INTRODUCTION:Opioid prescriptions and abuse remain a significant national concern. Cannabinoids offer a potentially attractive nonopioid analgesic option for orthopaedic patients, and 32 US states ...have passed medical cannabis laws (MCLs), legalizing patient access to cannabinoids. We examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients between 2013 and 2017.
METHODS:Using the Medicare Part D Prescription Drug Event database, we measured annual aggregate daily doses of all opioid medications (excluding buprenorphine) prescribed by orthopaedic surgeons in each US state (and DC), in addition to total daily doses of opioid medications by generic name (hydrocodone, oxycodone, fentanyl, morphine, methadone, and “other opioids”). We used adjusted linear regression models to examine associations between state-specific cannabis regulations (state MCL, MCL type—dispensary or home cultivation, and recreational cannabis legalization) and annual total daily doses of opioid medications (all opioids and opioid types, separately).
RESULTS:State MCLs were associated with a statistically significant reduction in aggregate opioid prescribing of 144,000 daily doses (19.7% reduction) annually (95% confidence interval CI, −0.535 to −0.024 million; P < 0.01). States with MCLs allowing access to in-state dispensaries had a statistically significant reduction in total opioid prescriptions of 96,000 daily doses (13.1%) annually (95% CI, −0.165 to −0.026 million; P < 0.01). Specifically, MCLs were associated with a statistically significant reduction of 72,000 daily doses of hydrocodone annually (95% CI, −0.164 to −0.019 million; P < 0.01). No significant association between recreational marijuana legalization and opioid prescribing was found.
CONCLUSION:Orthopaedic surgeons are among the highest prescribers of opioids, highlighting the importance of providing nonopioid analgesic alternatives in efforts to reduce opioid use in the patient cohort. This study is the first to examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients.
LEVEL OF EVIDENCE:Population-based ecological study.
As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). ...The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017.
This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization.
A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South.
This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.
Understanding the scope of the volume and costs of lumbar fusions and discectomy procedures, as well as identifying significant trends within the Medicare system, may be beneficial in enhancing ...cost-efficiency and care delivery. However, there is a paucity of studies which analyze recent trends in lumbar fusion volume, utilization, and reimbursements.
This study seeks to define the costs of lumbar fusions and discectomy procedures and identify trends and variations in volume, utilization, and surgeon and hospital reimbursement rates in the Medicare system between 2012 and 2017.
Retrospective database study.
Medicare Part A and Part B claims submitted for lumbar spine procedures from 2012 to 2017, as documented in the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use Files.
Procedure numbers and payments per episode.
This cross-sectional study tracked annual Medicare claims and payments to spine surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific and lumbar spine procedure utilization and reimbursements.
A total of 772,532 lumbar spine procedures were performed in the Medicare population from 2012 to 2017, including 634,335 lumbar fusion surgeries and 138,197 primary lumbar discectomy and microdiscectomy single-level surgeries. There was a 26.0% increase in annual lumbar fusion procedure volume during the study period, with a compound annual growth rate (CAGR) of 4.7%. Lumbar discectomy/microdiscectomy experienced a 23.5% decrease in annual procedure volume (CAGR, −5.2%). Mean Medicare surgeon reimbursements for lumbar fusions nominally decreased by 3.7% from $767 in 2012 to $738 in 2017, equivalent to an inflation-adjusted decrease of 11.4% (CAGR, −0.7%). Mean Medicare payments for lumbar discectomy and microdiscectomy procedures nominally increased by 16.3% from $517 in 2012 to $601 in 2017, equivalent to an inflation-adjusted increase of 6.9% (CAGR, 3.1%).
This present study found the volume and utilization of lumbar fusions have increased since 2012, while lumbar discectomy and microdiscectomy volume and utilization have fallen. Medicare payments to hospitals and surgeons for lumbar fusions have either declined or not kept pace with inflation, and reimbursements for lumbar discectomy and microdiscectomy to hospitals have risen at a disproportionate rate compared to surgeon payments. These trends in Medicare payments, especially seen in decreasing allocation of reimbursements for surgeons, may be the effect of value-based cost reduction measures, especially for high-cost orthopedic and spine surgeries.
Anterior cervical discectomy and fusion (ACDF) has been considered the gold standard for treating various cervical spine pathologies stemming from cervical degenerative disorders. While cervical ...artificial disc replacement has emerged as an alternative in select cases, ACDF still remains a commonly performed procedure.
This study seeks to define the costs of ACDF and identify trends and variations in ACDF volume, utilization, and surgeon and hospital reimbursement rates.
Retrospective analysis of patients undergoing ACDF
Medicare patients undergoing ACDF between 2012 and 2017
ACDF volume, utilization rates, and surgeon/hospital reimbursement rates
This study tracked annual Medicare claims and payments to ACDF surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific variables (ie, urban or rural, average household income, poverty rate, percent Medicare population, race/ethnicity demographics), and ACDF utilization and reimbursement rates.
A total of 264,673 ACDF surgeries were performed in the Medicare population from 2012 to 2017, with a 24.2% increase in annual procedure volume. Utilization also increased by 6.5% from 8.0 surgeries per 10,000 Medicare beneficiaries in 2012 to 8.5 in 2017. Hospital reimbursements for cervical spine fusion surgeries without complications or co-morbidities experienced nominal and inflation-adjusted increases of 9.5% and 0.7%, respectively, from $12,030.11 in 2012 to $13,167.64 in 2017. Surgeon reimbursements for single-level and multilevel ACDF each nominally decreased from $958.11 and $1,173.01, respectively, in 2012 to $950.34 and $1,138.41 in 2017 (a 0.8% and 2.9% decrease, respectively), but after adjusting for inflation, reimbursements per case fell by an average of 8.7% and 10.7%, respectively. In contrast, mean reimbursements per case for hospitals rose by 7.1% (1.5% inflation-adjusted decrease). A significant upward yearly trend in ambulatory surgical centers volume, resulted in a net increase of 184.5% between 2015 and 2017 (p<.001).
While ACDF volume and utilization has continued to increase since 2012, Medicare payments to hospitals and surgeons have struggled to keep up with inflation. Our study confirms that Medicare reimbursement per case continues to decrease at a disproportionate rate for surgeons, compared to hospitals. The increasing trend in procedures performed at ambulatory surgical centers shows promise for a future model of cost-efficient and value-based care.
This study aimed to develop machine learning (ML) models to predict hospital admission (overnight stay) as well as short-term complications and readmission rates following anterior cruciate ligament ...reconstruction (ACLR). Furthermore, we sought to compare the ML models with logistic regression models in predicting ACLR outcomes.
The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent elective ACLR from 2012 to 2018. Artificial neural network ML and logistic regression models were developed to predict overnight stay, 30-day postoperative complications, and ACL-related readmission, and model performance was compared using the area under the receiver operating characteristic curve. Regression analyses were used to identify variables that were significantly associated with the predicted outcomes.
A total of 21,636 elective ACLR cases met inclusion criteria. Variables associated with hospital admission included White race, obesity, hypertension, and American Society of Anesthesiologists classification 3 and greater, anesthesia other than general, prolonged operative time, and inpatient setting. The incidence of hospital admission (overnight stay) was 10.2%, 30-day complications was 1.3%, and 30-day readmission for ACLR-related causes was 0.9%. Compared with logistic regression models, artificial neural network models reported superior area under the receiver operating characteristic curve values in predicting overnight stay (0.835 vs 0.589), 30-day complications (0.742 vs 0.590), reoperation (0.842 vs 0.601), ACLR-related readmission (0.872 vs 0.606), deep-vein thrombosis (0.804 vs 0.608), and surgical-site infection (0.818 vs 0.596).
The ML models developed in this study demonstrate an application of ML in which data from a national surgical patient registry was used to predict hospital admission and 30-day postoperative complications after elective ACLR. ML models developed performed well, outperforming regression models in predicting hospital admission and short-term complications following elective ACLR. ML models performed best when predicting ACLR-related readmissions and reoperations, followed by overnight stay.
IV, retrospective comparative prognostic trial.
Background:
Focal cartilage lesions of the knee remain a difficult entity to treat. Current treatment options include arthroscopic debridement, microfracture, autograft or allograft osteochondral ...transplantation, and cell-based therapies such as autologous chondrocyte transplantation. Osteochondral transplantation techniques restore the normal topography of the condyles and provide mature hyaline cartilage in a single-stage procedure. However, clinical outcomes comparing autograft versus allograft techniques are scarce.
Purpose:
To perform a comprehensive systematic review and meta-analysis of high-quality studies to evaluate the results of osteochondral autograft and allograft transplantation for the treatment of symptomatic cartilage defects of the knee.
Study Design:
Systematic review and meta-analysis; Level of evidence, 2.
Methods:
A comprehensive search of the literature was conducted using various databases. Inclusion criteria were level 1 or 2 original studies, studies with patients reporting knee cartilage injuries and chondral defects, mean follow-up ≥2 years, and studies focusing on osteochondral transplant techniques. Exclusion criteria were studies with nonknee chondral defects, studies reporting clinical outcomes of osteochondral autograft or allograft combined with other procedures, animal studies, cadaveric studies, non–English language studies, case reports, and reviews or editorials. Primary outcomes included patient-reported outcomes and failure rates associated with both techniques, and factors such as lesion size, age, sex, and the number of plugs transplanted were assessed. Metaregression using a mixed-effects model was utilized for meta-analyses.
Results:
The search resulted in 20 included studies with 364 cases of osteochondral autograft and 272 cases of osteochondral allograft. Mean postoperative survival was 88.2% in the osteochondral autograft cohort as compared with 87.2% in the osteochondral allograft cohort at 5.4 and 5.2 years, respectively (P = .6605). Patient-reported outcomes improved by an average of 65.1% and 81.1% after osteochondral autograft and allograft, respectively (P = .0001). However, meta-analysis revealed no significant difference in patient-reported outcome percentage change between osteochondral autograft and allograft (P = .97) and a coefficient of 0.033 (95% CI, –1.91 to 1.98). Meta-analysis of the relative risk of graft failure after osteochondral autograft versus allograft showed no significant differences (P = .66) and a coefficient of 0.114 (95% CI, –0.46 to 0.69). Furthermore, the regression did not find other predictors (mean age, percentage of female patients, lesion size, number of plugs/grafts used, and treatment location) that may have significantly affected patient-reported outcome percentage change or postoperative failure between osteochondral autograft versus allograft.
Conclusion:
Osteochondral autograft and allograft result in favorable patient-reported outcomes and graft survival rates at medium-term follow-up. While predictors for outcomes such as mean age, percentage of female patients, lesion size, number of plugs/grafts used, and treatment location did not affect the comparison of the 2 cohorts, proper patient selection for either procedure remains paramount to the success and potentially long-term viability of the graft.
Recent efforts to contain health care costs and move toward value-based health care have intensified, with a continued focus on Medicare expenditures, especially for high-volume procedures. As total ...shoulder arthroplasty (TSA) volume continues to increase, especially within the Medicare population, it is important for orthopedic surgeons to understand recent trends in the allocation of health care expenditures and potential effects on reimbursements. The purpose of this study was to evaluate trends in annual Medicare utilization and provider reimbursement rates for shoulder arthroplasty procedures between 2012 and 2017.
This study tracked annual Medicare claims and payments to shoulder arthroplasty surgeons via publicly available databases and aggregated data at the county level. Descriptive statistics were used to evaluate trends in procedure volume, utilization rate (per 10,000 Medicare beneficiaries), and reimbursement rate. We used adjusted multiple linear regression models to examine associations between county-specific variables (ie, urban or rural, average household income, poverty rate, percentage Medicare population, and race and ethnicity demographics) and procedure volume, utilization rate, and reimbursement rate.
Between 2012 and 2017, there was an 81.3% increase in primary TSA volume and 55.5% increase in primary TSA utilization. The Midwest and South had higher utilization rates than the Northeast and West (P < .001). TSA utilization rates in metropolitan areas were significantly higher than in rural areas (P < .001). Utilization rates for primary TSA procedures also had a significant negative association with poverty rate (P < .001). Regarding reimbursements, the Medicare payment per TSA case decreased from 2012 to 2017, with overall inflation-adjusted decreases of 7.1% and 11.8% for primary and revision cases, respectively. TSAs performed in metropolitan areas received significantly higher reimbursements per case than TSAs performed in rural areas ($1108.05 and $1066.40, respectively; P = .002). Furthermore, reimbursements per case were on average higher in the Northeast and West than in the South and Midwest (P < .001).
Our study confirms that although TSA volume and per capita utilization have increased dramatically since 2012, Medicare Part B reimbursements to surgeons have continued to fall even after the adoption of bundled-payment models for orthopedic procedures. Cost-containment efforts continue to focus on Medicare reimbursements to surgeons, although other expenditures such as hospital payments and operational and implant costs must also be evaluated as part of an overall transition to value-based health care.
Artificial intelligence (AI) and machine learning (ML) modeling in hip and knee arthroplasty (total joint arthroplasty TJA) is becoming more commonplace. This systematic review aims to quantify the ...accuracy of current AI- and ML-based application for cognitive support and decision-making in TJA.
A comprehensive search of publications was conducted through the EMBASE, Medline, and PubMed databases using relevant keywords to maximize the sensitivity of the search. No limits were placed on level of evidence or timing of the study. Findings were reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Analysis of variance testing with post-hoc Tukey test was applied to compare the area under the curve (AUC) of the models.
After application of inclusion and exclusion criteria, 49 studies were included in this review. The application of AI/ML-based models and average AUC is as follows: cost prediction-0.77, LOS and discharges-0.78, readmissions and reoperations-0.66, preoperative patient selection/planning-0.79, adverse events and other postoperative complications-0.84, postoperative pain-0.83, postoperative patient-reported outcomes measures and functional outcome-0.81. Significant variability in model AUC across the different decision support applications was found (P < .001) with the AUC for readmission and reoperation models being significantly lower than that of the other decision support categories.
AI/ML-based applications in TJA continue to expand and have the potential to optimize patient selection and accurately predict postoperative outcomes, complications, and associated costs. On average, the AI/ML models performed best in predicting postoperative complications, pain, and patient-reported outcomes and were less accurate in predicting hospital readmissions and reoperations.
Patient selection for outpatient total joint arthroplasty (TJA) is important for optimizing patient outcomes. This study develops machine learning models that may aid in patient selection for ...outpatient TJA based on medical comorbidities and demographic factors.
This study queried elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) cases during 2010-2018 in the American College of Surgeons National Surgical Quality Improvement Program. Artificial neural network models predicted same-day discharge and length of stay (LOS) fewer than 2 days (short LOS). Multiple linear and logistic regression analyses were used to identify variables significantly associated with predicted outcomes.
A total of 284,731 TKA cases and 153,053 THA cases met inclusion criteria. For TKA, prediction of short LOS had an area under the receiver operating characteristic curve (AUC) of 0.767 and accuracy of 84.1%; prediction of same-day discharge had an AUC of 0.802 and accuracy of 89.2%. For THA, prediction of short LOS had an AUC of 0.757 and accuracy of 70.6%; prediction of same-day discharge had an AUC of 0.814 and accuracy of 78.8%.
This study developed machine learning models for aiding patient selection for outpatient TJA, through accurately predicting short LOS or outpatient vs inpatient cases. As outpatient TJA expands, it will be important to optimize preoperative patient selection and effectively screen surgical candidates from a broader patient population. Incorporating models such as these into electronic medical records could aid in decision-making and resource planning in real time.
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