A Retrospective Study on the Feasibility of Using Low-burden Patient-reported Pain Scores to Track Recovery and Outcomes After Total Joint Replacement.

Background: Patients undergo total joint arthroplasty to improve function and resolve pain. Patient-reported outcome measures (PROMs) are often sought to determine the success of total joint arthroplasty but are time-consuming and patient response rates are often low. This study sought to determine whether pain numeric rating scores (NRSs) were associated with PROMs and objective mobility outcomes. Methods: This is a retrospective review of data in patients who utilized a smartphone-based care management application prior to and following total joint arthroplasty. NRS, Hip Disability and Osteoarthritis Outcome Score, Joint Replacement and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, and objective mobility data (step counts, gait speed, and gait asymmetry) were collected preoperatively and at 30 and 90 days postoperatively. Quantile regression was performed to evaluate the correlations between NRS and PROMs. Results: Total knee arthroplasty patients reported higher NRS than total hip arthroplasty patients postoperatively. NRS was significantly correlated with gait speed preoperatively and at 30 and 90 days postoperatively on quantile regression. Gait asymmetry was significantly associated with NRS at 30 days postoperatively. Regression results suggested significant correlations between NRS and PROMs scores; Hip Disability and Osteoarthritis Outcome Score, Joint Replacement, -0.46 (95% confidence interval: -0.48 to -0.44, P < .001) and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, -0.38 (95% confidence interval: -0.40 to -0.36, P < .001). Conclusions: NRS is correlated with both objective and subjective measures of function in patients undergoing arthroplasty. Simple pain ratings may be a valid measurement to help predict functional outcomes when collection of traditional PROMs is not feasible.

Registry Data Show Complication Rates and Cost in Revision Hip Arthroplasty.

BACKGROUND: Revision total hip arthroplaty (rTHA) places a burden on patients, surgeons, and health care systems because outcomes and costs are less predictable than primary THA. The purpose of this study was to define indications and treatments for rTHA, quantify risk for readmissions, and evaluate the economic impacts of rTHA in a hospital system. METHODS: The arthroplasty database of a hospital system was queried to generate a retrospective cohort of 793 rTHA procedures, performed on 518 patients, from 2017 to 2019 at 27 hospitals. Surgeons performed chart reviews to classify indication and revision procedure. Demographics, lengths of stay, discharge dispositions, and readmission data were collected. Analyses of direct costs were performed and categorized by revision type. RESULTS: Totally, 46.3% of patients presented for infection. Patients presenting for infection were 5.6 times more likely to have repeat rTHA than aseptic patients. Septic cases (4.3 days) had longer length of stay than aseptic ones (2.4) (P < .0001). However, 31% of patients discharged to a skilled nursing facility. Direct costs were greatest for a two-stage exchange ($37,642) and lowest for liner revision ($8,979). Septic revisions ($17,696) cost more than aseptic revisions ($11,204) (P < .0001). The 90-day readmission rate was 21.8%. Septic revisions had more readmissions (13.5%) than aseptic revisions (8.3%). CONCLUSIONS: Hip revisions, especially for infection, have an increased risk profile and create a major economic impact on hospital systems. Surgeons may use these data to counsel patients on risks of rTHA and advocate for improved reimbursement for the care of revision patients.

Use of a Smartphone-Based Care Platform After Primary Partial and Total Knee Arthroplasty: 1-Year Follow-Up of a Prospective Randomized Controlled Trial.

BACKGROUND: The rise in demand of knee arthroplasty has led the industry to develop methods to decrease costs of care, such as novel methods of delivering physiotherapy, including smartphone-based exercise educational platforms. The purpose of this study was to determine the noninferiority of one such system after primary knee arthroplasty as compared to traditional in-person physiotherapy. METHODS: A prospective, multicenter randomized clinical trial was conducted comparing standard of care rehabilitation to a smartphone-based care platform after primary knee arthroplasty from January 2019 to February 2020. One-year patient outcomes, satisfaction scores, and utilizations of health care resources were analyzed. A total of 401 patients was available for analysis-241 in the control and 160 in the treatment group. RESULTS: There were 194 (94.6%) patients in the control group who required 1 or more physiotherapy visits compared to only 97 (60.6%) patients in the treatment group (P < .001). Emergency department visits within 1 year occurred in 13 (5.4%) patients and 2 (1.3%) patients in the control and treatment groups, respectively (P = .03). The change in mean Knee Injury and Osteoarthritis Outcome Score for joint replacement scores at 1 year was similar between both the groups (32.1 ± 1 6.8 versus 30.1 ± 18.1, P = .32). CONCLUSION: Implementation of this smartphone/smart watch care platform showed similar outcomes to traditional care models at 1 year postoperative. Traditional physiotherapy and emergency department visits occurred at much lower rates in this cohort, which could alleviate the need for health care dollars spent by reducing postoperative costs and enhancing communication across the health care system.

The Economic Impact of Lower Extremity Periprosthetic Fractures in a Large Hospital System.

BACKGROUND: Periprosthetic fractures (PPFs) place a burden on hospital systems. They occur in older patients with medical comorbidities, as unplanned events requiring technically complex surgeries with expensive implants. The purpose of this study was to describe this patient population and evaluate the economic impact of PPFs on a hospital system. METHODS: We conducted a retrospective study of PPFs of the hip and knee between 2018 and 2019. Demographics, length of stay (LOS), and discharge disposition were collected. We performed chart and radiographic reviews to determine the fracture classification and type of treatment performed. An analysis of direct inpatient costs was performed and categorized by a fracture type. RESULTS: We identified 213 periprosthetic hip and 151 periprosthetic knee fractures. The mean age of hip patients was 77 years, and 71% were female. The average surgery time was 194 minutes, LOS was 5.01 days, and 71% were discharged to a skilled nursing facility (SNF). The mean age of knee patients was 76 years, and 79% were female. The average surgery time was 174 minutes, LOS was 5.12 days, and 70% were discharged to a SNF. The median direct cost of hip fractures was $17,108, with Vancouver B2 and B3 costing significantly more at $19,987 and $23,935, respectively (P value <.0001). The median direct cost of knee fractures was $13,713. Type 3 distal femur fractures cost significantly more at $37,445 (P value <.0001). CONCLUSION: PPFs create a significant economic impact on hospital systems. We stratified the costs of treatment based on the fracture type. Significantly higher costs are associated with injuries requiring revision implants.

Trends of Femoral Neck Fracture Treatment Using Total Hip Arthroplasty: Reported From the American Joint Replacement Registry.

INTRODUCTION: Total hip arthroplasty (THA) rather than hemiarthroplasty for displaced femoral neck fracture (FNF) is often chosen for younger patients who are more active and/or have underlying hip osteoarthritis. However, instability remains the primary concern of doing THA. Dual mobility (DM) has been shown to decrease this risk through a larger effective head size and greater head-to-neck ratio compared with conventional THA. The purpose of this study was to identify femoral head size and DM usage patterns for the treatment of FNF with THA in the United States using the American Joint Replacement Registry. METHODS: A retrospective cohort study was conducted, including all primary THAs done for FNF from 2012 to 2019. THA and FNF were defined using Current Procedural Terminology or International Classification of Diseases-9 or -10 diagnosis and procedure codes. Analysis was based on patient demographics, femoral head size, and DM usage. Descriptive statistics were used using a Pearson chi-square test. All analyses were conducted using SAS version 9.4, and statistical significance was set at P < 0.05. RESULTS: There were 18,752 THAs done by 3,242 surgeons at 789 institutions during the 8-year study period. The overall population was 66% female, and the mean age was 72.3 ± 11.8 years. The most commonly used femoral head size was 36 mm (48.5%) followed by 32 mm (24.5%), ≤28 mm (10.7%), DM (10.8%), and ≥40 mm (5.7%). A trend was observed toward decreased use of ≤28, 32, and ≥40-mm heads starting in 2016 across the years and increased use of 36-mm heads (P < 0.0001). A significant increase was observed in the usage of DM over time from 6.4% in 2012 to 16.2% in 2019 (P < 0.0001). DISCUSSION: Most of the femoral heads used were ≥36 mm, and the use of DM increased during the study period. Additional analysis is warranted to understand how these trends will affect overall outcomes and postoperative dislocation rates.

Robotic Versus Manual Total Knee Arthroplasty in High Volume Surgeons: A Comparison of Cost and Quality Metrics.

BACKGROUND: Robotic-assisted total knee arthroplasty (RTKA) was introduced to improve surgical accuracy and patient outcomes. However, RTKA may also increase operating time and add cost to TKA. This study sought to compare the differences in cost and quality measures between manual TKA (MTKA) and RTKA METHODS: All MTKAs and RTKAs performed between January 1, 2017 and December 31, 2019, by 6 high volume surgeons in each cohort, were retrospectively reviewed. Cohorts were propensity score matched. Operative time, length of stay (LOS), total direct cost, 90-day complications, utilization of postacute services, and 30-day readmissions were studied. RESULTS: After one-to-one matching, 2392 MTKAs and 2392 RTKAs were studied. In-room/out-of-room operating time was longer for RTKA (139 minutes) than for MTKA (107 minutes) P < .0001, as was procedure time (RTKA 78 minutes; MTKA 70 minutes), P < .0001. Median LOS was equal for MTKA and RTKA (33 hours). Total cost per case was greater for RTKA ($11,615) than MTKA ($8674), P < .0001. Home health care was utilized more frequently after RTKA (38%) than MTKA (29%), P < .0001. There was no significant difference in 90-day complication rates. Thirty-day readmissions occurred more often after MTKA (4.9%) than RTKA (1.2%), P < .0001. CONCLUSION: RTKA was a longer and costlier procedure than MTKA for experienced surgeons, without clinically significant differences in LOS or complications. Home health care was utilized more often after RTKA, but fewer readmissions occurred after RTKA. Longer term follow-up and functional outcome studies are required to determine if the greater cost of RTKA is offset by lower revision rates and/or improved functional results.

Cementless Fixation Is Associated With Increased Risk of Early and All-Time Revision After Hemiarthroplasty But Not After THA for Femoral Neck Fracture: Results From the American Joint Replacement Registry.

BACKGROUND: Despite ample evidence supporting cemented femoral fixation for both hemiarthroplasty and THA for surgical treatment of displaced femoral neck fractures, cementless fixation is the preferred fixation method in the United States. To our knowledge, no nationally representative registry from the United States has compared revision rates by fixation for this surgical treatment. QUESTION/PURPOSE: After controlling for relevant confounding variables, is femoral fixation method (cemented or cementless) in hemiarthroplasty or THA for femoral neck fracture associated with a greater risk of (1) all-cause revision or (2) revision for periprosthetic fracture? METHODS: Patients with Medicare insurance who had femoral neck fractures treated with hemiarthroplasty or THA reported in the American Joint Replacement Registry database from 2012 to 2017 and Centers for Medicare and Medicaid Services claims data from 2012 to 2017 were analyzed in this retrospective, large-database study. Of the 37,201 hemiarthroplasties, 42% (15,748) used cemented fixation and 58% (21,453) used cementless fixation. Of the 7732 THAs, 20% (1511) used cemented stem fixation and 80% (6221) used cementless stem fixation. For both the hemiarthroplasty and THA cohorts, most patients were women and had cementless femoral fixation. Early revision was defined as a procedure that occurred less than 90 days from the index procedure. All patients submitted to the registry were included in the analysis. Patient follow-up was limited to the study period. No patients were lost to follow-up. Due to inherent limitations with the registry, we did not compare medical complications, including deaths attributed directly to cemented fixation. A logistic regression model including the index arthroplasty, age, gender, stem fixation method, hospital size, hospital teaching affiliation, and Charlson comorbidity index score was used to determine associations between the index procedure and revision rates. RESULTS: For the hemiarthroplasty cohort, risk factors for any revision were cementless stem fixation (odds ratio 1.42 [95% confidence interval 1.20 to 1.68]; p < 0.001), younger age (OR 0.96 [95% CI 0.95 to 0.97]; p < 0.001), and higher Charlson comorbidity index (OR 1.06 [95% CI 1.02 to 1.11]; p = 0.004). Risk factors for early revision were cementless stem fixation (OR 1.77 [95% CI 1.43 to 2.20]; p < 0.001), younger age (OR 0.98 [95% CI 0.97 to 0.99]; p < 0.001), and higher Charlson comorbidity index (OR 1.09 [95% CI 1.04 to 1.15]; p < 0.001). Risk factors for revision due to periprosthetic fracture were cementless fixation (OR 6.19 [95% CI 3.08 to 12.42]; p < 0.001) and higher Charlson comorbidity index (OR 1.16 [95% CI 1.06 to 1.28]; p = 0.002). Risk factors for early revision due to periprosthetic fracture were cementless fixation (OR 7.38 [95% CI 3.17 to 17.17]; p < 0.001), major teaching hospital (OR 2.10 [95% CI 1.08 to 4.10]; p = 0.03), and higher Charlson comorbidity index (OR 1.20 [95% CI 1.09 to 1.33]; p < 0.001). For the THA cohort, there were no associations. CONCLUSION: These data suggest that cemented fixation should be the preferred technique for most patients with displaced femoral neck fractures treated with hemiarthroplasty. The fact that stem fixation method did not affect revision rates for those patients with displaced femoral neck fractures treated with THA may be due to current practice patterns in the United States. LEVEL OF EVIDENCE: Level III, therapeutic study.

Early outcomes of primary total hip arthroplasty with use of a smartphone-based care platform: a prospective randomized controlled trial.

AIMS: The purpose of this study is to evaluate early outcomes with the use of a smartphone-based exercise and educational care management system after total hip arthroplasty (THA) and demonstrate decreased use of in-person physiotherapy (PT). METHODS: A multicentre, prospective randomized controlled trial was conducted to evaluate a smartphone-based care platform for primary THA. Patients randomized to the control group (198) received the institution's standard of care. Those randomized to the treatment group (167) were provided with a smartwatch and smartphone application. PT use, THA complications, readmissions, emergency department/urgent care visits, and physician office visits were evaluated. Outcome scores include the Hip disability and Osteoarthritis Outcome Score (HOOS, JR), health-related quality-of-life EuroQol five-dimension five-level score (EQ-5D-5L), single leg stance (SLS) test, and the Timed Up and Go (TUG) test. RESULTS: The control group was significantly younger by a mean 3.0 years (SD 9.8 for control, 10.4 for treatment group; p = 0.007), but there were no significant differences between groups in BMI, sex, or preoperative diagnosis. Postoperative PT use was significantly lower in the treatment group (34%) than in the control group (55.4%; p = 0.001). There were no statistically significant differences in complications, readmissions, or outpatient visits. The 90-day outcomes showed no significant differences in mean hip flexion between controls (101° (SD 10.8)) and treatment (100° (SD 11.3); p = 0.507) groups. The HOOS, JR scores were not significantly different between control group (73 points (SD 13.8)) and treatment group (73.6 points (SD 13); p = 0.660). Mean 30-day SLS time was 22.9 seconds (SD 19.8) in the control group and 20.7 seconds (SD 19.5) in the treatment group (p = 0.342). Mean TUG time was 11.8 seconds (SD 5.1) for the control group and 11.9 (SD 5) seconds for the treatment group (p = 0.859). CONCLUSION: The use of the smartphone care management system demonstrated similar early outcomes to those achieved using traditional care models, along with a significant decrease in PT use. Noninferiority was demonstrated with regard to complications, readmissions, and ED and urgent care visits. This technology allows patients to rehabilitate on a more flexible schedule and avoid unnecessary healthcare visits, as well as potentially reducing overall healthcare costs. Cite this article: Bone Joint J 2021;103-B(7 Supple B):91-97.

2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial.

AIMS: The purpose is to determine the non-inferiority of a smartphone-based exercise educational care management system after primary knee arthroplasty compared with a traditional in-person physiotherapy rehabilitation model. METHODS: A multicentre prospective randomized controlled trial was conducted evaluating the use of a smartphone-based care management system for primary total knee arthroplasty (TKA) and partial knee arthroplasty (PKA). Patients in the control group (n = 244) received the respective institution's standard of care with formal physiotherapy. The treatment group (n = 208) were provided a smartwatch and smartphone application. Early outcomes assessed included 90-day knee range of movement, EuroQoL five-dimension five-level score, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score, 30-day single leg stance (SLS) time, Time up and Go (TUG) time, and need for manipulation under anaesthesia (MUA). RESULTS: Overall, 90-day mean flexion was not significantly different between the control (121° (SD 11.7°)) and treatment groups (121o; p = 0.559); 90-day mean SLS was 22.7 seconds (SD 9.8) in controls and 24.3 seconds (SD 20.8) in treatment (p = 0.519); 90-day mean TUG times were 10.1 seconds (SD 4.8) in control and 9.3 seconds (SD 3.3) in treatment (p = 0.139). Mean KOOS JR scores were significantly different between control group (73.6 (SD 13.4)) and treatment group (70.4 (SD 12.6); p = 0.026). MUAs were performed in nine (3.7%) patients in the control group and four (1.9%) in the treatment group (p = 0.398). Physiotherapy was performed by 230 (94.4%) of control group and 123 (59.3%) of treatment group (p < 0.001). There were no significant differences between groups in postoperative urgent care visits, or readmissions within 90 days, with significantly fewer emergency department visits in the treatment group (16 (8.2%) vs five (2.5%), p = 0.014). CONCLUSION: The use of the smartwatch/smartphone care platform demonstrated non-inferiority of clinically significant outcomes to traditional care models, while requiring significantly less postoperative physiotherapy and fewer emergency department visits. This platform could aid in decreasing postoperative costs, while improving patient engagement and communication with the healthcare team. Cite this article: Bone Joint J 2021;103-B(6 Supple A):3-12.

Evaluation of Endoscopic Iliopsoas Tenotomy for Treatment of Iliopsoas Impingement After Total Hip Arthroplasty.

BACKGROUND: Iliopsoas impingement after total hip arthroplasty (THA) occurs in up to 4.3% of patients resulting in functional groin pain. Operative treatment historically has included open iliopsoas tenotomy or acetabulum revision. We present a large single surgeon series of patients treated with endoscopic iliopsoas tenotomy for iliopsoas impingement after THA to evaluate the effectiveness and risks. METHODS: A consecutive series of 60 patients with iliopsoas impingement after THA treated with endoscopic iliopsoas tenotomy was retrospectively evaluated. Outcomes assessed were resolution of pain, change in Hip Outcome Score (HOS), and complications. Radiographs were reviewed by a musculoskeletal radiologist to evaluate component positioning and to compare with a control cohort. RESULTS: At last follow-up (mean 5.5 months), 93.3% of patients had resolution of pain. The HOS activities of daily living (ADL) subscale mean was 57.5 (range 10.9-89.3, standard deviation [SD] 18.8) preoperatively and 71.6 (range 14.1-100, SD 26.1) postoperatively (P = .005). The HOS sports subscale mean was 37.3 (range 0-83.3, SD 24.0) preoperatively and 58.1 (range 0-100, SD 33.2) postoperatively (P = .002). One complication was reported, a postoperative hematoma managed conservatively. Body mass index and increased offset were associated with iliopsoas symptoms after THA in this series. CONCLUSION: Endoscopic iliopsoas tenotomy after THA had a 93.3% resolution of pain, clinically important improvements in HOS, and low rate of complications. Endoscopic tenotomy should be considered as a treatment option in patients with iliopsoas impingement after THA.

Do Patient Expectations Influence Patient-Reported Outcomes and Satisfaction in Total Hip Arthroplasty? A Prospective, Multicenter Study.

BACKGROUND: The relationship between patient expectations and patient-reported outcomes (PROs) in total hip arthroplasty (THA) patients is controversial. The purpose of this study was to examine the impact of preoperative patient expectations on postoperative PROs and patient satisfaction. METHODS: This was a prospective multicenter observational cohort study of primary THA patients. Preoperatively, patients completed Hospital for Special Surgery (HSS) Hip Replacement Expectations Survey (expectations), 12 item Short Form Survey (SF-12), University of California, Los Angeles (UCLA) activity score, and Hip Disability and Osteoarthritis Score (HOOS). Postoperatively at 6 months and 1 year, patients completed the Hospital for Special Surgery Hip Replacement Fulfillment of Expectations Survey (fulfillment of expectations), a satisfaction survey, and the same PROs as preoperatively. Stepwise multivariate regression models were created. RESULTS: A total of 207 patients were enrolled. Follow-up rate was 91% at 6 months and 92% at 1 year. Being employed and lower baseline HOOS predicted higher expectations (employment status: B = -7.5, P = .002; HOOS: B = -0.27, P = .002). Higher preoperative expectations predicted greater improvements in UCLA activity, SF-12 physical component score, and HOOS at 6 months (UCLA activity: B = 0.03, P = .001; SF-12 physical component score: B = 0.15, P = .001; HOOS: B = 0.20; P = .008) and UCLA activity at 1 year (B = 0.02, P = .004). Furthermore, higher expectations predicted higher postoperative satisfaction and fulfillment of expectations at 6 months (satisfaction: B = 0.21, P < .001; fulfillment of expectations: B = 0.30, P < .001) and higher fulfillment of expectations at 1 year (B = 0.17, P = .006). CONCLUSION: In patients undergoing THA, being employed and worse preoperative hip function predict of higher preoperative expectations of surgery. Higher expectations predict greater improvement in PROs, greater patient satisfaction, and the fulfillment of expectations. These findings can be used to guide patient counseling and shared decision making preoperatively.

Arthroplasty for Unreconstructable Acute Fractures and Failed Fracture Fixation About the Hip and Knee in the Active Elderly: A New Paradigm.

The techniques, materials, and designs for total joint arthroplasty underwent major improvements in the past 30 years. During this time, trauma surgeons classified the severity of fractures as well as identified certain articular fractures that do not have good outcomes and have a high rate of failure after internal fixation. Advanced improvements in arthroplasty have increased its reliability and longevity. Total joint arthroplasty is becoming a standard of care for some acute articular fractures, particularly displaced femoral neck fractures in the active elderly. Total joint arthroplasty also has become the standard of care after failed internal fixation in patients who have very complicated fractures about the knee, hip, and shoulder. As the population ages, fractures worldwide continue to rapidly increase. Elderly patients have a high risk for fractures that result from falls because of their poor bone quality. The current active elderly population participates in higher risk activities than previous elderly populations, which places them at risk for more injuries. This has become both a worldwide healthcare problem and an economic problem. Surgeons need to manage fractures in the active elderly with the latest advancements in technology and patient selection to ensure rapid recovery and the reduction of complications.

Higher Patient Expectations Predict Higher Patient-Reported Outcomes, But Not Satisfaction, in Total Knee Arthroplasty Patients: A Prospective Multicenter Study.

BACKGROUND: The relationship between patient expectations, patient-reported outcomes (PROs), and satisfaction in total knee arthroplasty (TKA) patients is not well understood. METHODS: We prospectively evaluated patients who underwent primary TKA at 4 institutions. Demographics were collected. Preoperatively, patients completed the Hospital for Special Surgery Knee Replacement Expectations Survey (HSS-KRES), SF-12, UCLA activity, and Knee Disability and Osteoarthritis Score. At 6 months and 1 year postoperatively, patients completed the Hospital for Special Surgery Knee Replacement Fulfillment of Expectations Survey (HSS-KRFES), a satisfaction survey, and PROs. Step-wise multivariate regression models were created. RESULTS: Eighty-three patients were enrolled. At 6 months and 1 year postoperatively, the follow-up rate was 84.3% and 92.7%, respectively. No demographics or preoperative PROs were predictive of HSS-KRES. Preoperative HSS-KRES did not predict postoperative satisfaction, but higher HSS-KRES predicted higher HSS-KRFES at 1 year, greater improvement in UCLA activity at 6 months and 1 year, and SF-12 Physical Composite Scale and Knee Disability and Osteoarthritis Score at 6 months. Higher HSS-KRFES predicted higher satisfaction at 6 months and 1 year. CONCLUSION: In TKA patients, preoperative expectations are not influenced by patient demographics or preoperative function. Higher preoperative expectations predict greater postoperative improvement in PROs and fulfillment of expectations. These findings highlight the importance of preoperative patient expectations on postoperative outcome.

Impact of Anterior vs Posterior Approach for Total Hip Arthroplasty on Post-Acute Care Service Utilization.

BACKGROUND: Controversy exists as to which surgical approach is best for total hip arthroplasty (THA). Previous studies suggested that the tissue-sparing anterior approach should result in a more rapid recovery requiring fewer postacute services, ultimately decreasing overall episodic cost. The purpose of this cross-sectional study was to determine if any significant differences exist between the anterior vs posterior approaches on postacute care service utilization, readmissions, or episodic cost. METHODS: Claims data from 26,773 Medicare fee-for-service beneficiaries receiving elective THAs (Medical Severity-Diagnosis Related Groups (MS-DRGs) 469/470) were analyzed. Claims data were collected from the 2-year period, January 2013 through December 2014. The posterior surgical approach was performed on 23,653 patients while 3120 patients received the anterior approach. RESULTS: Data analysis showed negligible effect sizes in postacute care service utilization, readmission rate, and cost between the surgical approaches for elective THA (MS-DRG 469 and 470). Average THA total episode cost was negligibly higher for procedures using the anterior approach compared to the posterior approach ($22,517 and $22,068, respectively). Statistically significant differences were observed in inpatient rehab and home health cost and service utilization. However, the effect sizes of these comparisons are negligible when accounting for the large sample size. All other comparisons showed minimal and statistically insignificant variation. CONCLUSION: The results indicate that surgical approach alone is not the primary driver of postacute care service utilization, quality outcomes, or cost. Other factors such as physician-led patient-focused care pathways, care coordination, rapid rehabilitation protocols, perioperative pain management protocols, and patient education are integral for effective patient care.

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.

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.