The Centers for Medicare and Medicaid Services 2021 Physician Fee Schedule (PFS) includes increases in office reimbursement but decreases in the valuation of total hip arthroplasty and total knee ...arthroplasty and the conversion factor. The purpose of this study was to determine the financial impact of these changes on arthroplasty surgeons.
We queried data for 35 arthroplasty surgeons within our practice from 10/2019 to 10/2020 and captured all office and arthroplasty-related surgical procedure codes. We compared the difference in both work relative value units (RVUs) and Medicare reimbursement by surgeon based on the current 2020 PFS to the 2021 changes. We also estimated the impact of several proposals to include office increases to the global surgical package for each code.
While the mean per surgeon RVU amount for primary arthroplasty procedures will decrease (6267 vs 6,088, P = .78), the mean office work RVU (2755 vs 3,220, P = .16) will increase in 2021. However, the reduction in surgical reimbursement ($530,076 in 2020 to $464,414 in 2021) far exceeds the gains from the office ($99,456 vs $107,374), leading to an overall decrease in reimbursement ($629,532 vs $571,788), a reduction of 9%. The passage of the coronavirus disease 2019 relief bill delays many of the PFS cuts and will result in an overall reduction in reimbursement of 2.4% ($629,532 vs $612,475, P = .61).
Arthroplasty surgeons are projected to lose 2.4% of Medicare reimbursement in 2021 with the changes in the Centers for Medicare and Medicaid Services PFS. Further study is needed to determine whether these cuts will limit access to care for Medicare patients.
Existing Cannabis sativa micropropagation protocols use a limited number of cultivars and the results are often not reproducible. Currently, Murashige and Skoog basal salt mixture (MS) + 0.5 μmol/L ...thidiazuron (TDZ) has been reported as the optimal medium for nodal micropropagation, yet our preliminary studies with this medium have resulted in abnormal morphology and high mortality rates in multiple cultivars. Following an initial screen of basal salt mixtures MS, B5, BABI, and Driver–Kuniyaki–Walnut (DKW), we determined that DKW produced the healthiest plants. In a second experiment, the multiplication rate and canopy area of explants grown on MS + 0.5 μmol/L TDZ and DKW + 0.5 μmol/L TDZ were compared using five drug-type cultivars. The combined multiplication average of explants grown on DKW + 0.5 μmol/L TDZ was 1.5× higher than explants grown on MS + 0.5 μmol/L TDZ. Similarly, the combined average of the canopy area was twice as large on DKW + 0.5 μmol/L TDZ. In the third experiment, callogenesis was compared using a concentration range of 2,4-dichlorophenoxyacetic acid (0–30 μmol/L) on both MS and DKW, and similarly, callus growth was superior on DKW. This study presents the largest comparison of basal salt compositions on the micropropagation of five commercially grown Cannabis cultivars to date.
Celotno besedilo
Dostopno za:
BF, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Studies have shown that lower socioeconomic status may result in adverse outcomes following total hip (THA) and total knee arthroplasty (TKA). The optimal method of defining socioeconomic status, ...however, continues to be debated. The purpose of this study is to determine which socioeconomic variables are associated with poor outcomes following THA and TKA.
We reviewed a consecutive series of 2770 primary THA and TKA patients from 2015 to 2018. Utilizing census data based upon the patient’s ZIP code, we extracted poverty, unemployment, high school graduation, and vehicle possession rates. We collected demographics, comorbidities, discharge disposition, 90-day readmissions, and postoperative functional outcome scores for each patient. We then performed a multivariate regression analysis to identify the effect of each socioeconomic variable on postoperative outcomes.
Patients from areas with high unemployment (P = .008) and low high school graduation rates (P = .019) had a higher age-adjusted Charlson Comorbidity Index. High poverty levels, high unemployment, lower high school graduation rate, and lower vehicle possession rates did not have a significant effect on functional outcomes (all P > .05). In the multivariate analysis, no socioeconomic variable demonstrated an increased rate of rehabilitation discharge, revision, or readmission (all P > .05).
Patients undergoing THA and TKA from areas with high unemployment and lower educational levels do have more medical comorbidities. However, none of the 4 socioeconomic variables studied are independently associated with higher rates of readmission, discharge to rehabilitation, or worse functional outcomes. Patients from disadvantaged areas should not be denied access to arthroplasty care based on socioeconomic status alone.
Extensor mechanism disruption is a devastating complication after TKA. Extensor mechanism reconstruction can be performed using an allograft or synthetic mesh. Recent studies have disagreed about the ...durability of these reconstructions. Evaluating a larger series of reconstructions that use current popular techniques and principles provides information to guide patient and surgeon expectations while bringing to light the potential fate of patients who experience an infection postoperatively.
(1) What was the 5-year survival free of repeat revision surgery or persistent extensor lag of more than 30° after allograft or synthetic mesh reconstruction of extensor mechanism disruptions after TKA, and did this differ between techniques? (2) What was the 5-year survival free of infection after allograft or mesh reconstruction, and what proportion of those patients experienced a secondary severe complication (arthrodesis or amputation)?
Between April 2008 and December 2020, 123 patients underwent extensor mechanism reconstruction after TKA at one center. Of those, 37% (45) were lost to follow-up before 2 years, had not been seen in the past 5 years, did not reach a study endpoint (repeat revision or extensor lag > 30°) before that time, or underwent primary repair and thus could not be analyzed, leaving 63% (78) for analysis here. During the study period, we considered extensor mechanism surgery when acute or chronic disruption of the patellar or quadriceps tendon was present or there was a fracture of the patella resulting in extensor lag. The decision to use either mesh or an allograft largely depended on surgeon experience and familiarity with either technique. We collected patient demographics, operative details (location of disruption and presence of a hinged prosthesis), subsequent periprosthetic joint infection (PJI), and postoperative SF-12 and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, scores. We used Kaplan-Meier survivorship analysis, with endpoints of extensor lag more than 30° or revision of the reconstruction and PJI. The mean follow-up duration was 5.3 ± 3.2 years.
Survivorship free from revision or recurrent extensor lag was 54% (95% CI 44% to 66%) at 5 years. There was no difference between those undergoing reconstruction with allografts and those with mesh in terms of survivorship free from those endpoints at that timepoint (52% 95% CI 40% to 68% versus 57% 95 CI% 41 to 78%; p = 0.99). Survivorship free from PJI was 81% (95% CI 73% to 90%) at 2 years. There was no difference between those with allografts and those with mesh in terms of survivorship free from PJI at that timepoint (79% 95% CI 69% to 92% versus 83% 95% CI 71% to 98%; p = 0.75). Of the 17 patients who experienced PJI, four ultimately underwent arthrodesis and three more underwent transfemoral amputation.
Allograft and synthetic mesh reconstructions commonly left patients with persistent limb dysfunction, while several patients had PJI and some underwent salvage procedures. Although improvements have been made with regard to treating extensor mechanism disruptions, patients and surgeons should be well aware of the potential adverse outcomes when determining management and use these findings to conduct risk-benefit analyses. There is a need for future studies to identify protocols that improve the durability of reconstructions and to determine whether interventions such as prolonged prophylactic antibiotic therapy have a role in minimizing the risk of PJI.
Level III, therapeutic study.
A retrospective observational cohort study was conducted using data from Oregon's Death with Dignity Act (DWDA) to characterize patients with head and neck cancer (HNC) who seek physician-assisted ...suicide (PAS). Between 1998 and 2018, a total of 57 patients with HNC received DWDA prescriptions, of whom 39 (68.4%) died by administration of the prescribed medication. There were no associated complications with medication administration. The most commonly involved subsites were oral cavity (33.3%) and oropharynx (30.8%), and the most commonly cited end-of-life concerns were loss of ability to engage in activities that make life enjoyable (79.5%) and loss of autonomy (74.4%). There were no differences in age, race, marital status, or hospice enrollment rates between patients with HNC who died by administration and those who were prescribed but did not administer the medication. Patients who died by administration were generally less educated as compared to those who were prescribed but did not administer the medication (
= .015).
Abstract Background Alternative payment models, such as bundled payments, aim to control rising costs for total knee arthroplasty (TKA) and total hip arthroplasty (THA). Without risk adjustment for ...patients who may utilize more resources, concerns exist about patient selection and access to care. The purpose of this study was to determine whether lower socioeconomic status (SES) was associated with increased resource utilization following TKA and THA. Methods Using the Michigan Arthroplasty Registry Collaborative Quality Initiative database, we reviewed a consecutive series of 4168 primary TKA and THA patients over a 3-year period. We defined lowest SES based upon the median household income of the patient's ZIP code. Demographics, medical comorbidities, length of stay, discharge destination, and readmission rates were compared between patients of lowest SES and higher SES. Results Patients in the lowest SES group had a longer hospital length of stay (2.79 vs 2.22 days, P < .001), were more likely to be discharged to a rehabilitation facility (27% vs 18%, P < .001), and be readmitted to the hospital within 90 days (11% vs 8%, P = .002) than the higher SES group. Multivariate analysis revealed that lowest SES was an independent risk factor for all 3 outcome variables (all P < .001). Conclusion Patients in the lowest SES group utilize more resources in the 90-day postoperative period. Therefore, risk adjustment models, including SES, may be necessary to fairly compensate hospitals and surgeons and to avoid potential problems with access to joint arthroplasty care.
Chronic kidney disease (CKD) affects up to 15% of the adult population and is strongly associated with other non-communicable chronic diseases including diabetes. However, there is limited ...information on a population basis of the relationship between CKD and health-related quality of life (HRQoL) and the consequent economic cost. We investigated this relationship in a representative sample in England using the 2010 Health Survey for England. Multivariable Tobit models were used to examine the relationship between HRQoL and CKD severity. HRQoL was converted to quality adjusted life year (QALY) measures by combining decrements in quality of life with reductions in life expectancy associated with increased disease severity. QALYs were adjusted for discounting and monetised using the UK threshold for reimbursement of £30,000. The QALYs were then used in conjunction with forecasted prevalence to estimate the HRQoL burden associated with CKD among individuals with diabetes up to 2025. Individuals with more severe CKD had lower HRQoL compared to those with better kidney function. Compared to those with normal/low normal kidney function and stage 1 CKD, those with stage 2, stage 3 with albuminuria and stage 4/5 CKD experienced a decrement of 0.11, 0.18 and 0.28 in their utility index, respectively. Applying the UK reimbursement threshold for a QALY, the monetised lifetime burden of reduced HRQoL due to stage 2, stage 3 with albuminuria and stage 4/5 CKD were £103,734; £83,399; £125,335 in males and £143,582; £70,288; £203,804 in females, respectively. Utilizing the predicted prevalence of CKD among individuals with diabetes mellitus, the economic burden of CKD per million of individuals with diabetes is forecasted at approximately £11.4 billion in 2025. In conclusion, CKD has a strong adverse impact on HRQoL in multiple domains. The estimated economic burden of CKD among individuals with diabetes mellitus in the UK is projected to rise markedly over time.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Cannabis sativa is relatively recalcitrant to de novo regeneration, but several studies have reported shoot organogenesis or somatic embryogenesis from non-meristematic tissues. Most report ...infrequent regeneration rates from these tissues, but a landmark publication from 2010 achieved regeneration from leaf explants with a 96% response rate, producing an average of 12.3 shoots per explant in a single drug-type accession. Despite the importance regeneration plays in plant biotechnology and the renewed interest in this crop the aforementioned protocol has not been used in subsequent papers in the decade since it was published, raising concerns over its reproducibility. Here we attempted to replicate this important Cannabis regeneration study and expand the original scope of the study by testing it across 10 drug-type C. sativa genotypes to assess genotypic variation. In our study, callus was induced in all 10 genotypes but callus growth and appearance substantially differed among cultivars, with the most responsive genotype producing 6-fold more callus than the least responsive. The shoot induction medium failed to induce shoot organogenesis in any of the 10 cultivars tested, instead resulting in necrosis of the calli. The findings of this replication study raise concerns about the replicability of existing methods. However, some details of the protocol could not be replicated due to missing details in the original paper and regulatory issues, which could have impacted the outcome. These results highlight the importance of using multiple genotypes in such studies and providing detailed methods to facilitate replication.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
In 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the inpatient-only list, resulting in payment through the Outpatient Prospective Payment System with ...an average $3157 reduction. The purpose of this study is to determine if the reimbursement is justified by comparing the difference in facility costs between inpatient and outpatient TKAs.
We identified 4496 consecutive primary TKA procedures performed at 2 hospitals from 2015 to 2019. Itemized facility costs were calculated using a time-driven activity-based costing algorithm. Outpatient procedures were defined as those with a length of stay of less than 2 midnights (3851, 86%). Patient demographics, comorbidities, and itemized costs were compared between groups. A multivariate regression analysis was performed to determine the independent effect of outpatient status on true facility costs.
Outpatient TKA patients had lower mean postoperative personnel costs ($1809 vs $947, P < .001), supply costs ($4347 vs $4229, P < .001), and overall total facility costs ($7371 vs $6937, P < .001) than inpatient TKA patients. Controlling for a younger patient cohort with fewer medical comorbidities, outpatient status was associated with a reduction in total facility costs of $972 (95% confidence interval $883-$1060, P < .001) compared to inpatient TKA.
Outpatient TKA costs hospitals nearly $1000 per patient less than inpatient TKA, yet the average difference in Medicare reimbursement for an outpatient procedure is $3157 less per patient. Centers for Medicare and Medicaid Services should reconsider the Outpatient Prospective Payment System classification of TKA to better incentivize surgeons to perform TKA as a lower cost outpatient procedure when safe and appropriate.
Both modular and monoblock tapered fluted titanium (TFT) stems have gained popularity over fully porous-coated cylindrical (FPCC) femoral stem designs, but limited data exist comparing subsidence ...rates following revision total hip arthroplasty (THA). The purpose of this study is to determine differences in subsidence and clinical outcomes among 3 revision femoral stem designs.
We reviewed a consecutive series of 335 patients who underwent femoral component revision to a cementless modular TFT (n = 225), monoblock TFT (n = 63), or FPCC (n = 47) stem between 2012 and 2019. We evaluated radiographic subsidence rates, re-revision rates, and patient-reported outcomes between the 3 stems. A multivariate regression analysis was performed to determine the independent effect of stem type on the risk of subsidence >5 mm.
At an average follow-up of 39 months (range, 12 to 96 months), there were no differences in mean subsidence rates (3.5 vs 2.4 vs 2.1 mm, P = .14), HOOS Jr scores (78 vs 74 vs 64 points, P = .15), or aseptic re-revision rates (4% vs 3% vs 0%, P = .29) between modular TFT, monoblock TFT, and FPCC stems. Although modular TFT stems were more often used in patients with extensive femoral bone loss (Paprosky III and IV), there were no differences in subsidence rates >5 mm among the 3 stems (P > .05) in multivariate analysis.
Modular TFT, monoblock TFT, and FPCC femoral stem designs all perform well in revision THA with no difference in clinical outcomes or subsidence rates. Surgeons should select the stem which they feel is the most clinically appropriate.
PDF
