare has enacted a mandatory bundled payment program for primary total joint arthroplasty that includes nonelective primary total hip arthroplasty (THA). Efficient postacute care management has been identified as an opportunity to improve value for patients. We aimed to identify risk factors for and compare rates of complications by discharge destination and then use those factors to risk-stratify non-elective THA patients. METHODS: Patients who underwent nonelective primary THA from 2011 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database and categorized into those discharged to skilled nursing facility or inpatient rehabilitation facility vs home self-managed/home health (HHH). Bivariate and multivariate analyses of risk factors for postdischarge adverse events were performed using patient characteristics and intraoperative variables. RESULTS: In bivariate analysis, skilled nursing facility or inpatient rehabilitation facility patients compared with HHH patients, had lower rates of postdischarge severe adverse events (SAEs; 49% vs 58%; P < .001) and unplanned 30-day readmissions (71% vs 83%; P < .001). HHH discharged patients with 1 or more of risk factors had a 1.85-6.18 times odds of complications within the first 14 days. CONCLUSION: The most important risk factors for predicting postdischarge SAE and readmission are predischarge SAE, dependent functional status, body mass index >40 kg/m2, smoking, diabetes, chronic steroid use, and American Society of Anesthesiologists class 3/4. Nonelective THA patients without these risk factors may be safely discharged to home after THA. Orthopedic surgeons and their nonelective THA patients must agree on the most appropriate discharge destination through a shared decision-making process that takes into account these significant risk factors and other psychosocial factors.

Home Discharge After Primary Elective Total Joint Arthroplasty: Postdischarge Complication Timing and Risk Factor Analysis.

BACKGROUND: Bundled payment programs for primary total joint arthroplasty (TJA) have identified reducing nonhome discharge as a major area of cost savings. Health care providers must therefore identify, risk stratify, and appropriately care for home-discharged TJA patients. This study aimed to analyze risk factors and timing of postdischarge complications among home-discharged primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients and risk stratify them to identify those who would benefit from higher level care. METHODS: Patients discharged home after elective primary THA/TKA from 2011 to 2014 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were performed using perioperative variables. RESULTS: A total of 50,376 and 71,293 home-discharged THA and TKA patients were included for analysis, of which, 1575 THA (3.1%) and 2490 TKA (3.5%) patients suffered postdischarge severe complications or unplanned readmissions. These patients were older, smokers, obese, and functionally dependent (P < .001 for all). In multivariate analysis, severe adverse event predischarge, age, male gender, functional status, and 10 other variables were all associated with ≥1.22 odds of postdischarge severe adverse event or readmission (P < .05). THA and TKA patients with 2, 3, or ≥4 risk factors had 1.43-5.06 times odds of complications within 14 days post discharge and 1.41-3.68 times odds of complications beyond 14 days compared to those with 0 risk factors (P < .001 for all). CONCLUSION: Risk factors can be used to predict which home-discharged TJA patients are at greatest risk of postdischarge complications. Given that this is a growing population, we recommend the development of formal risk-stratification protocols for home-discharged TJA patients.