A Stepwise Replicable Approach to Negotiating Value-driven Supply Chain Contracts for Orthobiologics.

INTRODUCTION: Orthobiologics are increasingly used to augment healing of tissues. Despite growing demand for orthobiologic products, many health systems do not enjoy substantial savings expected with high-volume purchases. The primary goal of this study was to evaluate an institutional program designed to (1) prioritize high-value orthobiologics and (2) incentivize vendor participation in value-driven contractual programs. METHODS: A three-step approach was used to reduce costs through optimization of orthobiologics supply chain. First, surgeons with orthobiologics expertise were engaged in key supply chain purchasing decisions. Second, eight orthobiologics formulary categories were defined. Capitated pricing expectations were established for each product category. Capitated pricing expectations were established for each product using institutional invoice data and market pricing data. In comparison with similar institutions, products offered by multiple vendors were priced at a lower benchmark (10th percentile of market price) than more rare products priced at the 25th percentile of the market price. Pricing expectations were transparent to vendors. Third, a competitive bidding process required vendors to submit pricing proposals for products. Clinicians and supply chain leaders jointly awarded contracts to vendors that met pricing expectations. RESULTS: Compared with our projected estimate of $423,946 savings using capitated product prices, our actual annual savings was $542,216. Seventy-nine percent of savings came from allograft products. Although the number of total vendors decreased from 14 to 11, each of the nine returning vendors received a larger, three-year institutional contract. Average pricing decreased across seven of the eight formulary categories. DISCUSSION: This study demonstrates a three-step replicable approach to increase institutional savings for orthobiologic products, engaging clinician experts, and strengthening relationships with select vendors. Vendor consolidation permits a symbiotic win-win relationship: Health systems achieve increased value by reducing unnecessary complexity of multiple contracts, and vendors obtain larger contracts with increased market share. LEVEL OF EVIDENCE: Level IV study.

Optimizing Orthopaedic Trauma Implant Pricing Through a Data-Driven and Surgeon-Integrated Approach.

OBJECTIVE: To determine whether market-based pricing could be coupled with surgeon integration into negotiation strategies to achieve lower pricing levels for orthopaedic trauma implants. A secondary aim was to identify specific types of implants that may offer larger opportunities for cost savings. METHODS: Market pricing levels were reviewed from 2 industry implant databases. This information was used by surgeons and supply chain management at our institution to select appropriate target pricing levels (25th percentile) for commonly used orthopaedic trauma implants. Target price values were provided to the existing 12 vendors used by our institution with a clear expectation that vendors meet these thresholds. RESULTS: Benchmark modeling projected a potential savings of 20.0% over our prior annual spend on trauma implants. After 2 rounds of negotiation, savings amounted to 23.0% of prior annual spend. Total savings exceeded 1,000,000 USD with 11 of 12 vendors (91.7%) offering net savings. Total percent savings were highest for external fixators, drill bits, and K-wires. Plates and screws comprised the greatest proportion of our prior annual spend and achieved similar savings. CONCLUSION: A surgeon and supply chain coordinated effort led to major cost savings without a need for consolidation of vendors. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Physicians' Awareness of Depression Among Their Patients in Saudi Arabia.

Background Depression is a global public health burden, and although it is multifactorial, its development is highly associated with chronic diseases. Thus, physicians' knowledge and attitude toward depression are vital for the recognition and treatment of depression among patients with chronic illnesses. This study aims to examine physicians' knowledge and attitude toward depression in Saudi Arabia and to determine factors that significantly influence them. Methodology An online survey using a 12-item questionnaire was completed by 50 physicians between January and June 2020. Knowledge (K) and attitude (A) scores were calculated and compared nonparametrically based on scores by gender and years of experience. Results Participants' years of clinical experience was found to significantly influence the participants' K scores, with those with fewer than one year of experience having the highest K scores of all participants (p < 0.05). Years of experience had a similar influence on the A scores. Furthermore, gender was an influencing factor as male participants had higher A scores than female participants. Years of experience and gender influenced the A scores independently. Male physicians more commonly referred patients to a mental health specialist than female physicians, and had significantly higher A scores and more years of experience. There was a direct correlation between the K and A score, indicating that participants' knowledge of depression positively influenced their attitude toward depression. Conclusions In this study, participants' gender and years of experience have been identified to have a significant impact on their knowledge and attitude toward comorbid depression when treating patients with chronic illnesses. This identifies an important gap and offers preliminary insight into the readiness and practice of holistic care for patients, particularly for those treated by physicians of differing gender and experience levels. Findings further demonstrate that it is most beneficial to patients with chronic illnesses that physicians utilize a holistic approach and consider depression when developing their treatment plans. This would involve being able to detect and manage depression among their patients properly, as well as referring patients to mental health specialists when needed. Clinical guidelines should be updated to emphasize the use of depression screening tools for patients with chronic diseases.

The Effect of an Electronic Prescribing Policy for Opioids on Physician Prescribing Patterns Following Common Upper Extremity Procedures.

Purpose: We evaluated physician prescribing patterns before and after the implementation of a state-mandated opioid electronic prescribing (ePrescribing) program after 4 common outpatient hand surgeries. Specifically, we aimed to answer the following: (1) is there a change in the number of opioids prescribed after the institution of ePrescribing for carpal tunnel release (CTR), ganglion excision, distal radius fracture (DRF) open reduction internal fixation (ORIF), and carpometacarpal (CMC) arthroplasty and (2) what factors are associated with an increased number of tablets or total morphine milligram equivalents (MMEs) prescribed. Methods: We retrospectively reviewed patients who underwent CTR, ganglion excision, DRF ORIF, or CMC arthroplasty and analyzed the number of tablets and MMEs prescribed before and after the policy implementation, as well as which factors were associated with an increased total number of opioid tablets and MMEs prescribed. Results: A total of 428 patients were included. After policy implementation, there was a significant decrease in MMEs prescribed for ganglion excision (68 [SD, 45] vs 50 [SD, 60], P = .03) and CMC arthroplasty (283 [SD, 147] vs 217 [SD, 92], P < .01). There was also a significant decrease in the total number of tablets prescribed for ganglion excision (11 [SD, 5.7] vs 6.8 [SD, 8.0], P < .01), CMC arthroplasty (36 [SD, 13] vs 29 [SD, 12], P < .01), and DRF ORIF (31 [SD, 8.6] vs 28 [SD, 8.5], P = .04). The number of patients receiving any opioid prescription also significantly decreased following CTR (30% vs 51%, P = .03) and ganglion excision (11% vs 53%, P < .01). Conclusions: The initiation of state-mandated ePrescribing was associated with a decreased number of opioids-both MMEs and tablets-prescribed after surgery by hand surgeons for a variety of common procedures. Furthermore, a greater percentage of patients received no opioid prescriptions after ePrescribing. These findings support the value of ePrescribing as a potential tool to further decrease excess opioid prescriptions. Type of study/level of evidence: Therapeutic III.

Does healthcare system device volume correlate with price paid for spinal implants: a cross-sectional analysis of a national purchasing database.

OBJECTIVES: Amid continuously rising US healthcare costs, particularly for inpatient and surgical services, strategies to more effectively manage supply chain expenses are urgently necessary. Across industries, the 'economy of scale' principle indicates that larger purchasing volumes should correspond to lower prices due to 'bulk discounts'. Even as such advantages of scale have driven health system mergers in the USA, it is not clear whether they are being achieved, including for specialised products like surgical implants which may be more vulnerable to cost inefficiency. The objective of this observational cross-sectional study was to investigate whether purchasing volumes for spinal implants was correlated with price paid. SETTING: USA. PARTICIPANTS: Market data based on pricing levels for spine implants were reviewed from industry implant price databases. Filters were applied to narrow the sample to include comparable institutions based on procedural volume, patient characteristics and geographical considerations. Information on the attributes of 619 health systems representing 12 471 provider locations was derived from national databases and analytics platforms. PRIMARY OUTCOME MEASURE: Institution-specific price index paid for spinal implants, normalised to the national average price point achieved. RESULTS: A Spearman's correlation test indicated a weak relationship between purchasing volume and price index paid (ρ=-0.35, p<0.001). Multivariable linear regression adjusting for institutional characteristics including type of hospital, accountable care organisation status, payer-mix, geography, number of staffed beds, number of affiliated physicians and volume of patient throughput also did not exhibit a statistically significant relationship between purchasing volume and price index performance (p=0.085). CONCLUSIONS: National supply chain data revealed that there was no significant relationship between purchasing volume and price paid by health systems for spinal implants. These findings suggest that factors other than purchasing or patient volume are responsible for setting prices paid by health systems to surgical vendors and/or larger healthcare systems are not negotiating in a way to consistently achieve optimal pricing.

Performance of a Commonly Used Pressure Injury Risk Model Under Changing Incidence.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) cause patient harm and increase health care costs. We sought to evaluate the performance of the Braden QD Scale-associated changes in HAPI incidence. METHODS: Using electronic health records data from a quaternary children's hospital, we evaluated the association between Braden QD scores and patient risk of HAPI. We analyzed how this relationship changed during a hospitalwide quality HAPI reduction initiative. RESULTS: Of 23,532 unique patients, 108 (0.46%, 95% confidence interval [CI] = 0.38%-0.55%) experienced a HAPI. Every 1-point increase in the Braden QD score was associated with a 41% increase in the patient's odds of developing a HAPI (odds ratio [OR] = 1.41, 95% CI = 1.36-1.46, p < 0.001). HAPI incidence declined significantly following implementation of a HAPI-reduction initiative (ß = -0.09, 95% CI = -0.11 - -0.07, p < 0.001), as did Braden QD positive predictive value (ß = -0.29, 95% CI = -0.44 - -0.14, p < 0.001) and specificity (ß = -0.28, 95% CI = -0.43 - -0.14, p < 0.001), while sensitivity (ß = 0.93, 95% CI = 0.30-1.75, p = 0.01) and the concordance statistic (ß = 0.18, 95% CI = 0.15-0.21, p < 0.001) increased significantly. CONCLUSION: Decreases in HAPI incidence following a quality improvement initiative were associated with (1) significant deterioration in threshold-dependent performance measures such as specificity and precision and (2) significant improvements in threshold-independent performance measures such as the concordance statistic. The performance of the Braden QD Scale is more stable as a tool that continuously measures risk than as a prediction tool.

Nationwide Ethnic/Racial Differences in Surgical Treatment of Discoid Meniscus in Children: A PHIS Database Study.

BACKGROUND: Discoid meniscus, a congenital meniscus variant, may have greater incidence in Asian populations. No US population-based studies have examined the discoid meniscus ethnic/racial distribution. In pediatric patients undergoing meniscus surgery, it is hypothesized that ethnic/racial variability exists in patients with discoid meniscus and this variability is different than in patients with medial meniscus tears. METHODS: The Pediatric Health Information System was queried from 48 hospitals to examine patients 18 years of age and younger between 2015 and 2019, using International Classification of Diseases, 10th Revision, Clinical Modification codes. A cohort of patients treated surgically for discoid meniscus was compared with a cohort of patients treated surgically for medial meniscal tear. These 2 populations were compared based on age, sex, ethnicity/race, Current Procedural Terminology code, insurance, urban versus rural, and region of country. Univariate testing and multivariable logistic modeling were used to test for associations. RESULTS: A discoid meniscus cohort of 399 children (median age, 13.0 y) was compared with a medial meniscus tear cohort of 3157 children (median age, 16.0 y) (P<0.001). Hispanic/Latino children accounted for 36.8% of the discoid lateral meniscus and 22.7% of the medial meniscus populations (P<0.001). Among pediatric patients that had surgery for discoid lateral meniscus or medial meniscus, Hispanic/Latino children had 2.36 times the odds of surgery for discoid meniscus compared with White patients after adjusting for age and insurance (P<0.001). Asian children also had 2.41 times the odds of surgery for discoid meniscus compared with White patients (P=0.017). CONCLUSIONS: This study shows a significant association of ethnicity/race with discoid versus medial meniscus surgical treatment in children. Among pediatric patients undergoing surgery for discoid meniscus, Hispanic/Latino and Asian patients were a significantly larger percentage of the population than White patients. Hispanic/Latino children made up a greater percentage of the population having surgery for a torn discoid meniscus versus a torn medial mensicus. When evaluating pediatric patients, younger age and Asian or Hispanic/Latino ethnicity should increase attention to the possibility of a discoid meniscus. LEVEL OF EVIDENCE: Level IV.

Increased incidence of acute patellar dislocations and patellar instability surgical procedures across the United States in paediatric and adolescent patients.

PURPOSE: Patellofemoral instability is a common cause of knee pain and dysfunction in paediatric and adolescent patients. The purpose of the study was to evaluate the frequency of patellar dislocations seen in emergency departments (EDs) and the rates of surgical procedures for patellar instability at paediatric hospitals in the United States between 2004 and 2014. METHODS: The Pediatric Health Information System database was queried for all paediatric patients who underwent surgery for patellar instability or were seen in the ED for acute patellar dislocation between 2004 and 2014. This was compared with the annual numbers of overall orthopaedic surgical procedures. RESULTS: Between 2004 and 2014, there were 3481 patellar instability procedures and 447 285 overall orthopaedic surgical procedures performed at the included institutions, suggesting a rate of 7.8 per 1000 orthopaedic surgeries. An additional 5244 patellar dislocations treated in EDs were identified. Between 2004 and 2014, the number of patellar instability procedures increased 2.1-fold (95% confidence interval (CI) 1.4 to 3.0), while orthopaedic surgical procedures increased 1.7-fold (95% CI 1.3 to 2.0), suggesting a 1.2-fold relative increase in patellar instability procedures, compared with total paediatric orthopaedic surgeries. CONCLUSION: This study shows a significant rise in the rate of acute patellar instability treatment events in paediatric and adolescent patients across the country. Surgery for patellar instability also increased over the study period, though only slightly more than the rate of all paediatric orthopaedic surgical procedures. This may suggest that increasing youth sports participation may be leading to a spectrum of increasing injuries and associated surgeries in children. LEVEL OF EVIDENCE: IV.

Trapeziometacarpal Joint Arthritis: Is Duration of Symptoms a Predictor of Surgical Outcomes?

PURPOSE: Great effort has been placed on determining the optimal surgical treatment for trapeziometacarpal joint arthritis (TMA). However, a paucity of literature exists concerning the optimal timing of surgical intervention. We hypothesized that an increased duration of TMA symptoms before operative intervention would negatively affect surgical outcomes. METHODS: We performed a retrospective review on 109 adult patients with 121 joints with symptomatic TMA treated with trapeziectomy and ligament reconstruction with tendon interposition (LRTI) from 2006 to 2017. Outcome measures included Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, complication rates, and surgical revision rates. RESULTS: Among 109 patients, average QuickDASH score at initial presentation was 41.1 ± 17.9. Patients had symptoms of TMA for an average of 3.2 years (median, 2.1 years) before undergoing operative intervention. Patients were divided into 2 groups: those with symptoms less than 2 years and those with symptoms greater than 2 years. Patients who underwent LRTI after less than 2 years of symptoms achieved a significantly greater degree of improvement in the QuickDASH score compared with patients with symptoms greater than 2 years (26.2 vs 5.3). CONCLUSIONS: Patients with less than 2 years of symptomatic TMA before LRTI can expect the greatest improvement in patient-reported disability impairment compared with those with more than 2 years of symptoms. This can be used to counsel patients regarding the optimal timing of surgery if nonsurgical treatment has failed to provide durable symptomatic relief. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Risk Factors for Hardware-Related Complications After Olecranon Fracture Fixation.

The aim of this study was to evaluate risk factors for symptomatic hardware and removal of hardware (ROH) after olecranon open reduction and internal fixation (ORIF) and to assess differences between olecranon locking plate and screws (P&S) or tension band (TB) wire cohorts. The medical records of 331 patients with olecranon fractures treated at two academic level I trauma centers with ORIF from 2012 to 2016 were reviewed. A total of 189 patients were included in the study. Complications, ROH, and subsequent surgery were assessed and compared between cohorts. There were 124 cases in the P&S cohort and 65 in the TB cohort. The overall reoperation rate was 31.2% (59 of 189). The overall incidence of ROH for all cases was 29.1% (55 of 189). Patients who required ROH or developed symptomatic hardware were significantly younger than those who did not (P&S, P<.003; TB, P<.004). Age and body mass index (BMI) were associated with ROH plus symptomatic hardware after P&S. Age (but not BMI) was associated with ROH/symptomatic hardware after TB. Measured hardware prominence was not associated with ROH or ROH plus symptomatic hardware for either the P&S or the TB cohort. Risk factors including patient age and BMI were found to be significantly associated with hardware-related complications. [Orthopedics. 2020;43(3):141-146.].