Relationship between hospital specialization and health outcomes in patients with nonsurgical spinal joint disease in South Korea: A nationwide evidence-based study using national health insurance data.

ABSTRACT: Previous studies on hospital specialization in spinal joint disease have been limited to patients requiring surgical treatment. The lack of similar research on the nonsurgical spinal joint disease in specialized hospitals provides limited information to hospital executives.To analyze the relationship between hospital specialization and health outcomes (length of stay and medical expenses) with a focus on nonsurgical spinal joint diseases.The data of 56,516 patients, which were obtained from the 2018 National Inpatient Sample, provided by the Health Insurance Review and Assessment Service, were utilized. The study focused on inpatients with nonsurgical spinal joint disease and used a generalized linear mixed model with specialization status as the independent variable. Hospital specialization was measured using the Inner Herfindahl-Hirschman Index (IHI). The IHI (value ≤1) was calculated as the proportion of hospital discharges accounted for by each service category out of the hospital's total discharges. Patient and hospital characteristics were the control variables, and the mean length of hospital stay and medical expenses were the dependent variables.The majority of the patients with the nonsurgical spinal joint disease were female. More than half of all patients were middle-aged (40-64 years old). The majority did not undergo surgery and had mild disease, with Charlson Comorbidity Index score ≤1. The mean inpatient expense was 1265.22 USD per patient, and the mean length of stay was 9.2 days. The specialization status of a hospital had a negative correlation with the length of stay, as well as with medical expenses. An increase in specialization status, that is, IHI, was associated with a decrease in medical expenses and the length of stay, after adjusting for patient and hospital characteristics.Hospital specialization had a positive effect on hospital efficiency. The results of this study could inform decision-making by hospital executives and specialty hospital-related medical policymakers.

Robotic total knee arthroplasty: A missed opportunity for cost savings in Bundled Payment for Care Improvement initiatives?

BACKGROUND: The use of robotic total knee arthroplasty has become increasingly prevalent. Proponents of robotic total knee arthroplasty tout its potential to not only improve outcomes, but also to reduce costs compared with traditional total knee arthroplasty. Despite its potential to deliver on the value proposition, whether robotic total knee arthroplasty has led to improved outcomes and cost savings within Medicare's Bundled Payment for Care Improvement initiative remains unexplored. METHODS: Medicare beneficiaries who underwent total knee arthroplasty designated under Medicare severity diagnosis related group 469 or 470 in the year 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals participating in the Bundled Payment for Care Improvement were identified using the Bundled Payment for Care Improvement analytic file. We calculated risk-adjusted, price-standardized payments for the surgical episode from admission through 90-days postdischarge. Outcomes, utilization, and spending were assessed relative to variation between robotic and traditional total knee arthroplasty. RESULTS: Overall, 198,371 patients underwent total knee arthroplasty (traditional total knee arthroplasty: n= 194,020, 97.8% versus robotic total knee arthroplasty: n = 4,351, 2.2%). Among the 3,272 hospitals that performed total knee arthroplasty, only 300 (9.3%) performed robotic total knee arthroplasty. Among the 183 participating in the Bundled Payment for Care Improvement, only 40 (19%) hospitals performed robotic total knee arthroplasty. Risk-adjusted 90-day episode spending was $14,263 (95% confidence interval $14,231-$14,294) among patients who underwent traditional total knee arthroplasty versus $13,676 (95% confidence interval $13,467-$13,885) among patients who had robotic total knee arthroplasty. Patients who underwent robotic total knee arthroplasty had a shorter length of stay (traditional total knee arthroplasty: 2.3 days, 95% confidence interval: 2.3-2.3 versus robotic total knee arthroplasty: 1.9 days, 95% confidence interval: 1.9-2.0), as well as a lower incidence of complications (traditional total knee arthroplasty: 3.3%, 95% confidence interval: 3.2-3.3 versus robotic total knee arthroplasty: 2.7%, 95% confidence interval: 2.3-3.1). Of note, patients who underwent robotic total knee arthroplasty were less often discharged to a postacute care facility than patients who underwent traditional total knee arthroplasty (traditional total knee arthroplasty: 32.4%, 95% confidence interval: 32.3-32.5 versus robotic total knee arthroplasty: 16.8%, 95% confidence interval 16.1-17.6). Both Bundled Payment for Care Improvement and non-Bundled Payment for Care Improvement hospitals with greater than 50% robotic total knee arthroplasty utilization had lower spending per episode of care versus spending at hospitals with less than 50% robotic total knee arthroplasty utilization. CONCLUSION: Overall 90-day episode spending for robotic total knee arthroplasty was lower than traditional total knee arthroplasty (Δ $-587, 95% confidence interval: $-798 to $-375). The decrease in spending was attributable to shorter length of stay, fewer complications, as well as lower utilization of postacute care facility. The cost savings associated with robotic total knee arthroplasty was only realized when robotic total knee arthroplasty volume surpassed 50% of all total knee arthroplasty volume. Hospitals participating in the Bundled Payment for Care Improvement may experience cost-saving with increased utilization of robotic total knee arthroplasty.

Dissociation between the growing opioid demands and drug policy directions among the U.S. older adults with degenerative joint diseases.

We aim to examine temporal trends of orthopedic operations and opioid-related hospital stays among seniors in the nation and states of Oregon and Washington where marijuana legalization was accepted earlier than any others.As aging society advances in the United States (U.S.), orthopedic operations and opioid-related hospital stays among seniors increase in the nation.A serial cross-sectional cohort study using the healthcare cost and utilization project fast stats from 2006 through 2015 measured annual rate per 100,000 populations of orthopedic operations by age groups (45-64 vs 65 and older) as well as annual rate per 100,000 populations of opioid-related hospital stays among 65 and older in the nation, Oregon and Washington states from 2008 through 2017. Orthopedic operations (knee arthroplasty, total or partial hip replacement, spinal fusion or laminectomy) and opioid-related hospital stays were measured. The compound annual growth rate (CAGR) was used to quantify temporal trends of orthopedic operations by age groups as well as opioid-related hospital stays and was tested by Rao-Scott correction of χ for categorical variables.The CAGR (4.06%) of orthopedic operations among age 65 and older increased (P < .001) unlike the unchanged rate among age 45 to 64. The CAGRs of opioid-related hospital stays among age 65 and older were upward trends among seniors in general (6.79%) and in Oregon (10.32%) and Washington (15.48%) in particular (all P < .001).Orthopedic operations and opioid-related hospital stays among seniors increased over time in the U.S. Marijuana legalization might have played a role of gateway drug to opioid among seniors.

Opioid Use is Associated with Higher Severity-Adjusted Episode Costs in Patients with Conservatively Managed Degenerative Joint Disease of the Back and Neck.

BACKGROUND: Opioid use and misuse are urgent health issues. Previous studies suggest that opioid use increases healthcare resource use but severity adjustment is lacking. OBJECTIVE: The objective of this study was to evaluate the severity-adjusted cost difference between opioid users and non-users among patients with conservatively managed degenerative joint disease of the spine within a large commercial health plan population in the United States. METHODS: A retrospective observational study was performed using a national commercial database covering 531,819 patients aged 18-64 years with non-surgically managed cervical or lumbar degenerative spine disease during 2015-6. Patients were grouped based on whether there was evidence for an opioid prescription. Costs for the opioids themselves were excluded. Severity adjustment, on an ascending integer scale from 1 to 4, was performed based on member demographics, clinical comorbidities, disease progression indicators, and complications. RESULTS: Median episode costs for patients given opioids were approximately twice that for patients not given opioids after severity adjustment. For patients with episodes in both years and stable severity, patients with new prescriptions for opioids in 2016 doubled their median 2015 costs, and patients who had opioids discontinued in 2016 had a 60% cost reduction. Episode costs showed a nearly linear increase based on the length of time taking opioids, as well as with a higher average daily dose. Cost increases with opioids were broad across service categories even when comparing within the same severity-adjusted episodes of care. CONCLUSIONS: The data suggest a clinically and statistically significant increase in episode costs associated with opioid use for degenerative joint disease of the spine, both within and between patients, and higher costs with a longer duration of opioid use as well as with higher daily dosages. Given the health consequences surrounding the overuse of opioids, concerted efforts to move towards a non-opioid pain control strategy are needed.

18F-Sodium Fluoride PET/CT and PET/MR Imaging of Bone and Joint Disorders.

18F-sodium fluoride (18F-NaF) PET/CT provides high sensitivity and specificity for the assessment of bone and joint diseases. It is able to accurately differentiate malignant from benign bone lesions, especially when using dynamic quantitative approaches. Its high-quality, clinical accuracy, and high feasibility for patient management and greater availability of PET/CT scanners as well as decreasing trend of the cost of radiotracer all indicate the need to consider the use of 18F-NaF PET/CT as standard bone imaging, particularly in malignant diseases of the skeleton.

General Practitioners Referring Adults to MR Imaging for Knee Pain: A Randomized Controlled Trial to Assess Cost-effectiveness.

Purpose To determine the cost-effectiveness of early referral by the general practitioner for magnetic resonance (MR) imaging compared with usual care alone in patients aged 18-45 years with traumatic knee symptoms. Materials and Methods Cost-utility analysis was performed parallel to a prospective multicenter randomized controlled trial in Dutch general practice. A total of 356 patients with traumatic knee symptoms were included from November 2012 to December 2015 (mean age, 33 years ± 8 [standard deviation]; 222 men [62%]). Patients were randomly assigned to usual care (n = 177; MR imaging was not performed, but patients were referred to an orthopedic surgeon when conservative treatment was unsatisfactory) or MR imaging (n = 179) within 2 weeks after injury. Main outcome measures were quality-adjusted life years (QALYs) and costs from a healthcare and societal perspective. Multiple imputation was used for missing data. The Student t test was used to assess differences in mean QALYs, costs, and net benefits. Results Mean QALYs were 0.888 in the MR imaging group and 0.899 in the usual care group (P = .255). Healthcare costs per patient were higher in the MR imaging group (€1109) than in the usual care group (€837) (P = .050), mainly due to higher costs for MR imaging, with no reduction in the number of referrals to an orthopedic surgeon in the MR imaging group. Conclusion MR imaging referral by the general practitioner was not cost-effective in patients with traumatic knee symptoms; in fact, MR imaging led to more healthcare costs, without an improvement in health outcomes.

Hematologic Malignancies Are Associated with Adverse Perioperative Outcomes following Total Knee Arthroplasty.

The treatment of hematologic malignancies has advanced over the years, resulting in an improved survival of patients. As a result, these patients may be a part of the increasing population requiring total knee arthroplasty (TKA); however, they might be at a higher risk of adverse perioperative outcomes. The purpose of this study was to determine the perioperative outcomes (complications, length of stay [LOS], and costs) of patients with hematologic malignancies following TKA. This study used the Nationwide Inpatient Sample (NIS) to identify patients who underwent TKA in the United States from 2000 to 2011. Patients diagnosed with any hematologic malignancy (N = 24,714) were then stratified by Hodgkin's disease (N = 791), Non-Hodgkin's lymphoma (N = 7,096), plasma cell dyscrasias (N = 1,621), leukemia (N = 8,005), myeloproliferative disease (N = 5,746), and/or myelodysplastic syndromes (N = 1,608) for determining the complications that occurred during admission. Propensity matching was performed for demographics, hospital characteristics, and comorbidities, which yielded 24,491 patients with any hematologic malignancy and 24,458 control patients. Additionally, propensity matching was performed for the hematologic malignancy subtypes. Multivariable regression models were used to analyze the surgical and medical complications, LOS, and costs. The annual frequency of THA in patients with any hematologic malignancy increased from 2000 to 2011 (p < 0.0001). Hematologic malignancies were associated with an increased risk of any surgery-related complication (odds ratio [OR] = 1.31, p < 0.0001) and any general medical complication (OR = 1.38, p < 0.0001). Patients with any hematologic malignancy had increased odds of complications, including acute postoperative anemia (OR = 1.29, p < 0.0001), hematoma/seroma (OR = 1.65, p < 0.02), peripheral vascular disease (OR = 2.23, p = 0.046), deep venous thrombosis (DVT) (OR = 1.95, p = 0.02), and blood transfusion (OR = 1.61, p < 0.0001). Hematologic malignancies were associated with an increased incremental LOS (0.13 d, p < 0.0001) and an increased incremental cost ($788, p < 0.0001). Thus, we conclude that following TKA, patients with hematologic malignancies are at an increased risk of perioperative complications, longer LOS, and higher costs. The risk quantification for adverse perioperative outcomes in association with an increased cost may help design different risk stratification and reimbursement methods in such patients when undergoing TKA.

Do higher-volume hospitals provide better value in revision hip and knee arthroplasty?

AIMS: The purpose of this study is to determine if higher volume hospitals have lower costs in revision hip and knee arthroplasty. MATERIALS AND METHODS: We questioned the Centres for Medicare and Medicaid Services (CMS) Inpatient Charge Data and identified 789 hospitals performing a total of 29 580 revision arthroplasties in 2014. Centres were dichotomised into high-volume (performing over 50 revision cases per year) and low-volume. Mean total hospital-specific charges and inpatient payments were obtained from the database and stratified based on Diagnosis Related Group (DRG) codes. Patient satisfaction scores were obtained from the multiyear CMS Hospital Compare database. RESULTS: High-volume hospitals comprised 178 (30%) of the total but performed 15 068 (51%) of all revision cases, including 509 of 522 (98%) of the most complex DRG 466 cases. While high-volume hospitals had higher Medicare inpatient payments for DRG 467 ($21 458 versus $20 632, p = 0.038) and DRG 468 ($17 003 versus $16 120, p = 0.011), there was no difference in hospital specific charges between the groups. Higher-volume facilities had a better CMS hospital star rating (3.63 versus 3.35, p < 0.001). When controlling for hospital geographic and demographic factors, high-volume revision hospitals are less likely to be in the upper quartile of inpatient Medicare costs for DRG 467 (odds ratio (OR) 0.593, 95% confidence intervals (CI) 0.374 to 0.941, p = 0.026) and DRG 468 (OR 0.451, 95% CI 0.297 to 0.687, p < 0.001). CONCLUSION: While a high-volume hospital is less likely to be a high cost outlier, the higher mean Medicare reimbursements at these facilities may be due to increased case complexity. Further study should focus on measures for cost savings in revision total joint arthroplasties. Cite this article: Bone Joint J 2017;99-B:1611-17.

Arthrofibrosis Associated With Total Knee Arthroplasty.

BACKGROUND: Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. METHODS: In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. RESULTS: Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. CONCLUSION: Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.

Cost-benefit analysis of routine pathology examination in primary shoulder arthroplasty.

BACKGROUND: The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice. METHODS: This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis. RESULTS: We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78. DISCUSSION/CONCLUSION: Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.

Global Forum: The Burden of Bone and Joint Infections: A Growing Demand for More Resources.

The rate and severity of septic complications following joint replacement surgery and the incidence of posttraumatic infections are projected to increase at a faster pace because of a tendency to operate on high-risk patients, including older patients, patients with diabetes, and patients who are immunocompromised or have comorbidities. Musculoskeletal infections are devastating adverse events that may become life-threatening conditions. They create an additional burden on total health-care expenditures, and can lead to functional impairment, long-lasting disability, or even permanent handicap, with the inevitable social and economic burdens. The scientific community should take a more active role to draw public attention to the plight of hundreds of thousands of people across the globe who experience complications, become disabled, and, in some cases, die, and it should highlight what could be achieved if the global community takes decisive steps to improve access, early detection, and appropriate care. However, mitigating the adverse personal, clinical, and socioeconomic effects of these conditions requires increasing financial resources provided by both governments and funding organizations. Furthermore, a targeted action plan from the providers and the professional societies should be put in place so that the burden created by bone and joint infections is included in the agenda for global health-care priorities.

Prosthetic Joint Infections and Cost Analysis?

Prosthetic joint infection is a devastating complication of arthroplasty surgery that can lead to debilitating morbidity for the patient and significant expense for the healthcare system. With the continual rise of arthroplasty cases worldwide every year, the revision load for infection is becoming a greater financial burden on healthcare budgets. Prevention of infection has to be the key to reducing this burden. For treatment, it is critical for us to collect quality data that can guide future management strategies to minimise healthcare costs and morbidity / mortality for patients. There has been a management shift in many countries to a less expensive 1-stage strategy and in selective cases to the use of debridement, antibiotics and implant retention. These appear very attractive options on many levels, not least cost. However, with a consensus on the definition of joint infection only clarified in 2011, there is still the need for high quality cost analysis data to be collected on how the use of these different methods could impact the healthcare expenditure of countries around the world. With a projected spend on revision for infection at US$1.62 billion in the US alone, this data is vital and urgently needed.

[Differences in chronic back pain and joint disorders among health insurance funds : Results of a cross-sectional study based on the data of the Socioeconomic Panel from 2013]. / Kassenunterschiede bei chronischen Rückenschmerzen und Gelenkerkrankungen : Ergebnisse einer Querschnittsstudie auf Grundlage der Daten des sozioökonomischen Panels von 2013.

BACKGROUND: Health services research uses increasingly data from health insurance funds. It is well known that the funds differ with regard to sociodemographic characteristics and morbidity. It is uncertain if there are also differences in the prevalence of musculoskeletal disorders. OBJECTIVE: To compare the sociodemographic characteristics in various health insurance funds and the prevalence of joint disorders and chronic back pain. METHOD: The 30th wave (2013) of the German Socioeconomic Panel served as a database. Average age, sex distribution, nationality, education, and employment status were evaluated according to the health insurance funds. The prevalence of joint disorders and chronic back pain were also stratified according to the insurance funds and standardized according to age and sex. RESULTS: A total of 19,146 participants were included. Most participants (4,934) were insured by AOK, followed by BKK (2,632) and BARMER GEK (2,398). There were huge differences among the health insurance funds with regard to the sociodemographic characteristics. For example, the proportion of unemployed insurants was between 33.3 % (IKK) and 50.6 % (AOK). The prevalence of joint disorders standardized according to age and sex (20.7 %; 95 % CI: 20.1-21.3) was between 17.4 % (95 % CI: 15.8-19.0; PKV) and 22.4 % (95 % CI: 21.1-23.6; AOK). The prevalence of chronic back pain (18.0 %; 95 % CI: 17.4-18.5) was between 13.5 % (95 % CI: 12.2-14.9; PKV) and 20.6 % (95 % CI: 19.4-21.8; AOK). CONCLUSION: There are differences in the prevalence of musculoskeletal disorders among health insurance funds. The extrapolation of analyses of one health insurance fund to the German population is thus limited.

Disparities in TKA Outcomes: Census Tract Data Show Interactions Between Race and Poverty.

BACKGROUND: Race is an important predictor of TKA outcomes in the United States; however, analyses of race can be confounded by socioeconomic factors, which can result in difficulty determining the root cause of disparate outcomes after TKA. QUESTIONS/PURPOSES: We asked: (1) Are race and socioeconomic factors at the individual level associated with patient-reported pain and function 2 years after TKA? (2) What is the interaction between race and community poverty and patient-reported pain and function 2 years after TKA? METHODS: We identified all patients undergoing TKA enrolled in a hospital-based registry between 2007 and 2011 who provided 2-year outcomes and lived in New York, Connecticut, or New Jersey. Of patients approached to participate in the registry, more than 82% consented and provided baseline data, and of these patients, 72% provided 2-year data. Proportions of patients with complete followup at 2 years were lower among blacks (57%) than whites (74%), among patients with Medicaid insurance (51%) compared with patients without Medicaid insurance (72%), and among patients without a college education (67%) compared with those with a college education (71%). Our final study cohort consisted of 4035 patients, 3841 (95%) of whom were white and 194 (5%) of whom were black. Using geocoding, we linked individual-level registry data to US census tracts data through patient addresses. We constructed a multivariate linear mixed-effect model in multilevel frameworks to assess the interaction between race and census tract poverty on WOMAC pain and function scores 2 years after TKA. We defined a clinically important effect as 10 points on the WOMAC (which is scaled from 1 to 100 points, with higher scores being better). RESULTS: Race, education, patient expectations, and baseline WOMAC scores are all associated with 2-year WOMAC pain and function; however, the effect sizes were small, and below the threshold of clinical importance. Whites and blacks from census tracts with less than 10% poverty have similar levels of pain and function 2 years after TKA (WOMAC pain, 1.01 ± 1.59 points lower for blacks than for whites, p = 0.53; WOMAC function, 2.32 ± 1.56 lower for blacks than for whites, p = 0.14). WOMAC pain and function scores 2 years after TKA worsen with increasing levels of community poverty, but do so to a greater extent among blacks than whites. Disparities in pain and function between blacks and whites are evident only in the poorest communities; decreasing in a linear fashion as poverty increases. In census tracts with greater than 40% poverty, blacks score 6 ± 3 points lower (worse) than whites for WOMAC pain (p = 0.03) and 7 ± 3 points lower than whites for WOMAC function (p = 0.01). CONCLUSIONS: Blacks and whites living in communities with little poverty have similar patient-reported TKA outcomes, whereas in communities with high levels of poverty, there are important racial disparities. Efforts to improve TKA outcomes among blacks will need to address individual- and community-level socioeconomic factors. LEVEL OF EVIDENCE: Level III, therapeutic study.

Bundled Payments: Our Experience at an Academic Medical Center.

BACKGROUND: The landscape of health care is transitioning from a fee-for-service model to value-based purchasing. METHODS: We developed evidence-based clinical pathways and risk stratification measures to effectively implement the Bundled Payments for Care Improvement model of value-based purchasing. RESULTS: We decreased patients' length of stay, discharge to inpatient facilities, and cost of an episode of patient care. CONCLUSION: The bundled care payment initiative has been successfully implemented for Diagnosis Related Groups 469 and 470, delivering high-quality patient care at a reduced price.

Prevalence and Costs of Rehabilitation and Physical Therapy After Primary TJA.

This study evaluated the trends in discharge patterns and the prevalence and cost of post-discharge PT. The 5% Medicare database (1997-2010) was used to identify 50,886 primary THA and 107,675 TKA patients. More than 50% of patients were discharged from hospital to an inpatient facility. There were an increase in discharges to skilled nursing units and a reduced rate to rehabilitation facilities. In contrast to hospital, surgeon reimbursement, and implant costs, the average annual PT cost per patient rose through the study period. Approximately 25% of PT costs were used on less common modalities. PT costs more than $648 million a year. With the increased pressure to control costs for primary TJA, these patterns may change unless PT effectiveness can be demonstrated.

The association of market competition with hospital charges, length of stay, and quality outcomes for patients with joint diseases: a longitudinal study in Korea.

This study investigated the association of market competition with hospital charges, length of stay, and quality outcomes. A total of 279,847 patients from 851 hospitals were analyzed. The Herfindahl-Hirschman Index was used as a measure of hospital market competition level. Our results suggest that hospitals in less competitive markets charged more on charge per admission, possibly by increasing the length of stays, however, hospitals in more competitive markets charged more for daily services by providing more intensive services while reducing the length of stays, thereby reducing the overall charge per admission. Quality outcomes measured by mortality within 30 days of admission and readmission within 30 days of discharge were better for surgical procedures within competitive areas. Continued government monitoring of hospital response to market competition level is recommended in order to determine whether changes in hospitals' strategies influence the long-term outcomes of services performance and health care spending.

Clinical negligence in foot and ankle surgery: A 17-year review of claims to the NHS Litigation Authority.

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012. A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed. During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million. There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement. Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.