The Centers for Medicare & Medicaid Services (CMS) has finalized a landmark national policy to standardize and expand the collection and reporting of patient-reported outcome measures (PROMs) ...following total hip arthroplasty (THA) and total knee arthroplasty (TKA). This policy will be rolled out through phased implementation, beginning with voluntary reporting starting in 2023 and transitioning to mandatory reporting starting in 2025, which will be tied to hospital payment determinations in fiscal year 2028. The overarching goal of this policy is to gather meaningful pre- and postoperative PROM data directly from patients to enhance clinical care, shared decision-making, and quality measurement for these common elective procedures. This national initiative underscores the value of incorporating patient perspectives and priorities into assessments of surgical care quality. For orthopaedic surgeons and hospitals, participating in the initial voluntary reporting period provides an opportunity to integrate PROM collection into clinical workflows and to leverage these data to improve patient care. The achievement of robust PROM response rates and a strong performance on the underlying THA/TKA Patient-Reported Outcome-Based Performance Measure may have increasing relevance as payment models shift toward value-based care. The aim of the present forum was to provide an in-depth review of this new CMS policy and key details regarding required PROM instruments, data-collection time frames, and other specifications that surgical teams should understand as they prepare for implementation. The goal was to equip orthopaedic surgeons with actionable information as they embark on this new era of national PROM collection and reporting.
The purpose of this study was to investigate the cost-effectiveness of robotic-assisted total knee arthroplasty (TKA) versus conventional manual TKA in patients with knee osteoarthritis.
A Markov ...model simulated the lifetime outcomes of TKA of patients at average age 60 years. Costs of robotic-assisted TKA included a preoperative CT scan and the costs for acquisition and use of robotic equipment (average $706,250). We used three institutional case volumes to generate average per-case robotic costs: low volume (10 cases, $71,025 per case), mid volume (100 cases, $7,463 per case), and high volume (200 cases, $3,931 per case). Systematic reviews were used to determine early (≤1 year) and late (> 1 year) revision rates after robotic-assisted TKA (0.3 and 0.6%, respectively) and conventional TKA (0.78% and 1.5%, respectively). Outcomes were total costs and health outcomes measured in quality-adjusted life-years (QALYs). Costs and QALYs were organized into incremental cost-effectiveness ratios (ICERs). A procedure was considered cost-effective if its ICER fell below willingness-to-pay (WTP) thresholds of $50,000 and $100,000/QALY. Sensitivity analyses evaluated the effect of data uncertainty.
Robotic-assisted TKA produced 13.55 QALYs versus 13.29 QALYs for conventional TKA. Total costs per case for robotic-assisted TKA were $92,823 (low volume), $29,261 (mid volume), and $25,730 (high volume) compared with $25,113 for conventional. The ICERs for robotic-assisted TKAs were $256,055/QALY (low volume), $15,685/QALY (mid volume), and $2,331/QALY (high volume). ICERs for mid- and high-volume institutions were below WTP. Average number needed to treat was >42 and >24 robotic-assisted TKAs for cost-effectiveness at the $50,000 and $100,000/QALY WTP. Robotic-assisted TKAs remained cost-effective when annual revision rates <1.6% and quality of life values were >0.85.
With lower annualized revision rates and higher postoperative quality of life, robotic-assisted TKAs potentially offer improved health outcomes, especially when annual institutional case volume >24 cases per year. Continued prospective investigation will be crucial to demonstrate the value of this new technology.
➢ Clinicians should exercise a high level of suspicion in at-risk patients (those who use corticosteroids, consume excessive alcohol, have sickle cell disease, etc.) in order to diagnose ...osteonecrosis of the femoral head in its earliest stage.
➢ Nonoperative treatment modalities have generally been ineffective at halting progression. Thus, nonoperative treatment is not appropriate in early stages when one is attempting to preserve the native joint, except potentially on rare occasions for small-sized, medially located lesions, which may heal without surgery.
➢ Joint-preserving procedures should be attempted in early-stage lesions to save the femoral head.
➢ Cell-based augmentation of joint-preserving procedures continues to show promising results, and thus should be considered as an ancillary treatment method that may improve clinical outcomes.
➢ The outcomes of total hip arthroplasty in the setting of osteonecrosis are excellent, with results similar to those in patients who have an underlying diagnosis of osteoarthritis.
With an increasing shift toward a value-based and outcome-driven healthcare system, patient-reported outcome measures (PROMs) will continue to play a prominent role in assessing performance, making ...clinical decisions, shared decision making, and determining the comparative effectiveness of procedures such as total joint arthroplasty for lower extremity conditions, such as ankle, hip, and knee osteoarthritis. As the application of PROMs in evaluating surgical outcomes has evolved from that of a research setting to that of a clinical setting, their use in the decision-making process has become more prevalent. As a result, preoperative optimization, surgical indications, and improved outcomes after surgery have been greatly enhanced. To enable benchmarking, quality reporting, and performance measurement at an aggregate level, it is crucial to have a comprehensive PROM collection system. However, achieving this goal is contingent upon addressing the variability in reported PROMs and the patient-centered benchmarks used to analyze clinical significance.
In this review, we (1) evaluated the effect of adult spine deformity (ASD) and its surgical correction on patients who had a total hip arthroplasty (THA); (2) evaluated the outcomes of THA in ...patients who have had previous spinal fusion; and (3) we presented an algorithm on how to surgically address patients who simultaneously require THA and ASD correction.
A comprehensive literature search was conducted. Our final analysis included 14 studies. Overall, there were 3 studies that reported on the impact of ASD on THA outcomes, 6 studies reported on the effect of ASD correction on THA outcomes, and 5 studies reported on the effect of spinal fusion on THA outcomes.
Patients with concurrent ASD and THA are at increased risk of THA dislocations and revisions with studies reporting a compiled 2.9% dislocation rate in 1167 patients. Patients who underwent ASD correction demonstrated a post-operative reduction of acetabular anteversion (mean reduction range 4.96°-11.2°, P < .001) and tilt (mean −7° ± 10°, P < .001). In THA patients with concurrent lumbosacral fusion, dislocation rates ranged between 3% at 1 year and 7.5% at 2 years compared to 0.4%-2.1% dislocation rates in matching cohorts (P < .001).
Spine balance can alter THA outcomes, but the exact mechanism is yet to be elucidated. We aimed at bridging the gap between hip and spine surgeons with an up-to-date analysis of the best available evidence and presented an algorithm for approaching patients who may simultaneously need ASD correction and THA.
Rogue stem cell clinics Murray, Iain R; Chahla, Jorge; Frank, Rachel M ...
The bone & joint journal,
02/2020, Letnik:
102-B, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Cell therapies hold significant promise for the treatment of injured or diseased musculoskeletal tissues. However, despite advances in research, there is growing concern about the increasing number ...of clinical centres around the world that are making unwarranted claims or are performing risky biological procedures. Such providers have been known to recommend, prescribe, or deliver so called 'stem cell' preparations without sufficient data to support their true content and efficacy. In this annotation, we outline the current environment of stem cell-based treatments and the strategies of marketing directly to consumers. We also outline the difficulties in the regulation of these clinics and make recommendations for best practice and the identification and reporting of illegitimate providers. Cite this article:
2020;102-B(2):148-154.
The Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons (AAOS) have developed Appropriate Use Criteria for the Early Screening for Psychosocial Risk ...and Protective Factors. Evidence and clinical expertise were used to develop criteria for addressing mental and social health opportunities to help people recover from musculoskeletal injuries to the extremity, spine, and pelvis. The criteria were developed by identifying observable symptoms and results of screening that suggest mental and social health challenges among patients with lower extremity trauma in clinical practice. The 32 patient scenarios and three interventions (evaluate for psychological distress, evaluate for social health opportunities, and evaluate coping and resilience strategies) were developed by the writing panel of clinicians who are specialists in mental and social health in musculoskeletal illness. Next, a separate, multidisciplinary, voting panel made up of specialists and nonspecialists rated the appropriateness of treatment for each patient scenario using a 9-point scale to designate a treatment as "appropriate" (median rating, 7 to 9), "may be appropriate" (median rating, 4 to 6), or "rarely appropriate" (median rating, 1 to 3). Notably, with a high level of agreement, the voting panel determined that interventions to address mental and social health were appropriate in all scenarios as follows: 86% were rated appropriate, 14% were rated possibly appropriate, and none were rated rarely appropriate.
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