Physicians With Defined Clear Care Pathways Have Better Discharge Disposition and Lower Cost.

BACKGROUND: There is a pronounced need for a sustainable care model for total joint arthroplasty in the United States. Total hip and knee arthroplasty is expected to increase 673% by 2030, and Medicare is the payor for a majority of these episodes. Our objective was to compare orthopedic cohort groups with and without defined postacute care pathways and the effects of the care pathways on service utilization and cost for Medicare patients in the Bundled Payments for Care Improvement program. METHODS: Claims data for elective hip and knee arthroplasty episodes from a national bundled payments for care improvement database were the source of our study data. Independent reviewers were used to determine which groups had defined clinical pathways. The 2 cohort groups were then compared between those with defined clinical pathways and those without. Outcomes measures included postacute care costs, utilization rates (both frequency and length of time) for inpatient rehabilitation facilities, skilled nursing facilities, home health, and readmissions. RESULTS: Orthopedic physicians with defined postacute care pathways showed consistent decreases in cost and utilization as compared to physicians without defined postacute care pathways. Elective hip arthroplasty per episode cost differential was $3189 per episode between physicians with care pathways ($19,005) and those without ($22,195; P < .001). Elective knee arthroplasty per episode cost difference was $2466 per episode between physicians with care pathways ($18,866) and those without ($21,332; P < .001). Incident rates of utilization for postacute care services displayed significant differences between physicians with and without postacute care pathways. Physicians with defined postacute pathways demonstrated utilization reductions ranging from 7% to 79% with incident rate reductions ranging from 44% to 79%. CONCLUSION: The results suggest that orthopedic physicians with defined postacute care pathways affect discharge disposition. The findings show significant cost and utilization reductions for physicians with defined postacute care pathways.

The Epidemiology of Primary and Revision Total Hip Arthroplasty in Teaching and Nonteaching Hospitals in the United States.

INTRODUCTION: The purpose of this study was to examine the epidemiology of primary and revision total hip arthroplasty (THA) in teaching and nonteaching hospitals. METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried from 2006 to 2010 to identify primary and revision THAs at teaching and nonteaching hospitals. RESULTS: A total of 1,336,396 primary and 223,520 revision procedures were identified. Forty-six percent of all primary and 54% of all revision procedures were performed at teaching hospitals. Teaching hospitals performed 17% of their THAs as revisions; nonteaching hospitals performed 12% as revisions. For primary and revision THAs, teaching hospitals had fewer patients aged >65 years, fewer Medicare patients, similar gender rates, more nonwhite patients, and more patients in the highest income quartile compared with nonteaching hospitals. Costs, length of stay, and Charlson Comorbidity Index scores were similar; however, the mortality rate was lower at teaching hospitals. CONCLUSIONS: This study found small but significant differences in key epidemiologic and outcome variables in examining primary and revision THA at teaching and nonteaching hospitals. LEVEL OF EVIDENCE: Level III.

Frequency and Treatment Trends for Periprosthetic Fractures About Total Hip Arthroplasty in the United States.

BACKGROUND: Periprosthetic hip fractures (PPHFx) are challenging complications that have become increasingly more prevalent. Wide variability exists in the quality and size of prior studies pertaining to hospital stay information. This study used the largest publicly available database in the United States to evaluate perioperative hospital data of PPHFx. METHODS: The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample was used to analyze trends related to the frequency, fracture type, mortality, treatment, patient demographics, time to surgery, length of stay (LOS), and hospital charges associated with PPHFx from 2006-2010. RESULTS: From 2006-2010, average patient age (76.7 years), hospital characteristics, rate of PPHFx, treatment choice, LOS (8.03 days), mortality (2.6%), disposition (78.1% to skilled nursing facility or inpatient rehab), and time to procedure (1.98 days) all remained relatively stable. The southern United States had the highest frequency of PPHFx and females had nearly twice the rate of PPHFx each year at an average of 67%. Despite these consistencies, hospital charges increased by an average of 8.3% per year over the study period ($27,683 over 5 years, P < .0001). CONCLUSION: In the era of containing cost while improving quality of care, this study demonstrates that despite consistent treatment trends of PPHFx, hospital charges are increasing independently. Regardless, surgeons can work to reduce LOS and charge to post acute care facilities to lessen spending. Refining our understanding of these relationships will be fundamental to further improving quality of care and cutting cost associated with these fractures.

Standardizing Care and Improving Quality under a Bundled Payment Initiative for Total Joint Arthroplasty.

Increasing demands for episodic bundled payments in total hip and knee arthroplasty are motivating providers to wring out inefficiencies and coordinate services. This study describes a care pathway and gainshare arrangement as the mechanism by which improvements in efficiency were realized under a bundled payment pilot. Analysis of cut-to-close time, LOS, discharge destination, implant cost, and total allowed claims between pre-pilot and pilot cohorts showed an 18% reduction in average LOS (70.8 to 58.2 hours) and a shift from home health and skilled nursing facility discharge to home self-care (54.1% to 63.7%). No significant differences were observed for cut-to-close time and implant cost. Improvements resulted in a 6% reduction in the average total allowed claims per case.

Patient-specific versus conventional instrumentation for total knee arthroplasty: peri-operative and cost differences.

The role of patient-specific instrumentation in total knee arthroplasty (TKA) is yet to be clearly defined. Current evidence evaluating peri-operative and cost differences against conventional TKA is unclear. We reviewed 356 TKAs between July 2008 and April 2013; 306 TKAs used patient-specific instrumentation while 50 had conventional instrumentation. The patient-specific instrumentation cohort averaged 20.4 min less surgical time (P < 0.01) and had a 42% decrease in operating room turnover time (P = 0.022). At our institution, the money saved through increased operating room efficiency offset the cost of the custom cutting blocks and pre-operative advanced imaging. Routine use of patient-specific TKA can be performed with less surgical time, no increase in peri-operative morbidity, and at no increased cost when compared to conventional TKA.

Popliteal artery injury associated with total knee arthroplasty: trends, costs and risk factors.

Popliteal artery injury is a relatively rare but potentially devastating complication of total knee arthroplasty (TKA). We analyzed the Nationwide Inpatient Sample from 1998 to 2009 to determine the actual incidence, risk factors and consequences of this complication. There were 1,120,508 hospitalizations coded for TKA; of these, 633 (0.057%) were identified as having a popliteal artery injury. The rate of injury remained relatively constant though the number of both TKAs and injuries have risen annually by 0.65% and 0.5%, respectively. Significant risk factors included revision surgery, peripheral vascular disease, weight loss, renal failure, coagulopathy, and metastatic cancer. Consequences were increased hospital charges, length of stay, and mortality rates. Because the rate of popliteal artery injury is not diminishing with time and morbidity and mortality are high, patients should be assessed for known risk factors for popliteal artery injury.