Do Medicare's Patient-Reported Outcome Measures Collection Windows Accurately Reflect Academic Clinical Practice?

BACKGROUND: The Comprehensive Care for Joint Replacement (CJR) mandates collection of patient-reported outcome measures (PROMs) for eligible total hip and total knee arthroplasty (THA and TKA) procedures during specific time periods that may not be attainable within routine academic practice. METHODS: We performed a retrospective analysis of prospectively collected PROM data from a 2017 cohort of primary THA and TKA patients who completed the Patient-Reported Outcomes Measurement Information System-10 global health survey in preoperative or postoperative time periods. The primary outcome was completion rates of Patient-Reported Outcomes Measurement Information System-10 per the CJR collection periods (90-0 days preoperative and 270-365 days postoperative) compared to an extended postoperative collection period of 270-396 days. Bivariate analysis and logistic regression were used to analyze the association between survey completion rates and patient characteristics. RESULTS: Of the 860 primary THAs and TKAs in 2017, 725 (84.3%) had preoperative surveys completed 90-0 days before surgery. Among the 725 patients, 215 (29.7%) completed postoperative surveys within the CJR timeline of 270-365 days. Completion increased by 120 additional surveys (+16.5%) in the additional postoperative time period of 270-396 days (P < .001). No patient or procedural factors significantly correlated with a higher likelihood of postoperative PROM completion (P > .05 for all covariates). CONCLUSION: In an academic clinical practice, completion rates of postoperative PROMs as part of routine clinical practice within the CJR mandated period was low for THA and TKA patients. CJR may consider additional time beyond 365 days to improve PROM completion rates.

Long-Term Implant Survivorship and Modes of Failure in Simultaneous Concurrent Bilateral Total Knee Arthroplasty.

BACKGROUND: There is limited evidence describing long-term implant survivorship and modes of failure in simultaneous concurrent bilateral total knee arthroplasty (TKA). METHODS: We performed a retrospective review of 266 consecutive patients (532 knees) who underwent simultaneous concurrent bilateral TKA. We reviewed medical records for preoperative characteristics, perioperative complications, and revision surgeries. The primary outcome was TKA survivorship. Secondary outcomes included indication and type of revision surgery. We used the Kaplan-Meier method to estimate survivorship and characterize risk of revision up to 20 years post-TKA. RESULTS: Our cohort had median follow-up of 9.8 years (interquartile range, 3.9-15.9). Forty-four patients (17%) underwent revision. Revision was more common among younger and male patients. The cumulative incidence of first-time revision per knee (n = 532) was 1.27 per 100 component-years. Implant survival was 99% (confidence interval, 97%-99%) at 5 years, 92% (89%-95%) at 10 years, 83% (77%-87%) at 15 years, and 62% (50%-73%) at 20 years. Five and 10-year survivorship compared favorably to estimates of TKA survivorship in the literature. The cumulative incidence of revision surgery per patient was 1.91 per 100 component-years. Implant survival at 5-, 10-, 15-, and 20-year time points was 96% (CI, 92%-98%), 84% (77%-89%), 71% (62%-79%), and 59% (46%-70%), respectively. Aseptic loosening (40%), polyethylene wear (34%), and infection (11%) were the most common indications for revision. CONCLUSION: Simultaneous concurrent bilateral TKA is associated with a higher risk of reoperation for the patient when both knees are evaluated but similar implant survivorship to the literature when each knee was evaluated in isolation.

Resident Participation is Not Associated With Worse Outcomes After TKA.

BACKGROUND: Approximately one-half of all US surgical procedures, and one-third of orthopaedic procedures, are performed at teaching hospitals. However, the effect of resident participation and their level of training on patient care for TKA postoperative physical function, operative time, length of stay, and facility discharge are unclear. QUESTIONS/PURPOSES: (1) Are resident participation, postgraduate year (PGY) training level, and number of residents associated with absolute postoperative Patient-Reported Outcomes Measurement Information System (PROMIS®-10) global physical function score (PCS), and achieving minimum clinically important difference (MCID) PCS improvement, after TKA? (2) Are resident participation, PGY, and number of residents associated with increased TKA operative time? (3) Are resident participation, PGY, and number of residents associated with increased length of stay after TKA? (4) Are resident participation, PGY, and number of residents associated with higher odds of patients being discharged to another inpatient facility, rather than to their home (facility discharge)? METHODS: We performed a retrospective study using a longitudinally maintained institutional registry of TKAs that included 1626 patients at a single tertiary academic institution from April 2011 through July 2016. All patients who underwent primary, elective unilateral TKA were included with no exclusions. All patients were included in the operative time, length of stay, and facility discharge models. The PCS model required postoperative PCS score (n = 1417; 87%; mean, 46.4; SD, 8.5) and the MCID PCS model required pre- and postoperative PCS (n = 1333; 82%; 55% achieved MCID). Resident participation was defined as named residents being present in the operating room and documented in the operative notes, and resident PGY level was determined by the date of TKA and its duration since the resident entered the program and using the standard resident academic calendar (July - June). Multivariable regression was used to assess PCS scores, operative time, length of stay, and facility discharge in patients whose surgery was performed with and without intraoperative resident participation, accounting for PGY training level and number of residents. We defined the MCID PCS score improvement as 5 points on a 100-point scale. Adjusting variables included surgeon, academic year, age, sex, race-ethnicity, Charlson Comorbidity Index, preoperative PCS, and patient-reported mental function, BMI, tobacco use, alcohol use, and postoperative PCS time for the PCS models. We had postoperative PCS for 1417 (87%) surgeries. RESULTS: Compared with attending-only TKAs (5% of procedures), no postgraduate year or number of residents was associated with either postoperative PCS or MCID PCS improvement (PCS: PGY-1 = -0.98, 95% CI, -6.14 to 4.17, p = 0.708; PGY-2 = -0.26, 95% CI, -2.01to 1.49, p = 0.768; PGY-3 = -0.32, 95% CI, -2.16 to 1.51, p = 0.730; PGY-4 = -0.28, 95% CI, -1.99 to 1.43, p = 0.746; PGY-5 = -0.47, 95% CI, -2.13 to 1.18, p = 0.575; two residents = 0.28, 95% CI, -1.05 to 1.62, p = 0.677) (MCID PCS: PGY-1 = odds ratio [OR], 0.30, 95% CI, 0.07-1.30, p = 0.108; PGY-2 = OR, 0.86, 95% CI, 0.46-1.62, p = 0.641; PGY-3 = OR, 0.97, 95% CI, 0.49-1.89, p = 0.921; PGY-4 = OR, 0.73, 95% CI, 0.39-1.36, p = 0.325; PGY-5 = OR, 0.71, 95% CI, 0.39-1.29, p = 0.259; two residents = OR, 1.23, 95% CI, 0.80-1.89, p = 0.337). Longer operative times were associated with all PGY levels except for PGY-5 (attending surgeon only [reference] = 85.60 minutes, SD, 14.5 minutes; PGY-1 = 100. 13 minutes, SD, 21.22 minutes, +8.44 minutes, p = 0.015; PGY-2 = 103.40 minutes, SD, 23.01 minutes, +11.63 minutes, p < 0.001; PGY-3 = 97.82 minutes, SD, 18.24 minutes, +9.68 minutes, p < 0.001; PGY-4 = 96.39 minutes, SD, 18.94 minutes, +4.19 minutes, p = 0.011; PGY-5 = 88.91 minutes, SD, 19.81 minutes, -0.29 minutes, p = 0.853) or the presence of multiple residents (+4.39 minutes, p = 0.024). There were no associations with length of stay (PGY-1 = +0.04 days, 95% CI, -0.63 to 0.71 days, p = 0.912; PGY-2 = -0.08 days, 95% CI, -0.48 to 0.33 days, p = 0.711; PGY-3 = -0.29 days, 95% CI, -0.66 to 0.09 days, p = 0.131; PGY-4 = -0.30 days, 95% CI, -0.69 to 0.08 days, p = 0.120; PGY-5 = -0.28 days, 95% CI, -0.66 to 0.10 days, p = 0.145; two residents = -0.12 days, 95% CI, -0.29 to 0.06 days, p = 0.196) or facility discharge (PGY-1 = OR, 1.03, 95% CI, 0.26-4.08, p = 0.970; PGY-2 = OR, 0.61, 95% CI, 0.31-1.20, p = 0.154; PGY-3 = OR, 0.98, 95% CI, 0.48-2.02, p = 0.964; PGY-4 = OR, 0.83, 95% CI, 0.43-1.57, p = 0.599; PGY-5 = OR, 0.7, 95% CI, 0.41-1.40, p = 0.372; two residents = OR, 0.93, 95% CI, 0.56-1.54, p = 0.766) for any PGY or number of residents. CONCLUSIONS: Our findings should help assure patients, residents, physicians, insurers, and hospital administrators that resident participation, after adjusting for numerous patient and clinical factors, does not have any association with key medical and financial metrics, including postoperative PCS, MCID PCS, length of stay, and facility discharge. Future research in this field should focus on whether residents affect knee-specific patient-reported outcomes such as the Knee Injury and Osteoarthritis Score and additional orthopaedic procedures, and determine how resident medical education can be further enhanced without compromising patient care and safety.Level of Evidence Level III, therapeutic study.

Prognostic Factors for Success After Irrigation and Debridement With Modular Component Exchange for Infected Total Knee Arthroplasty.

BACKGROUND: Irrigation and debridement with modular component exchange (IDMCE) can treat prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Compared to 2-stage revision, IDMCE is associated with lower morbidity but may carry higher infection recurrence rates. We aimed to identify prognostic factors associated with successful IDMCE in patients with PJI. METHODS: We identified 99 consecutive patients who underwent IDMCE following TKA PJI at a tertiary academic medical center from November 2009 through January 2016. Examined variables included age, gender, symptom duration, body mass index, Charlson comorbidity index, total protein, albumin, hemoglobin A1c, erythrocyte sedimentation rate (ESR), C-reactive protein, white blood cell count, gram stain results, final cultures, and use of long-term antibiotic suppression. Success was defined as no further operation on the ipsilateral knee. We used t tests and chi-square analyses to determine whether each preoperative factor was associated with IDMCE reoperation. RESULTS: At mean follow-up of 2.6 years, 64 patients who underwent IDMCE were defined as successful. Thirty-five patients required one or more additional procedures for recurrent infection; of these, 20 patients underwent 2-stage revision. Patients with symptom duration of less than 2 days avoided additional surgery in 88% of cases. Elevated ESR >47 mm/h was the only variable associated with reoperation (P = .005). There were no associations among the other examined variables. CONCLUSION: Using IDMCE for PJI after TKA required reoperation in 35% of cases. Elevated preoperative ESR laboratory values and duration of symptoms >2 days were associated with reoperation.

Patient Outcomes After Total Knee Arthroplasty in Patients Older Than 80 Years.

BACKGROUND: Patients aged 80 and above who suffer from end-stage osteoarthritis may benefit from total knee arthroplasty (TKA), but at high potential risk. Additionally, there is controversy about whether functional improvement in patients above age 80 is similar to younger patients. We compared functional improvement, length of stay (LOS), and facility discharge rates after TKA between this cohort and patients less than 80 years of age. METHODS: We completed a retrospective cohort study comparing TKA patients aged 80 and above with all patients younger than 80. We utilized data from a prospectively collected institutional repository of 2308 TKAs performed from April 2011 through July 2016 at an academic medical center in the United States. We performed multivariable logistic regression to determine the association between age group and clinically significant improvement in the Patient-Reported Outcome Measurement Information System (PROMIS)-10 physical component summary (PCS) score. Secondary outcomes included the magnitude of PCS change, LOS, and facility discharge. RESULTS: There were 175 (7.6%) TKAs in patients older than 80 years compared with 2133 TKAs in patients younger than 80. Patients over 80 had similar adjusted odds of achieving clinically significant PCS improvement following TKA (P = .366), and there was no statistical difference in adjusted postoperative PCS improvement between the 2 age groups. Age 80 and above was associated with a longer adjusted LOS and demonstrated increased odds of facility discharge (odds ratio 4.11, P < .001) after TKA. CONCLUSION: Following TKA, patients older than 80 years demonstrate similar adjusted functional improvement in comparison to younger patients. However, older patients did require substantially more resources as they remained in the hospital longer and were discharged to rehabilitation more often.

Are Barbed Sutures Associated With 90-day Reoperation Rates After Primary TKA?

BACKGROUND: Studies have suggested that barbed sutures for wound closure in TKAs are an acceptable alternative to standard methods. However others have observed a higher risk of wound-related complications with barbed sutures. QUESTIONS/PURPOSES: (1) Do 90-day TKA reoperation rates differ between patients undergoing a barbed suture arthrotomy closure compared with a traditional interrupted closure? (2) Do the 90-day reoperation rates of wound-related, deep infection, and arthrotomy failure complications differ between barbed suture and traditional closures? METHODS: A retrospective analysis of a longitudinally maintained institutional primary TKA database was conducted on all TKAs performed between April 2011 and September 2015. We compared 884 primary TKAs, where the arthrotomy was closed with a barbed suture, with 1598 primary TKAs closed with the standard interrupted suture. After barbed sutures were introduced at our institution in 2012, the majority of surgeons gradually switched to barbed suture closures, with many using them exclusively by the end of the data collection period. We confirmed in-person followups and available data past 90 days for 97.4% (1556 of 1598) of the knees in patients with standard sutures and 94.8% (838 of 884) of the knees in patients with barbed sutures. Our primary endpoint was all-cause 90-day reoperation; our secondary endpoints considered: wound-related reoperation, as defined by previous studies; deep infection per Musculoskeletal Infection Society guidelines; and arthrotomy failure, defined intraoperatively as an opening or dehiscence through the previous arthrotomy closure. T tests and chi-square analyses were used to determine differences between the suture cohorts, and bivariate logistic regression was used to determine associations with our 90-day reoperation outcomes. RESULTS: With the numbers available, there was no association between suture type and 90-day all-cause reoperation (odds ratio [OR], 1.70; 95% CI, 0.82-3.53; p = 0.156). Suture type was not associated with wound-related reoperation (OR, 2.73; 95% CI, 0.97-7.69; p = 0.058). A 0.6% (five of 884) arthrotomy failure rate was observed in the barbed cohort while no (0 of 1598) arthrotomy failures were noted in the traditional group (p = 0.003). Deep infections were rare in both groups (two of 884 barbed sutures, 0 of 1598 standard sutures) and could not be compared. CONCLUSIONS: Although we saw no difference in overall and wound-related 90-day reoperation rates by suture type with the numbers available, we observed a higher frequency in our secondary question of arthrotomy failures when barbed sutures are used for arthrotomy closure during TKA. Given the widespread use of this closure technique, our preliminary pilot results warrant further investigation in larger multicenter cohorts. LEVEL OF EVIDENCE: Level III, therapeutic study.

Do Aggregate Socioeconomic Status Factors Predict Outcomes for Total Knee Arthroplasty in a Rural Population?

BACKGROUND: We sought to determine whether several preoperative socioeconomic status (SES) variables meaningfully improve predictive models for primary total knee arthroplasty (TKA) length of stay (LOS), facility discharge, and clinically significant Veterans RAND-12 physical component score (PCS) improvement. METHODS: We prospectively collected clinical data on 2198 TKAs at a high-volume rural tertiary academic hospital from April 2011 through March 2016. SES variables included race and/or ethnicity, living alone, education, employment, and household income, along with numerous adjusting variables. We determined individual SES predictors and whether the inclusion of all SES variables contributed to each 10-fold cross-validated area under the model's area under the receiver operating characteristic (AUC). We also used 1000-fold bootstrapping methods to determine whether the SES and non-SES models were statistically different from each other. RESULTS: At least 1 SES predicted each outcome. Ethnic minority patients and those with incomes <$35,000 predicted longer LOS. Ethnic minority patients, the unemployed, and those living alone predicted facility discharge. Unemployed patients were less likely to achieve PCS improvement. Without the 5 SES variables, the AUC values of the LOS, discharge, and PCS models were 0.74 (95% confidence interval [CI] 0.72-0.77, "acceptable"); 0.86 (CI 0.84-0.87, "excellent"); and 0.80 (CI 0.78-0.82, "excellent"), respectively. Including the 5 SES variables, the 10-fold cross-validated and bootstrapped AUC values were 0.76 (CI 0.74-0.79); 0.87 (CI 0.85-0.88); and 0.81 (0.79-0.83), respectively. CONCLUSION: We developed validated predictive models for outcomes after TKA. Although inclusion of multiple SES variables provided statistical predictive value in our models, the amount of improvement may not be clinically meaningful.

A Comparison of Radiographic Outcomes After Total Hip Arthroplasty Between the Posterior Approach and Direct Anterior Approach With Intraoperative Fluoroscopy.

BACKGROUND: Radiographic outcomes after total hip arthroplasty (THA) have been linked to clinical outcomes. The direct anterior approach (DAA) for THA has been criticized by some for providing limited exposure and compromised implant position but allows for routine use of intraoperative fluoroscopy. We sought to determine whether radiographic measurements differed by THA approach using prospective cohorts. METHODS: Two reviewers blinded to surgical approach examined 194 radiographs, obtained 4-6 weeks after primary THA, and obtained measurements for acetabular inclination angle, acetabular anteversion, radiographic limb length discrepancy (LLD), and femoral offset. All surgeries were performed at a tertiary academic medical center in rural New England by an experienced fellowship-trained arthroplasty surgeon. Measurements for inclination angle, anteversion, LLD, and offset were made into binary yes/no responses based on whether the mean measurement (between the 2 reviewers) was acceptable or not based on established criteria. Multivariate logistic regression analyses were performed using preoperative and intraoperative characteristics to identify predictors of acceptability for each measurement. RESULTS: The DAA group had higher rates of acceptable acetabular angle (96 vs 85%, P = .005) and was protective against an unacceptable angle in an adjusted predictive model (odds ratios 0.16, P = .005). There were no significant differences between approaches for acceptable anteversion, LLD, or offset. Body mass index of 30-34 was associated with higher odds of unacceptable inclination angle compared to the nonobese group (adjusted odds ratio, 6.82, P = .013). CONCLUSION: DAA for THA was associated with lower odds of unacceptable inclination angle compared to the posterior approach, with no differences in anteversion, LLD, or offset.

Patient-Reported Outcomes After Revision of Metal-on-Metal Total Bearings in Total Hip Arthroplasty.

BACKGROUND: Failure of metal-on-metal (MOM) total hip arthroplasty (THA) bearings is often accompanied by an aggressive local reaction associated with destruction of bone, muscle, and other soft tissues around the hip. Little is known about whether patient-reported physical and mental function following revision THA in MOM patients is compromised by this soft tissue damage, and whether revision of MOM THA is comparable with revision of hard-on-soft bearings such as metal-on-polyethylene (MOP). METHODS: We identified 75 first-time MOM THA revisions and compared them with 104 first-time MOP revisions. Using prospective patient-reported measures via the Veterans RAND-12, we compared Physical Component Score and Mental Component Score function at preoperative baseline and postoperative follow-up between revision MOM THA and revision MOP THA. RESULTS: Physical Component Score did not vary between the groups preoperatively and at 1 month, 3 months, and 1 year postoperatively. Mental Component Score preoperatively and 1 and 3 months postoperatively were lower in patients in the MOM cohort compared with patients with MOP revisions (baseline: 43.7 vs 51.3, P < .001; 1 month: 44.9 vs 53.3, P < .001; 3 months: 46.0 vs 52.3, P = .016). However, by 1 year, MCS scores were not significantly different between the revision cohorts. CONCLUSION: Postrevision physical function in revised MOM THA patients does not differ significantly from the outcomes of revised MOP THA. Mental function is markedly lower in MOM patients at baseline and early in the postoperative period, but does not differ from MOP patients at 1 year after revision. This information should be useful to surgeons and physicians facing MOM THA revision.

Does Surgical Approach Affect Patient-reported Function After Primary THA?

BACKGROUND: Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach. QUESTIONS/PURPOSES: We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA? METHODS: Between October 2008 and February 2010, an arthroplasty fellowship-trained surgeon performed 135 THAs. All 135 were performed using the posterior approach. During that period, we used this approach when patients had any moderate to severe degenerative joint disease of the hip attributable to any type of arthritis refractory to nonoperative treatment measures. Of the patients who were treated with this approach, 21 (17%; 23 hips) were lost to followup, whereas 109 (83%; 112 hips) were available for followup at 1 year. Between February and September 2011, the same surgeon performed 86 THAs. All 86 were performed using the direct-anterior approach. During that period, we used this approach when patients with all types of moderate to severe degenerative joint disease had nonoperative treatment measures fail. Of the patients who were treated with this approach, 35 (41%; 35 hips) were lost to followup, whereas 51 (59%; 51 hips) were available for followup at 1 year. THAs during the surgeon's direct-anterior approach learning period (February 2010 through January 2011) were excluded because both approaches were being used selectively depending on patient characteristics. Clinical outcomes included operative blood loss; allogeneic transfusion; adverse events; patient-reported Veterans RAND-12 Physical (PCS) and Mental Component Summary (MCS) scores, and University of California Los Angeles (UCLA) activity scores at 1 month, 3 months, and 1 year after surgery. Resource utilization outcomes included operative time, length of stay, and discharge disposition (home versus institution). Outcomes were compared using logistic and linear regression techniques. RESULTS: After controlling for relevant confounding variables including age, sex, and BMI, the direct-anterior approach was associated with worse adjusted MCS changes 1 and 3 months after surgery (1-month score change, -9; 95% CI, -13 to -5; standard error, 2), compared with the posterior approach (3-month score change, -9; 95% CI, -14 to -3; standard error, 3) (both p < 0.001), while the direct-anterior approach was associated with greater PCS improvement at 3 months compared with the posterior approach (score change, 6; 95% CI, 2-10; standard error, 2; p = 0.008). There were no differences in adjusted PCS at either 1 month or 12 months, and no clinically important differences in UCLA scores. Although the PCS score differences are greater than the minimum clinically important difference of 5 points for this endpoint, the clinical importance of such a small effect is questionable. At 1 year after THA, there were no intergroup differences in self-reported physical function, although both groups had significant loss-to-followup at that time. Operative time (skin incision to skin closure) between the two groups did not differ (81 versus 79 minutes; p = 0.411). Mean surgical blood loss (403 versus 293 mL; p < 0.001; adjusted, 119 more mL; 95% CI, 79-160; p < 0.001) and in-hospital transfusion rates (direct-anterior approach, 20% [17/86] versus posterior approach, 10% [14/135], p = 0.050; adjusted odds ratio, 3.6; 95% CI, 1.3-10.1; p = 0.016) were higher in the direct-anterior approach group. With the numbers available, there was no difference in the frequency of adverse events between groups when comparing intraoperative complications, perioperative Technical Expert Panel complications, and other non-Technical Expert Panel complications within 1 year of surgery, although this study was not adequately powered to detect differences in rare adverse events. CONCLUSIONS: With suitable experience, the direct-anterior approach can be performed with expected results similar to those of the posterior approach. There may be transient and small benefits to the direct-anterior approach, including improved physical function at 3 months after surgery. However, the greater operative blood loss and greater likelihood of blood transfusions, even when the surgeon is experienced, may be a disadvantage. Given some of the kinds of bias present that we found, including loss to followup, the conclusions we present should be considered preliminary, but it appears that any benefits that accrue to the patients who had the direct-anterior approach would be transient and modest. Prospective randomized studies on the topic are needed to address the differences between surgical approaches more definitively. LEVEL OF EVIDENCE: Level III, therapeutic study.

Predictors of Facility Discharge, Range of Motion, and Patient-Reported Physical Function Improvement After Primary Total Knee Arthroplasty: A Prospective Cohort Analysis.

BACKGROUND: Patients are discharged to home or inpatient settings after primary unilateral total knee arthroplasty (TKA). Few studies have compared patient outcomes following these 2 rehabilitation models for TKA patients. We identified predictors of inpatient discharge, 3-month postoperative range of motion (ROM), and 3-month postoperative patient-reported physical function improvement (Veterans RAND 12-Item Physical Component Score [PCS]) between these discharge settings. METHODS: We studied prospectively collected cohort data for 738 TKAs between April 2011 and April 2013 at a high-volume tertiary academic medical center in a rural setting. All patients followed a standardized care pathway that involved prospective data collection as part of routine clinical care. Adjusting variables included age, sex, preoperative PCS, surgeon, modified Charlson Comorbidity Index, preoperative body mass index, laterality, and preoperative ROM; the 3-month models also included length of stay and discharge disposition as adjusters. RESULTS: Significant adjusted predictors of inpatient discharge included older age, female sex, surgeon, comorbidity, lower PCS, and body mass index greater than 40. Only lower preoperative ROM predicted postoperative ROM. Inpatient discharge and higher preoperative PCS predicted lower PCS improvement. Home-based rehabilitation was associated with greater 3-month PCS improvement and showed no difference with 3-month ROM. CONCLUSION: Discharge to home-based rehabilitation after TKA, rather than inpatient facility, is associated with higher physical function at 3 months postsurgery and shows no difference with 3-month ROM. Total knee arthroplasty inpatient discharge should be based on patient care requirements rather than perceived benefit of improved ROM and physical function.

Provider perceptions of the electronic health record incentive programs: a survey of eligible professionals who have and have not attested to meaningful use.

BACKGROUND: The HITECH Act of 2009 enabled the Centers for Medicare & Medicaid Services (CMS) to provide financial incentives to health care providers who demonstrate "meaningful use" (MU) of their electronic health records (EHRs). Despite stakeholder involvement in the rule-making phase, formal input about the MU program from a cross section of providers has not been reported since incentive payments began. OBJECTIVE: To examine the perspectives and experiences of a random sample of health care professionals eligible for financial incentives (eligible professionals or EPs) for demonstrating meaningful use of their EHRs. It was hypothesized that EPs actively participating in the MU program would generally view the purported benefits of MU more positively than EPs not yet participating in the incentive program. DESIGN: Survey data were collected by mail from a random sample of EPs in Washington State and Idaho. Two follow-up mailings were made to non-respondents. PARTICIPANTS: The sample included EPs who had registered for incentive payments or attested to MU (MU-Active) and EPs not yet participating in the incentive program (MU-Inactive). MAIN MEASURES: The survey assessed perceptions of general realities and influences of MU on health care; views on the influence of MU on clinics; and personal views about MU. EP opinions were assessed with close- and open-ended items. KEY RESULTS: Close-ended responses indicated that MU-Active providers were generally more positive about the program than MU-Inactive providers. However, the majority of respondents in both groups felt that MU would not reduce care disparities or improve the accuracy of patient information. The additional workload on EPs and their staff was viewed as too great a burden on productivity relative to the level of reimbursement for achieving MU goals. The majority of open-ended responses in each group reinforced the general perception that the MU program diverted attention from treating patients by imposing greater reporting requirements. CONCLUSIONS: Survey results indicate the need by CMS to step up engagement with EPs in future planning for the MU program, while also providing support for achieving MU standards.

Measuring primary care organizational capacity for diabetes care coordination: the Diabetes Care Coordination Readiness Assessment.

BACKGROUND: Not all primary care clinics are prepared to implement care coordination services for chronic conditions, such as diabetes. Understanding true capacity to coordinate care is an important first-step toward establishing effective and efficient care coordination. Yet, we could identify no diabetes-specific instruments to systematically assess readiness and/or status of primary care clinics to engage in diabetes care coordination. OBJECTIVE: This report describes the development and initial validation of the Diabetes Care Coordination Readiness Assessment (DCCRA), which is intended to measure primary care clinic readiness to coordinate care for adult patients with diabetes. DESIGN: The instrument was developed through iterative item generation within a framework of five domains of care coordination: Organizational Capacity, Care Coordination, Clinical Management, Quality Improvement, and Technical Infrastructure. PARTICIPANTS: Validation data was collected on 39 primary care clinics. MAIN MEASURES: Content validity, inter-rater reliability, internal consistency, and construct validity of the 49-item instrument were assessed. KEY RESULTS: Inter-rater agreement indices per item ranged from 0.50 to 1.0. Cronbach's alpha of the entire instrument was 0.964, and for the five domain scales ranged from 0.688 to 0.961. Clinics with existing care coordinators were rated as more ready to support care coordination than clinics without care coordinators for the entire DCCRA and for each domain, supporting construct validity. CONCLUSIONS: As providers increasingly attempt to adopt patient-centered approaches, introduction of the DCCRA is timely and appropriate for assisting clinics with identifying gaps in provision of care coordination services. The DCCRA's strengths include promising psychometric properties. A valid measure of diabetes care coordination readiness should be useful in diabetes program evaluation, assistance with quality improvement initiatives, and measurement of patient-centered care in research.

The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes: An Observational Study.

BACKGROUND: A preoperative medical evaluation (PME) in total joint arthroplasty (TJA) is routine despite considerable variation and uncertainty regarding its benefits. The orthopaedic department in our academic health system established a perioperative medical clinic (PMC) to standardize perioperative management and to study the effect of this intervention on total hip arthroplasty (THA) and total knee arthroplasty (TKA) outcomes. This observational study compared the impact of a PME within 30 days prior to surgery at the PMC (Periop30) versus elsewhere ("Usual Care") on postoperative length of stay (LOS), extended LOS (i.e., a stay of >3 days), and Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10) Global Physical Health (GPH) score improvement in TJA. METHODS: We stratified adult patients (≥18 years of age) who underwent primary TJA between January 2015 and December 2020 into Periop30 or Usual Care. We utilized univariate tests (a chi-square test for categorical variables and a t test for continuous variables) to assess for differences in patient characteristics. For both TKA and THA, LOS was assessed with use of multivariable negative binomial regression models; extended LOS, with use of binary logistic regression; and PROMIS-10 GPH score, with use of mixed-effects models with random intercept and slope. Interaction terms between the focal predictor (Periop30, yes or no) and year of surgery were included in all models. RESULTS: Periop30 comprised 82.3% of TKAs (1,911 of 2,322 ) and 73.8% of THAs (1,876 of 2,541). For THA, the Periop30 group tended to be male (p = 0.005) and had a higher body mass index (p = 0.001) than the Usual Care group. The Periop30 group had a higher rate of staged bilateral THA (10.6% versus 7.5%; p = 0.028) and a lower rate of simultaneous bilateral TKA (5.1% versus 12.2%; p < 0.001) than the Usual Care group. Periop30 was associated with a lower mean LOS for both TKA (43.46 versus 54.15 hours; p < 0.001) and THA (41.07 versus 57.94 hours; p < 0.001). The rate of extended LOS was lower in the Periop30 group than in the Usual Care group for both TKA (15% versus 26.5%; p < 0.001) and THA (13.3% versus 27.4%; p < 0.001). There was no significant difference in GPH score improvement between Periop30 and Usual Care for either TKA or THA. CONCLUSIONS: Periop30 decreased mean LOS and the rate of extended LOS for TJA without an adverse effect on PROMIS-10 GPH scores. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Do Patients With Higher Preoperative Functional Outcome Scores Preferentially Seek Direct Anterior Approach Total Hip Arthroplasty?

BACKGROUND: There is focus on the direct anterior approach (DAA) for total hip arthroplasty because of perceived postoperative functional improvement. We compared baseline, short-term, and long-term outcomes between the DAA and the posterior approach focusing on baseline function. MATERIAL AND METHODS: Multivariate linear and logistic regression models were used to analyze prospective data on 1457 total hip arthroplasties comparing baseline characteristics, operative time, 90-day reoperation, length of stay (LOS), extended LOS (>3 days), and facility discharge. The Patient-Reported Outcome Measurement Information System-Global Health (PROMIS-10) was used to determine physical component score (PCS) and mental component score (MCS), with clinically significant improvement defined as >5 points. Adjusters included age, sex, race/ethnicity, year, Charlson Comorbidity Index, body mass index, alcohol, and tobacco use. RESULTS: DAA patients had higher preoperative MCS (DAA 50.4 vs posterior approach 47.4, P < .001), PCS (40.7 vs 38.5, P < .001), and postoperative PCS scores (48.9 vs 46.7, P < .001). There was no difference in mean PCS improvement (8.1 vs 8.2; P = .798) or clinically significant PCS change (P = .963). DAA was associated with shorter LOS by 0.49 days (95% confidence interval [CI] = 0.32-0.65, P < .001), lower odds of extended LOS (odds ratio = 0.33, 95% CI = 0.21-0.50, P < .001), and lower odds of facility discharge (odds ratio = 0.54, 95% CI = 0.37-0.79, P < .001). No difference in operative time (86 vs 87 minutes; P = .812) or 90-day reoperations (1 vs 1%; P = .347) was observed. CONCLUSION: DAA patients presented with higher preoperative PCS and MCS scores, yet both groups experienced significant improvement. DAA was associated with decreased LOS and lower odds of extended LOS and facility discharge. There was no difference in operative time or reoperation.

Patient-reported outcomes after above-knee amputation for prosthetic joint infection.

BACKGROUND: Prosthetic joint infection (PJI) is a challenging complication after total knee arthroplasty (TKA). Above-knee amputation (AKA) is a salvage procedure that may be performed after revision TKAs fail to eradicate PJI. Few studies have investigated patient-reported outcomes. This study investigates patient-reported functional outcomes and overall satisfaction in a cohort of patients who underwent AKA for PJI. METHODS: We performed a retrospective study of all patients who underwent AKA for PJI from 2002 to 2015 at a tertiary academic institution in the rural northeastern United States, along with prospective phone interviews. Functional outcomes and overall satisfaction were adapted from the Above-The-Knee Amputation Functional Ability Questionnaire. Additional variables included age, sex, American Society of Anesthesiologists (ASA) Score, and mortality. RESULTS: Forty-four patients were included in the study. Eighteen patients died prior to study initiation, with a mean time of 948 days (2.6 years) between AKA and death. The 5-year mortality rate was 50%. Among the 14 patients who completed the survey, 12 (86%) were fit for prosthesis following AKA. Of these, 10 (71%) required the use of an assistive device and one (seven percent) reported being functionally independent with their prosthesis. Five (36%) required further surgery after their AKA. Twelve (86%) stated that they were satisfied with their AKA and 5 (42%) would have done it sooner if offered. CONCLUSIONS: Patients who underwent AKA for PJI reported a low level of independence and ability to ambulate with a high mortality rate. However, most were satisfied with their AKA and would choose it again.

Patient outcomes after total hip arthroplasty in extreme elderly patients older than 80 years.

BACKGROUND: While extreme elderly patients (age 80 and above) benefit from joint replacement, there is controversy about whether their physical function improves as much as younger individuals following total hip arthroplasty. METHODS: We completed a retrospective cohort study comparing extreme elderly total hip arthroplasty (THA) patients to younger patients. We obtained data from a large institutional repository of 2327 consecutive THAs performed from April 2011 through July 2016 at an American academic medical centre. We performed multivariate regression analyses to determine associations between age group and clinically significant improvement in the Patient-Reported Outcome Measurement Information System (PROMIS)-10 physical component summary (PCS) score. Secondary outcomes included the magnitude of PCS change, length of stay (LOS), and facility discharge. RESULTS: There were 187 THAs (8.0%) in patients age ⩾ 80 years compared to 2140 THA procedures in patients < age 80. Extreme elderly patients had similar adjusted odds of achieving clinically significant PCS improvement after THA (p = 0.528) and there were no statistical differences in adjusted postoperative PCS score improvements between the cohorts. Extreme elderly patients were associated with a 0.68 day longer adjusted LOS (p < 0.001) and demonstrated higher adjusted odds of facility discharge following THA (OR 8.96, p < 0.001). CONCLUSIONS: Compared to younger patients, extreme elderly individuals had similar adjusted postoperative functional outcomes following THA but utilised substantially more resources in the form of increased time in the hospital and higher rates of facility discharges.

Nonmechanical Revision Indications Portend Repeat Limb-Salvage Failure Following Total Femoral Replacement.

BACKGROUND: There is scant evidence to guide decision-making for patients considering total femoral replacement (TFR). We aimed to identify the indication, patient, disease, and surgical technique-related factors associated with failure. We hypothesized that failure occurs more frequently in the setting of revision surgical procedures, with infection as the predominant failure mode. METHODS: We performed a retrospective cohort study of patients receiving total femoral endoprostheses for oncological and revision arthroplasty indications; 166 patients met these criteria. Our primary independent variable of interest was TFR for a revision indication (arthroplasty or limb salvage); the primary outcome was failure. Analyses were performed for patient variables (age, sex, diagnosis group, indication), implant variables (model, decade, length, materials), and treatment variables. We analyzed TFR failures with respect to patient factors, operative technique, and time to failure. We conducted bivariate logistic regressions predicting failure and used a multivariate model containing variables showing bivariate associations with failure. RESULTS: Forty-four patients (27%) had treatment failure. Failure occurred in 24 (23%) of 105 primary TFRs and in 20 (33%) of 61 revision TFRs; the difference was not significant (p = 0.134) in bivariate analysis but was significant (p = 0.044) in multivariate analysis. The mean age at the time of TFR was 37 years in the primary group and 51 years in the revision group (p = 0.0006). Of the patients who had mechanical failure, none had reoccurrence of their original failure mode, whereas all 8 patients from the nonmechanical cohort had reoccurrence of the original failure mode; this difference was significant (p = 0.0001). CONCLUSIONS: TFR has a high failure rate and a propensity for deep infection, especially in the setting of revision indications and prior infection. All failed TFRs performed for revision indications for infection or local recurrence failed by reoccurrence of the original failure mode and resulted in amputation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Weight Loss for Morbidly Obese Patients Undergoing Total Knee Arthroplasty: Determining the Necessary Amount.

BACKGROUND: Many surgeons require or request weight loss among morbidly obese patients (those with a body mass index [BMI] of ≥40 kg/m) before undergoing total knee arthroplasty. We sought to determine how much weight reduction was necessary to improve operative time, length of stay, discharge to a facility, and physical function improvement. METHODS: Using a retrospective review of cohort data that were prospectively collected from 2011 to 2016 at 1 tertiary institution, we identified 203 patients who were morbidly obese at least 90 days before the surgical procedure and had their BMI measured again at the immediate preoperative visit. All heights and weights were clinically measured. We used logistic and linear regression models that adjusted for preoperative age, sex, year of the surgical procedure, bilateral status, physical function (Patient-Reported Outcomes Measurement Information System [PROMIS]-10 physical component score [PCS]), mental function (PROMIS-10 mental component score [MCS]), and the Charlson Comorbidity Index. RESULTS: Of the 203 patients in the study, 41% lost at least 5 pounds (2.27 kg) before the surgical procedure, 29% lost at least 10 pounds (4.54 kg), and 14% lost at least 20 pounds (9.07 kg). Among morbidly obese patients, losing 20 pounds before a total knee arthroplasty was associated with lower adjusted odds of discharge to a facility (odds ratio [OR], 0.28 [95% confidence interval (CI), 0.09 to 0.94]; p = 0.039), lower odds of extended length of stay of at least 4 days (OR, 0.24 [95% CI, 0.07 to 0.88]; p = 0.031), and an absolute shorter length of stay (mean difference, -0.87 day [95% CI, -1.39 to -0.36 days]; p = 0.001). There were no differences in operative time or PCS improvement. Losing 5 or 10 pounds was not associated with differences in any outcome. CONCLUSIONS: Losing at least 20 pounds before total knee arthroplasty was associated with shorter length of stay and lower odds of facility discharge for morbidly obese patients, even while most patients remained morbidly or severely obese. Although there were no differences in operative time or physical function improvement, this has considerable implications for patient burden and cost reduction. Patients and providers may want to focus on larger preoperative weight loss targets. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short term patient outcomes after total knee arthroplasty: Does the implant matter?

BACKGROUND: Newer implants for total knee arthroplasty (TKA) often gain market share at higher cost with little patient-reported and long-term clinical data. We compared outcomes after TKA using two different implants: DePuy PFC Sigma and Attune. METHODS: Using a prospective data repository from an academic tertiary medical center, we analyzed 2116 TKAs (1603 Sigma and 513 Attune) from April 2011 through July 2016. Outcomes included length of surgery, length of stay, facility discharge, 90-day reoperation, range of motion (ROM) change, and patient-reported physical function (PCS). RESULTS: There was no difference in length of surgery (Attune -2.87 min, P = 0.143). Implant type was not associated with extended LOS (>3 days) (OR 0.80, P = 0.439). There was no difference in facility discharge (OR 0.65, P = 0.103). Unadjusted 90-day reoperations were 0.3% for Sigma and 1.0% for Attune cohorts (P = 0.158). Sigma implants were associated with more ROM improvement in unadjusted analyses (+2.1 degree improvement P = 0.031). Fifty nine percent of the Sigma cohort and 49% of the Attune cohort achieved the minimal clinically important (MCID) change for PCS improvement, although there was no adjusted difference in achieving MCID (Attune OR 0.84, P = 0.435). There was no adjusted difference in absolute PCS improvement (Attune +0.12 score, P = 0.864). CONCLUSIONS: Our data show no difference in physical function and most outcomes between Sigma and Attune. Attune implants had shorter absolute LOS, but there were no differences in extended LOS.