Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities Following Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine whether: (1) patients from communities of socioeconomic distress have higher readmission rates or postoperative healthcare resource utilization and (2) there are differences in patient-reported outcome measures (PROMs) based on socioeconomic distress. SUMMARY OF BACKGROUND DATA: Socioeconomic disparities affect health outcomes, but little evidence exists demonstrating the impact of socioeconomic distress on postoperative resource utilization or PROMs. METHODS: A retrospective review was performed on patients who underwent lumbar fusion at a single tertiary academic center from January 1, 2011 to June 30, 2021. Patients were classified according to the distressed communities index. Hospital readmission, postoperative prescriptions, patient telephone calls, follow-up office visits, and PROMs were recorded. Multivariate analysis with logistic, negative binomial regression or Poisson regression were used to investigate the effects of distressed communities index on postoperative resource utilization. Alpha was set at P <0.05. RESULTS: A total of 4472 patients were included for analysis. Readmission risk was higher in distressed communities (odds ratio, 1.75; 95% confidence interval, 1.06-2.87; P =0.028). Patients from distressed communities (odds ratio, 3.94; 95% confidence interval, 1.60-9.72; P =0.003) were also more likely to be readmitted for medical, but not surgical causes ( P =0.514), and distressed patients had worse preoperative (visual analog-scale Back, P <0.001) and postoperative (Oswestry disability index, P =0.048; visual analog-scale Leg, P =0.013) PROMs, while maintaining similar magnitudes of clinical improvement. Patients from distressed communities were more likely to be discharged to a nursing facility and inpatient rehabilitation unit (25.5%, P =0.032). The race was not independently associated with readmissions ( P =0.228). CONCLUSION: Socioeconomic distress is associated with increased postoperative health resource utilization. Patients from distressed communities have worse preoperative PROMs, but the overall magnitude of improvement is similar across all classes. LEVEL OF EVIDENCE: Level IV.

Staged BiCompartmental Knee Arthroplasty has Greater Functional Improvement, but Equivalent Midterm Survivorship, as Revision TKA for Progressive Osteoarthritis After Partial Knee Arthroplasty.

BACKGROUND: Progressive arthritis in the unresurfaced compartments of the knee is one failure mode after partial knee arthroplasty (PKA). While progressive arthritis after PKA is typically treated with revision to TKA (rTKA), staged bicompartmental knee arthroplasty (sBiKA) -the addition of another PKA - is an alternative. This study compared outcomes of sBiKA and rTKA for progressive arthritis after PKA. METHODS: A retrospective comparative study of non-consecutive cases at four institutions were performed in patients with an intact PKA, without loosening or wear, who underwent sBiKA (n = 27) or rTKA (n = 30), for progressive osteoarthritis. Outcomes studied were new Knee Society Function and Objective Scores (KSSF, KSSO), KOOS, Jr., ROM, operative times, length of stay, complication rates and the need for reoperations. RESULTS: Mean time to conversion was 7.4 ± 6 years for sBiKA and 9.7 ± 8 for rTKA, P = .178. Patient demographics and pre-operative outcomes were similar among cohorts. At an average of 5.7 ± 3 (sBiKA) and 3.2 ± 2 years (rTKA), KOOS, Jr. significantly improved, P < .001, by an equivalent amount. Post-operative KSSO and KSSF were significantly higher in the sBiKA cohort, respectively, (90.4 ± 10 vs 72.1 ± 20, P < .001) and (80.3 ± 18 vs 67.1 ± 19, P = .011). sBiKA patients had significantly greater improvement in KSSO (30.7 ± 33 vs 5.2 ± 18, P = .003). One sBiKA patient underwent reoperation for continued pain. CONCLUSION: SBiKA has equivalent survivorship, but greater improvement in functional outcomes as rTKA at short to midterm follow-up. Given the shorter operative times and length of stay, sBiKA is a safe and cost-effective alternative to rTKA for progressive osteoarthritis following PKA. Nevertheless, further follow-up is necessary to determine whether sBiKA is a durable option.

Surgical Helmets Used During Total Joint Arthroplasty Harbor Common Pathogens: A Cautionary Note.

BACKGROUND: The use of personal-protection surgical helmet/hood systems is now a part of the standard surgical attire during arthroplasty in North America. There are no protocols for the disinfection of these helmets. METHODS: This is a prospective, single-center, observational study. Helmets worn by 44 members of the surgical team and foreheads of 44 corresponding surgical personnel were swabbed at three distinct time points. In addition, 16 helmets were treated with hypochlorite spray to determine if pathogens could be eliminated. Swabs obtained were processed for culture and next-generation sequencing (NGS). RESULTS: Of the 132 helmet samples, 97 (73%) yielded bacteria on culture and 94 (71%) had evidence of bacterial-deoxyribonucleic acid (DNA) on NGS. Of the swabs sent for bacterial identification at the three time points, at least one from each helmet was positive for a pathogen(s). Of the 132 forehead samples, 124 (93%) yielded bacteria on culture and 103 (78%) had evidence of bacterial-DNA on NGS. The most commonly identified organism from helmets was Cutibacterium acnes (86/132) on NGS and Staphylococcus epidermidis (47/132) on culture. The most commonly identified organism from the foreheads of surgical personnel was Cutibacterium acnes (100/132) on NGS and Staphylococcus epidermidis (70/132) on culture. Sanitization of helmets was totally effective; no swabs taken the following morning for culture and NGS identified any bacteria. CONCLUSION: This study demonstrates that surgical helmets worn during orthopedic procedures are contaminated with common pathogens that can potentially cause surgical site infections. The findings of this study should at the minimum compel us to develop protocols for the disinfection of these helmets.

Stress and Strain During Total Joint Arthroplasty Are Not Impacted by Hand Dominance or Operative Laterality in Orthopedic Surgeons.

BACKGROUND: Orthopedic surgeons experience significant musculoskeletal pain and work-related injuries while performing total joint arthroplasty (TJA). We sought to investigate the impact of operative extremity and surgeon limb dominance on surgeon physiologic stress and energy expenditure during TJA. METHODS: This was a prospective cohort study conducted at a tertiary academic practice. Cardiorespiratory data was recorded continuously in 3 high-volume arthroplasty surgeons using a smart garment that measured heart rate (HR), HR variability, respiratory rate, minute ventilation, and energy expenditure (calories) during conventional total knee (TKA) and total hip arthroplasty (THA). RESULTS: Surgeon 1 and 2 (right-handed) performed 21 right TKAs, 10 left TKAs, 13 right THAs, and 10 left THAs. Surgeon 3 (left-handed) performed 6 right TKAs, 9 left TKAs, 16 right THAs, and 10 left THAs. While performing TKA or THA, limb laterality had no significant impact on operative time and no significant differences existed in HR, HR variability, respiratory rate, minute ventilation, or energy expenditure for any right-handed or left-handed surgeons, regardless of the operative limb laterality. While performing TKA, consistently standing on the side of hand dominance was associated with decreased strain and stress, compared to always standing on the operative side. CONCLUSION: This study suggests that surgeon hand dominance and operative limb laterality do not impact energy expenditure or physiologic strain during TJA. However, consistently standing on the side of hand dominance in TKA may lead to decreased physiologic strain and stress during surgery. Further study utilizing wearable technology during TJA may provide orthopedic surgeons with information about modifiable factors that contribute to differences in physiological parameters during surgery.

Robotic-Assisted Versus Manual Unicompartmental Knee Arthroplasty: A Time-Driven Activity-Based Cost Analysis.

BACKGROUND: The cost-effectiveness of robotic-assisted unicompartmental knee arthroplasty (RA-UKA) remains unclear. Time-driven activity-based costing (TDABC) has been shown to accurately reflect true resource utilization. This study aimed to compare true facility costs between RA-UKA and conventional UKA. METHODS: We identified 265 consecutive UKAs (133 RA, 132 conventional) performed at a specialty hospital in 2016-2020. Itemized facility costs were calculated using TDABC. Separate analyses including and excluding implant costs were performed. Multiple regression was performed to determine the independent effect of robotic assistance on facility costs. RESULTS: Due to longer operative time, RA-UKA patients had higher personnel costs and total facility costs ($2,270 vs $1,854, P < .001). Controlling for demographics and comorbidities, robotic assistance was associated with an increase in personnel costs of $399.25 (95% confidence interval [CI] $343.75-$454.74, P < .001), reduction in supply costs of $55.03 (95% CI $0.56-$109.50, P = .048), and increase in total facility costs of $344.27 (95% CI $265.24-$423.31, P < .001) per case. However, after factoring in implant costs, robotic assistance was associated with a reduction in total facility costs of $235.87 (95% CI $40.88-$430.85, P < .001) per case. CONCLUSION: Using TDABC, overall facility costs were lower in RA-UKA despite a longer operative time. To facilitate wider adoption of this technology, implant manufacturers may negotiate lower implant costs based on volume commitments when robotic assistance is used. These supply cost savings appear to offset a portion of the increased costs. Nonetheless, further research is needed to determine if RA-UKA can improve clinical outcomes and create value in arthroplasty.

Total Knee Arthroplasty With Robotic Surgical Assistance Results in Less Physician Stress and Strain Than Conventional Methods.

BACKGROUND: Poor surgical ergonomics and physiological stress have been shown to impair surgical performance and cause injuries. The prevalence of musculoskeletal pain among arthroplasty surgeons is inordinately high. This study compared surgeon stress and strain during robotic-assisted total knee arthroplasty (rTKA) and conventional TKA (cTKA). METHODS: Continuous cardiorespiratory and ergonomic data of a single surgeon were measured during 40 consecutive unilateral TKAs (20 rTKAs, 20 cTKAs) using a smart garment and wearable sensors. Heart rate (HR), HR variability, respiratory rate, minute ventilation, and calorie expenditure were used as surrogate measures for physiological stress. Intraoperative ergonomics were assessed by measuring cervical and lumbar flexion, extension and rotation, and shoulder abduction/adduction. RESULTS: Mean operative time was longer for rTKA (48.2 ± 9 vs 31.8 ± 7 min, P < .001). Calories expended per minute was lower for rTKA (2.53 vs 3.50, P < .001). Total calorie expenditure in rTKA cases 11-20 was significantly lower than the first 10 (107.1 ± 27 vs 137.6 ± 24, P = .015), and lower than cTKA (112.3 ± 37). Mean HR was lower for rTKA (81.5 ± 4 vs 90.1 ± 5, P < .001). Minute ventilation was also lower for rTKA (14.9 ± 1 vs 17.0 ± 1.0 L/min, P < .001). Mean lumbar flexion as well as the percentage of time spent in a demanding flexion position >20° were significantly lower during rTKA (P < .001). CONCLUSION: rTKA resulted in less surgeon physiologic stress, energy expenditure per minute, and postural strain compared to cTKA. Robotic assistance may help to increase surgical efficiency and reduce physician workload, but further studies are needed to determine whether these benefits will reduce musculoskeletal pain and injury among surgeons.

Orthopedic Specialty Hospital Reasons for Transfer and Subsequent Outcomes.

BACKGROUND: Surgical specialty hospitals provide patients, surgeons, and staff with a streamlined approach to elective surgery but may not be equipped to handle all complications arising postoperatively. The purpose of this study is to evaluate the immediate postoperative and 90-day outcomes of patients who were transferred from a high-volume specialty hospital following primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: All patients who were admitted to one orthopedic specialty hospital for primary THA or TKA between January 2015 and December 2019, and subsequently transferred to a tertiary care hospital, were identified and propensity matched to nontransferred patients. Emergency department visits, complications, readmissions, mortality, and revisions within 90 days of surgery were identified for each group. RESULTS: There were 26 TKAs (0.78%) and 20 THAs (0.48%) transferred, representing 0.62% of all primary THAs and TKAs performed over the study duration. Arrhythmia and chest pain were the most common reasons for transfer. Ninety-day readmissions were significantly higher in the transfer group (15.2% vs 4.3%, P = .020) with an odds ratio for readmission after transfer of 3.9 (95% confidence interval 1.3-12.4). Overall complications and orthopedic complications did not differ significantly, although transferred patients had a higher rate of medical complications (13.0% vs 2.2%, P = .008) with an odds ratio of 6.7 (95% confidence interval 1.6-28.2). CONCLUSION: Transfer from a specialty hospital is rarely required following primary TKA and THA. Although not at increased risk for orthopedic complications, these transferred patients are at increased risk for readmissions and medical complications within the first 90 days of their care, necessitating increased vigilance.

Prior Anterior Cruciate Ligament Reconstruction Does Not Compromise the Functional Outcomes of Medial Unicompartmental Knee Arthroplasty Although Revision for Progressive Arthritis May Occur Earlier.

BACKGROUND: Anterior cruciate ligament (ACL) deficiency is commonly considered a contraindication for unicompartmental knee arthroplasty (UKA). The purpose of this study is to compare the outcomes of UKA after prior ACL reconstruction (rACL cohort) to UKA with an intact native ACL (nACL cohort). METHODS: Forty-five patients from 3 institutions who underwent medial UKA after prior rACL were matched by age, gender, preoperative function scores, and body mass index to 90 patients who underwent UKA with an intact nACL. Primary outcomes were Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Oxford Knee Scores, Knee Society Functional Scores, and Kellgren-Lawrence scores in the unresurfaced, lateral tibiofemoral compartment. Secondary outcomes were postoperative complications and the need for revision to TKA. RESULTS: At a mean of 3.6 years, all PROMs improved significantly with no differences identified between groups. The incidence of revision TKA was similar between cohorts (P = 1.00); however, the mean time to revision for progressive osteoarthritis was 4.0 years in the nACL group and 2.2 years in the rACL group. Twenty percent of rACL patients had a postoperative complication compared to 8% in the nACL group. Despite presenting with a similar degree of lateral arthritis, a greater percentage of patients developed Kellgren-Lawrence scores of ≥3 in the rACL cohort (9%) than in the nACL cohort (0%). CONCLUSION: A previously reconstructed ACL does not appear to compromise the short-term functional outcomes of UKA; however, there is a higher rate of minor complications and progression of lateral compartment arthritis, which should be considered with patients in the shared decision process.

Surgeons Experience Greater Cardiorespiratory Strain and Stress During Total Hip Arthroplasty Than Total Knee Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are physically demanding, with a high prevalence of work-related injuries among arthroplasty surgeons. It is unknown whether there are differences in cardiorespiratory output for surgeons while performing THA and TKA. The objective of this study is to characterize whether differences in surgeon physiological response exist while performing primary THA vs TKA. METHODS: This is a prospective cohort study including 3 high-volume, fellowship-trained arthroplasty surgeons who wore a smart garment that recorded cardiorespiratory data on operative days during which they were performing primary conventional TKA and THA. Variables collected included patient body mass index (BMI), operative time (minutes), heart rate, heart rate variability, respiratory rate, minute ventilation, and energy expenditure (calories). RESULTS: Seventy-six consecutive cases (49 THAs and 27 TKAs) were studied. Patient BMI was similar between the 2 cohorts (P > .05), while operative time was significantly longer in TKAs (60.4 ± 12.0 vs 53.6 ± 11.8; P = .029). During THA, surgeons had a significantly higher heart rate (95.7 ± 9.1 vs 90.2 ± 8.9; P = .012), energy expenditure per minute (4.6 ± 1.23 vs 3.8 ± 1.2; P = .007), and minute ventilation (19.0 ± 3.0 vs 15.5 ± 3.3; P < .001) compared to TKA. CONCLUSION: Surgeons experience significantly higher physiological strain and stress while performing THA. While scheduling THAs and TKAs, surgeons should consider the higher physical demand associated with THAs and ensure adequate personal preparation and sequence of cases.

How the Shift in Arthroplasty Surgery Location Impacts the Relationship of Private Surgeons, Hospitals, and Ambulatory Surgery Centers.

The recent removal of total hip and knee arthroplasty from the Medicare inpatient-only list, COVID-19 pandemic, decreasing reimbursements, and bundled payment programs have all had tremendous impact on the practice of arthroplasty. Surgeons and practices must adapt to these challenges to achieve the ideal triad of quality patient care, low cost to payors, and sustainable financial margins for stakeholders. Here, we review institutional data and present our experience with the changing arthroplasty practice landscape. With the principle of demand matching, arthroplasty surgeons and practices can risk-stratify and shuttle patients in the appropriate operative and rehabilitation setting to optimize quality and efficiency.

Redefining Indications for Modern Cementless Total Knee Arthroplasty: Clinical Outcomes and Survivorship in Patients >75 Years Old.

BACKGROUND: Most studies on cementless total knee arthroplasty (TKA) have excluded patients >75 years due to concerns that older patients have poorer bone mineral density and osteogenic activity. This study compared the midterm outcomes and survivorship of cemented and cementless TKA of the same modern design performed in patients >75 years. METHODS: We identified a consecutive series of 120 primary cementless TKA performed in patients >75 years. Each case was propensity score matched 1:3 with 360 cemented TKA of the same modern design based on age, sex, body mass index, Charlson Comorbidity Index, bilateral procedures, liner type, and year of surgery. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Short Form-12 (SF-12) were collected preoperatively, at 6 months and 2 years. Implant survivorship was recorded at mean 4.2 years (range, 2.0-7.9). RESULTS: Mean age was 79.0 ± 3.4 years (range, 75-92) in the cemented cohort and 78.9 ± 3.5 (range, 75-91) in the cementless cohort (P = .769). There was no difference in final postoperative scores or improvement in scores at 2 years. The percentage of patients that met the minimal clinically important difference was also similar (KOOS-JR, 68.9% vs 69.2%, P = .955; SF-12 Physical, 71.7% vs 66.7%, P = .299). Seven-year survivorship free from aseptic revision was 99.4% for cemented knees and 100% for cementless knees (log-rank, P = .453). CONCLUSION: Patients over 75 years undergoing cementless or cemented TKA of the same modern design had comparable outcomes and survivorship in the midterm. The theoretical risks of cementless fixation in this age group were not realized in this study.

Total Hip and Knee Revisions are Really Outpatient Procedures? Implications of the Removal From the Inpatient Only List.

BACKGROUND: In 2021, the Centers for Medicare and Medicaid Services (CMS) removed over 200 procedures from the Inpatient Only (IPO) list including revision total hip (THA) and total knee arthroplasties (TKA). The purpose of this study is to determine if some revision TKA and THA procedures may be appropriate for outpatient status. METHODS: We reviewed a consecutive series of 1026 revision THA and TKA patients at our tertiary academic institution from 2015 to 2020. An outpatient procedure was defined as a length of stay of <2 midnights. We queried our prospectively collected arthroplasty database and compared demographics, comorbidities, surgical indication, type of procedure, discharge disposition, readmissions, and complications between the outpatient and inpatient groups. RESULTS: There were only 166 revision patients (16%) who met outpatient criteria. Revision THA outpatients were more likely to have a head and liner exchange (49% vs 25%, P < .001) and an indication of instability (93% vs 44%, P < .001). Revision TKA outpatients were more likely to have an isolated liner exchange (34% vs 14%, P < .001) and have an indication of instability (67% vs 25%, P < .001). Patients undergoing a revision for infection and aseptic loosening were more likely to require an inpatient stay than other revision indication (P < .05). CONCLUSION: The vast majority of revision TKA and THA patients met CMS inpatient criteria. In addition to a projected decrease in facility reimbursement, concerns exist for the safety of early discharge and access to care for these complex patients if CMS removes all revisions from the Inpatient Only list.

"Uncontrolled" Hypertension Is Not an Independent Risk Factor for Adverse Short-Term Outcomes Following Total Joint Arthroplasty.

BACKGROUND: Uncontrolled hypertension (HTN) is a risk factor for mortality following elective surgery and poor hemodynamic control during total joint arthroplasty (TJA). However, the relationship between uncontrolled HTN and TJA outcomes remains poorly understood. The purpose of this study is to better define HTN parameters that are predictive of adverse arthroplasty outcomes. METHODS: This is a retrospective cohort analysis on patients who underwent primary TJA for osteoarthritis between 2017 and 2021 at a large orthopedic practice. Uncontrolled HTN was defined as a systolic blood pressure (SBP) > 140 mm Hg, or diastolic blood pressure (DBP) > 90 mm Hg. Spearman's rank correlations were used to evaluate relationships among uncontrolled HTN and operative duration, hemoglobin drop, allogenic transfusions, length of stay, intraoperative/postoperative complications, and readmissions. RESULTS: Four thousand three hundred forty-five patients met the selection criteria, of which 55.1% (N = 2394) presented with uncontrolled HTN. In total, 17.1% (N = 745) and 3.2% (N = 138) of patients had an SBP ≥ 160 and 180 mm Hg, respectively. In addition, 1.9% of patients (N = 84) presented with SBP ≥ 200 mm Hg (N = 13) and/or DBP ≥ 100 mm Hg (N = 71). Eight-four percent (N = 626) of patients who presented with SBP > 160 mm Hg had been preoperatively prescribed HTN control medications. Receiver operator curve analysis demonstrated poor predictive value of blood pressure for all aforementioned outcome variables. CONCLUSION: Our findings suggest that as defined, uncontrolled HTN is not an appropriate individual predictor of TJA outcomes and should not be used as a "hard stop" when determining eligibility for elective surgery. Further research utilizing a larger cohort is needed to define the relationship between HTN and TJA outcomes.

Can Prior Episode-of-Care Costs Predict the Future? Identifying High-Cost Outliers for Subsequent Total Hip and Knee Arthroplasty.

BACKGROUND: It remains unknown if a patient's prior episode-of-care (EOC) costs for total hip (THA) or knee (TKA) arthroplasty procedure can be used to predict subsequent costs for future procedures. The purpose of this study is to evaluate whether there is a correlation between the EOC costs for a patient's index and subsequent THA or TKA. METHODS: We reviewed a consecutive series of 11,599 THA and TKA Medicare patients from 2015 to 2019 and identified all patients who underwent a subsequent THA and TKA during the study period. We collected demographics, comorbidities, short-term outcomes, and 90-day EOC claims costs. A multivariate analysis was performed to identify whether prior high-EOC costs were predictive of high costs for the subsequent procedure. RESULTS: Of the 774 patients (6.7%) who underwent a subsequent THA or TKA, there was no difference in readmissions (4% vs 5%, P = .70), rate of discharge to a skilled nursing facility (SNF) (15% vs 15%, P = .89), and mean costs ($18,534 vs $18,532, P = .99) between EOCs. High-cost patients for the initial TKA or THA were more likely to be high cost for subsequent procedure (odds ratio 14.33, P < .01). Repeat high-cost patients were more likely to discharge to an SNF for their first and second EOC compared to normative-cost patients (P < .01). CONCLUSION: High-cost patients for their initial THA or TKA are likely to be high cost for a subsequent procedure, secondary to a high rate of SNF utilization. Efforts to reduce costs in repeat high-cost patients should focus on addressing post-operative needs pre-operatively to facilitate safe discharge home.

A Crossover Randomized Trial of Visual Abstracts Versus Plain-Text Tweets for Disseminating Orthopedics Research.

BACKGROUND: Scientists, surgeons, and trainees are increasingly taking an active role on Twitter to find, disseminate, and exchange knowledge. The purpose of this study was to determine if peer-reviewed journal articles shared on Twitter using visual abstracts (VAs) improve user engagement compared with plain-text tweets. METHODS: A two-arm randomized controlled trial with crossover was performed. Manuscripts from the Journal of Arthroplasty were allocated to one of two arms and disseminated via the journal Twitter account (@JArthroplasty) as either a text-based tweet or a VA. The primary outcome was online engagement (a composite of retweets, replies, and likes) at 7 and 30 days after posting. Univariate analysis for nonparametric and parametric data was performed using Mann-Whitney test or Student t-tests, respectively; alpha was set at 0.05. RESULTS: 20 in-press manuscripts were randomized to standard tweets (10) or VAs (10) the same day of online publication. The mean number of engagements was higher in the VA group at seven (412 ± 216 vs 195 ± 133; P = .016) and 30 days (495 ± 204 vs 244 ± 162; P = .007). After the crossover, similar results were reported. Overall, VAs attracted a significantly greater number of engagements than standard tweets. Most engagement for both plain-text tweets and VAs occurred shortly after the tweet is posted. CONCLUSION: Online, public engagement with orthopedic research is generally low. However, when VAs are used to communicate research through social media outlets such as Twitter, the overall research engagement significantly increases compared with plain-text tweets.

The Hospital Frailty Risk Score is Not an Accurate Predictor of Treatment Costs for Total Joint Replacement Patients in a Medicare Bundled Payment Population.

BACKGROUND: Medically complex patients require more resources and experience higher costs within total joint arthroplasty (TJA) bundled payment models. While risk adjustment would be beneficial for such patients, no tool currently exists which can reliably identify these patients preoperatively. The purpose of this study is to determine if the Hospital Frailty Risk Score (HFRS) is a valid predictor of high-TJA treatment costs. METHODS: Retrospective analysis was performed on patients who underwent primary TJA between 2015 and 2020 from a single large orthopedic practice. ICD-10 codes from an institutional database were used to calculate HFRS. Cost data including inpatient, postacute, and episode of care (EOC) costs were collected. Charlson comorbidity index, demographics, readmissions, and complications were analyzed. RESULTS: 4936 patients had a calculable HFRS and those with intermediate and high scores experienced more frequent readmissions/complications after TJA, as well as higher EOC costs. However, HFRS did not reliably predict EOC costs, yielding a sensitivity of 49% and specificity of 66%. Multivariate analysis revealed that both patient age and sex are superior individual cost predictors when compared with HFRS. Secondary analyses indicated that HFRS more effectively predicts TJA complications and readmissions but is still nonideal for clinical applications. CONCLUSION: HFRS has poor sensitivity as a predictor of high-EOC costs for TJA patients but has adequate specificity for predicting postoperative readmissions and complications. Further research is needed to develop a scale that can appropriately predict orthopedic cost outcomes.

Projections of the Impact to Arthroplasty Surgeons With Changes to the 2021 Medicare Physician Fee Schedule-A Looming Crisis of Access to Care?

BACKGROUND: The Centers for Medicare and Medicaid Services 2021 Physician Fee Schedule (PFS) includes increases in office reimbursement but decreases in the valuation of total hip arthroplasty and total knee arthroplasty and the conversion factor. The purpose of this study was to determine the financial impact of these changes on arthroplasty surgeons. METHODS: We queried data for 35 arthroplasty surgeons within our practice from 10/2019 to 10/2020 and captured all office and arthroplasty-related surgical procedure codes. We compared the difference in both work relative value units (RVUs) and Medicare reimbursement by surgeon based on the current 2020 PFS to the 2021 changes. We also estimated the impact of several proposals to include office increases to the global surgical package for each code. RESULTS: While the mean per surgeon RVU amount for primary arthroplasty procedures will decrease (6267 vs 6,088, P = .78), the mean office work RVU (2755 vs 3,220, P = .16) will increase in 2021. However, the reduction in surgical reimbursement ($530,076 in 2020 to $464,414 in 2021) far exceeds the gains from the office ($99,456 vs $107,374), leading to an overall decrease in reimbursement ($629,532 vs $571,788), a reduction of 9%. The passage of the coronavirus disease 2019 relief bill delays many of the PFS cuts and will result in an overall reduction in reimbursement of 2.4% ($629,532 vs $612,475, P = .61). CONCLUSION: Arthroplasty surgeons are projected to lose 2.4% of Medicare reimbursement in 2021 with the changes in the Centers for Medicare and Medicaid Services PFS. Further study is needed to determine whether these cuts will limit access to care for Medicare patients.

Low Incidence of Asymptomatic Positive Patients Detected During Preoperative Testing for Total Joint Arthroplasty During the COVID-19 Pandemic.

INTRODUCTION: Although the pause in elective surgery was necessary to preserve healthcare resources at the height of the novel coronavirus disease 2019 (COVID-19) pandemic, recent data have highlighted the worsening pain, decline in physical activity, and increase in anxiety among cancelled total hip and knee arthroplasty patients. The purpose of this study was to evaluate the effectiveness of our staged reopening protocol and the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among elective arthroplasty patients. METHODS: We identified all elective hip and knee arthroplasty patients who underwent our universal COVID-19 testing protocol during our phased reopening between May 1, 2020, and July 21, 2020, at our institution. We recorded the SARS-CoV-2 test results of each patient along with their demographics, medical comorbidities, and symptoms at the time of testing. We followed each of these positive patients through their rescheduled cases and recorded any complications or potential SARS-CoV-2 healthcare exposures. RESULTS: Of the 2,329 patients, we identified five patients (0.21%) with a reverse transcription-polymerase chain reaction--confirmed SARS-CoV-2 positive test, none with symptoms. All patients were successfully rescheduled and underwent their elective arthroplasty procedure within 6 weeks of their original surgery date. None of these patients experienced a perioperative complication at the time of their rescheduled arthroplasty procedure. No orthopaedic surgeon or staff member caring for these patients reported a positive SARS-CoV-2 test. CONCLUSION: Our phased reopening protocol with universal preoperative virus testing was safe and identified a low incidence of SARS-CoV-2 among asymptomatic, elective arthroplasty patients at our institution. With uncertainty regarding the trajectory of the COVID-19 pandemic, we hope that this research can guide future policy decisions regarding elective surgery.

Despite Equivalent Medicare Reimbursement, Facility Costs for Outpatient Total Knee Arthroplasty Are Higher Than Unicompartmental Knee Arthroplasty.

BACKGROUND: With the recent removal of total knee arthroplasty (TKA) from the Centers for Medicare and Medicaid Services (CMS) Inpatient Only list, facility reimbursement for outpatient TKA now falls under the Outpatient Prospective Payment System at the same rate as unicompartmental knee arthroplasty (UKA). The purpose of this study was to compare true facility costs of patients undergoing outpatient TKA with those undergoing UKA. METHODS: We reviewed a consecutive series of 2310 outpatient TKA and 231 UKA patients from 2018 to 2019. Outpatient status was defined as a hospital stay of less than 2 midnights. Facility costs were calculated using a time-driven, activity-based costing algorithm. Implants, supplies, medications, and personnel costs were compared between outpatient TKA and UKA patients. A multivariate analysis was performed to control for confounding medical and demographic variables. RESULTS: When compared with patients undergoing UKA, outpatient TKA patients had higher implant costs ($3403 vs $3081; P < .001) and overall hospital costs ($6350 vs $5594; P < .001). Outpatient TKA patients had a greater length of stay (1.2 vs 0.5 days; P < .001) and greater postoperative personnel costs ($783 vs $166; P < .001) than UKA patients. When controlling for comorbidities, outpatient TKA was associated with a $803 (P < .001) increase in overall facility costs compared with UKA. CONCLUSION: Despite equivalent reimbursement from CMS as UKA, outpatient TKA has increased facility costs to the hospital. Although implant costs can vary greatly by institution, CMS should consider appropriately reimbursing outpatient TKA for the additional personnel costs when compared with UKA.

Canceled Total Joint Arthroplasty: Who, What, When, and Why?

BACKGROUND: Unexpected cancelation of scheduled total joint arthroplasty (TJA) procedures creates patient distress and disruption for the clinical team. The purpose of this study is to identify the etiology and fate of cancelations for scheduled TJAs. METHODS: A consecutive series of 11,670 patients at a single institution from 2013 to 2017 was reviewed in March 2020. All patients who were scheduled for a primary total hip arthroplasty or total knee arthroplasty and subsequently canceled were identified. The etiology of cancelation and time to rescheduling were recorded. RESULTS: Of the 505 (4.3%) canceled patients, 209 (42%) were due to medical reasons. Three hundred ninety-one patients (77%) eventually underwent their procedure at a mean delay of 165 days (19-1908). Only 53 (25%) patients canceled for a medical reason underwent further diagnostic or therapeutic intervention for their medical condition. When compared to patient-driven cancelations, those canceled for medical reasons had a higher mean Charlson Comorbidity Index (0.82 vs 0.39, P < .001), were canceled closer to the scheduled surgery date (8.55 vs 18.1 days, P < .001), and were more likely to eventually undergo surgery (86% vs 73%, P = .004). CONCLUSION: Canceled elective TJA surgeries are most often due to a medical concern, however only a minority of these patients undergo intervention for that medical condition. To minimize the risk of cancelation, healthcare providers may consider early referral of medically complex patients to the patient's primary care physician. After cancelation, patients should have a clearly defined path to return to the operative schedule to prevent further delays.