Same Day versus Staged Total Knee Arthroplasty: Do Cost Savings Justify the Risk?

Same-day bilateral total knee arthroplasties (BTKAs) are associated with increased complications compared with staged procedures; however, as complication rates and lengths of stay (LOS) for same-day procedures decrease, they may become attractive alternatives to staged procedures. The void of recent nationwide studies comparing the 30-day total cost and risks of these procedures inspired this propensity matched review. Therefore, we compared 30-day outcomes in staged and same-day BTKAs occurring in 2016 and 2017 using the National Readmission Database (NRD), a nationwide database. The NRD was queried for all same-day and staged BTKA patients from January 1 to November 30 for both 2016 and 2017. Since the NRD links readmissions within one calendar year, TKAs occurring in this month were excluded to allow 30-day follow-up. Propensity matching was performed based on demographics, producing 19,334 patients in both cohorts. Thirty-day readmission, revision, and mortality rates, hospital costs, LOS, discharge dispositions, and complications were analyzed. Chi-square and Student's t-tests assessed categorical and continuous variables, respectively. A p-value of <0.05 was set as the threshold for statistical significance. The analysis demonstrated that less same-day patients were readmitted, with statistical but not clinical difference in revisions, and mortality (all p < 0.050). Higher 30-day cost ($33,522 vs. $29,053, p < 0.001), decreased total LOS (4.52 vs. 4.94 days, p < 0.001), and lower rates of PEs (0.3 vs. 1.1%, p < 0.001) and transfusions (2.1 vs. 8.5%, p < 0.001) but similar total complications (p >0.050) were associated staged compared with same-day BTKAs. The results suggest inpatient cost savings associated with same-day surgeries should be weighed against the slight increase in LOS and PEs. Ultimately, as LOS and PE rates continue to decrease from innovations and quality improvements, same-day BTKA may become an attractive alternative to staged BTKAs, especially if payer's incentive surgeons by increasing physician reimbursements.

Access to Total Knee Arthroplasty Among Patients With Low Incomes Has Not Increased Under Global Budget Revenue.

In 2014, Maryland implemented an experimental reimbursement model, Global Budget Revenue (GBR). This model provided hospitals with a capitated annual budget each fiscal year to use toward all services, regardless of payer. Goals of GBR include reductions in cost, improvements in care quality, and increased access for patients to high-volume procedures, such as total knee arthroplasty (TKA). We assessed demographics and outcomes among patients with low incomes and patients of racial minority groups in Maryland who underwent TKA before and after GBR implementation. Patients undergoing TKAs from 2011 to 2016 were queried from the Maryland State Inpatient Database, resulting in 71,066 patients. There were 13,722 patients with low incomes and 19,846 patients of racial minority groups. The chi-square test was used for sex, income, insurance, Charlson Comorbidity Index, and morbid obesity, with the Student's t test being reserved for age before and after GBR. The proportion of patients with low incomes decreased the year before GBR but increased with GBR and maintained (P<.001). The proportion of patients of racial minority groups increased the year before GBR implementation, decreased slightly, and then maintained (P<.001). Mean cost decreased for both cohorts of patients (both P<.001). Discharges to home increased for both cohorts (P<.001), while length of stay decreased (both P<.001). Global Budget Revenue decreased cost while improving outcomes for TKA patients post-GBR. Patients with low incomes have not increased their use of TKA, contrary to patients of racial minority groups. This suggests that barriers remain. Further follow-up of GBR performance in subsequent years will increase understanding of the sustainability of this trend and the degree to which any increase in access is dependent on the implementation of the Affordable Care Act. [Orthopedics. 2022;45(1):e11-e16.].

Trends of Obese and Morbidly Obese Patients in Same-Day Bilateral Total Knee Arthroplasty from 2009 to 2016.

As obesity in the United States increases, the proportion of obese and morbidly obese patients undergoing same-day bilateral total knee arthroplasty (sd-BTKA) remains unknown. Therefore, this study analyzed: (1) incidence, (2) patient demographics, (3) patient course, and (4) patient outcomes in obese and morbidly obese patients undergoing sd-BTKA in the United States from 2009 to 2016. The National Inpatient Sample was queried for all sd-BTKA patients from 2009 to 2016, yielding 39,901 obese and 20,394 morbidly obese patients. Analyzed variables included overall incidence, age, length of stay (LOS), sex, race, payer, Charlson comorbidity index (CCI) status, disposition, complications, location/teaching status, region of hospital, costs, and charges. Categorical variables were evaluated with chi-square analysis, while continuous variables were analyzed by Student's t-tests. Overall, the number of sd-BTKAs decreased over the study period, although the proportion of both obese and morbidly obese patients increased (p < 0.001 for all). The most common CCI status, 3 + , decreased in proportion for both groups (p < 0.001 for all). Hospital costs decreased and charges increased for both groups (p < 0.001 for all). Mean LOS decreased and patients were most commonly discharged to skilled nursing facilities, although these proportions decreased (p < 0.001 for all). Respiratory failures (p < 0.001 for all) increased for both groups, while proportion of deep vein thromboses and hematomas/seromas (p < 0.001 for all) increased for obese patients and proportion of pulmonary emboli (p < 0.001) increased for morbidly obese patients. The results of this study appear to portray improving optimization and patient selection of higher body mass index (BMI) individuals undergoing this procedure. More information is needed comparing the safety of the sd-BTKA across patients of all BMI groups.

Social Media Presence Correlated with Improved Online Review Scores for Spine Surgeons.

BACKGROUND: In the next decade, health care reimbursement will be more aligned to patient clinical outcomes. These outcomes are influenced by the patient's perceived opinion of his or her care. An evaluation into the role of surgeon demographics, social media (SM) accessibility, and office wait times was conducted to identify correlations with these among 3 online review platforms. METHODS: A total of 206 (148 orthopedic, 58 neurosurgery trained) spine surgeons were included. Spine surgeon ratings and demographics data from 3 physician rating websites (Healthgrades.com [HG], Vitals.com, Google.com [G]) were collected in November 2019. Using the first 10 search results from G we then identified if the surgeons had publicly accessible Facebook, Twitter, or Instagram (IG) accounts. RESULTS: The mean age of the cohort was 54.3 years (±9.40 years), and 28.2% had one form of publicly accessible SM. Having any SM was significantly correlated with higher scores on HG and G. An IG account was associated with significantly higher scores on all 3 platforms, and having a Facebook account correlated with significantly higher scores on HG in multivariate analysis. An office wait time between 16 and 30 minutes and >30 minutes was associated with worse scores on all 3 platforms (all P < 0.05). An academic practice was associated with higher scores on all 3 platforms (P < 0.05). CONCLUSIONS: A shorter office wait time and an academic setting practice are associated with higher patient satisfaction scores on all 3 physician review websites. Accessible SM accounts are also associated with higher ratings on physician review websites, particularly IG.