In November 2017, CMS finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed TKA from the Medicare inpatient-only (IPO) list. This action had significant and unexpected ...consequences.
We looked at 3 levels of the IPO rule impact on TKA for Medicare beneficiaries: a national comparison of FFS inpatient and outpatient classification for 2017 vs 2018; a survey of AAHKS surgeons completed in April 2019; and an in-depth analysis of a large academic medical center experience. An analysis of change in admission classification of patients with TKA over time, number of QIO audits, compliance solutions for the new rule, and cost implications of those compliance solutions were evaluated.
Hospital reimbursement averages $10,122 in an outpatient facility but does not include the physician payment. Average hospital reimbursement in the inpatient setting is $11,760. The difference in hospital reimbursement varies widely (90th percentile decrease, $6725 vs 10th percentile $2048). Physician payments are the same in both settings (avg $1403). Patients with TKA not designated for inpatient admissions are not eligible for bundle payment programs. Patients designated as outpatients are subjected to higher out-of-pocket expenses. Patients may have an annual Medicare Part B Deductible ($185) and a 20% copay as well as prescription and durable medical equipment costs. An AAHKS survey demonstrated that 45.08% were with inpatient designation only, 17.62% were with outpatient designation only, 25.39% were designated as necessary, and 10.1% were designated by the hospital. This survey showed that 66 of 374 (17.65%) patients had undergone a QIO audit as a result of issues with the IPO rule. An evaluation of an AMC demonstrated that since January 1, 2018, 470 of 690 (68.1%) of CMS patients with TKA left in less than 2 midnights. The institution was subjected to 2 QIO audits.
There are many unintended consequences to the IPO rule application to TKA.
Recent regulatory changes made by the Center for Medicare and Medicaid Services (CMS) will result in a 9% decrease in reimbursement for hip and knee replacements by the end of 2022. Combining this ...with CMS’s recent removal of total knee and total hip arthroplasty from the inpatient-only list has begun to take effect on the bottom line for hospital systems, which now employ around 50% of the arthroplasty community. Employed joint replacement surgeons should continue to innovate and be leaders within their hospital systems in the outpatient and ambulatory surgery space to recoup lost value, increase autonomy, and should be compensated for this work. Employed arthroplasty surgeon leaders can better align goals with and control the narrative in the C-suite to redefine their value as the most consistent, dependable, and transparent department within a larger health system or corporate medical group.
Obesity, smoking, uncontrolled diabetes, and poor dental health are modifiable risk factors for revision total joint arthroplasty. To protect patients from revision surgery while also reducing cost, ...some joint arthroplasty practices use these conditions as contraindications until they are improved. However, this practice is variable among joint arthroplasty surgeons. We hypothesize that a relatively high rate of revision arthroplasty patients had modifiable risk factors at the time of primary surgery.
A retrospective review of all revision total hip and knee arthroplasties performed at an academic, tertiary referral center within 2 years of primary surgery was conducted. The presence of body mass index >40, hemoglobin A1c >8, poor dentition, and smoking status were obtained from the electronic medical record. Risk factors were described and compared between infected revisions and noninfected revisions.
A total of 128 revision arthroplasties were performed at our institution in one year. And 23 of 57 (40.4%) total hip revision and 31 of 71 (43.7%) total knee revision patients had at least 1 modifiable risk factor. Infected hip revision patients were more likely to have increased body mass index compared to noninfected patients. Infected knee revision patients were more likely to smoke, have poor dentition, and have >1 contraindication compared to noninfected patients.
A high percentage of patients undergoing early revision arthroplasty had at least 1 modifiable risk factor for a primary joint arthroplasty. Joint arthroplasty surgeons may help reduce revision surgery through counseling and appropriate referral for modification of risk factors.
Centers for Medicare and Medicaid Services removed total knee arthroplasties (TKAs) from the Inpatient-Only list on January 1, 2018, which meant TKAs could be performed on a hospital outpatient ...basis. We sought to understand (1) what the financial implications have been for hospitals, (2) to what extent financial incentives have influenced the adoption of outpatient TKAs across hospitals, (3) whether adoption of outpatient TKAs has impacted the success of hospitals with managing post-acute care (PAC) spend, and (4) the financial implications to Medicare of the adoption of outpatient TKAs.
We used national patient-level Medicare fee-for-service Part A claims data (100% sample) from January 2018 through June 2019 to calculate the inpatient and outpatient TKA payment rate for each hospital, and the distribution in these payments across the country. We then ran case-level regressions to understand the factors associated with adoption of outpatient TKAs, and the drivers of PAC spend. Finally, we quantified the savings to Medicare.
Hospitals on average received $3682 (30%) lower payment from Medicare for outpatient TKA cases, but this varied widely across hospitals. The difference in payment rates across hospitals was not statistically significantly related to their adoption rate of outpatient TKAs. PAC spend was higher for same-day discharges, but lower for cases that stayed at least 1 night. Based on the adoption rate of outpatient TKAs in Q2 2019, Medicare saved $355M on a run rate basis.
Hospitals have adopted outpatient TKAs independent of the financial impact. Medicare has benefited from lower PAC spend and lower payments to hospitals.
Many U.S. health systems are grappling with how to safely resume elective surgery amid the COVID-19 pandemic. We used online crowdsourcing to explore public perceptions and concerns toward resuming ...elective surgery during the pandemic, and to determine factors associated with the preferred timing of surgery after health systems reopen.
A 21-question survey was completed by 722 members of the public using Amazon Mechanical Turk. Multivariable logistic regression analysis was performed to determine factors associated with the timing of preferred surgery after health systems reopen.
Most (61%) participants were concerned with contracting COVID-19 during the surgical process, primarily during check-in and in waiting room areas, as well as through excessive interactions with staff. Overall, 57% would choose to have their surgery at a hospital over an outpatient surgery center. About 1 in 4 (27%) would feel comfortable undergoing elective surgery in the first month of health systems reopening. After multivariable adjustment, native English speaking (OR, 2.6; 95% CI, 1.04-6.4; P = .042), male sex (OR, 1.9; 95% CI, 1.3-2.7; P < .001), and Veterans Affairs insurance (OR, 4.5; 95% CI, 1.1-18.7; P = .036) were independent predictors of preferring earlier surgery.
Women and non-native English speakers may be more hesitant to undergo elective surgery amid the COVID-19 pandemic. Despite concerns of contagion, more than half of the public favors a hospital setting over an outpatient surgery center for their elective surgery. Concerted efforts to minimize patient congestion and unnecessary face-to-face interactions may prove most effective in reducing public anxiety and concerns over the safety of resuming elective care.
Predictive tools are useful adjuncts in surgical planning. They help guide patient selection, candidacy for inpatient vs outpatient surgery, and discharge disposition as well as predict the ...probability of readmissions and complications after total joint arthroplasty (TJA). Surgeons may find it difficult due to significant variation among risk calculators to decide which tool is best suited for a specific patient for optimal decision-based care. Our aim is to perform a systematic review of the literature to determine the existing post-TJA readmission calculators and compare the specific elements that comprise their formula. Second, we intend to evaluate the pros and cons of each calculator.
Using a Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols protocol, we conducted a systematic search through 3 major databases for publications addressing TJA risk stratification tools for readmission, discharge disposition, and early complications. We excluded those manuscripts that were not comprehensive for hips and knees, did not list discharge, readmission or complication as the primary outcome, or were published outside the North America.
Ten publications met our criteria and were compared on their sourced data, variable types, and overall algorithm quality. Seven of these were generated with single institution data and 3 from large administrative datasets. Three tools determined readmission risk, 5 calculated discharge disposition, and 2 predicted early complications. Only 4 prediction tools were validated by external studies. Seven studies utilized preoperative data points in their risk equations while 3 utilized intraoperative or postsurgical data to delineate risk.
The extensive variation among TJA risk calculators underscores the need for tools with more individualized stratification capabilities and verification. The transition to outpatient and same-day discharge TJA may preclude or change the need for many of these calculators. Further studies are needed to develop more streamlined risk calculator tools that predict readmission and surgical complications.
The use of narcotics has been found to be a modifiable risk factor for success of arthroplasty. We sought to determine the risk factors leading to increased narcotic use after total hip arthroplasty ...and total knee arthroplasty.
A retrospective chart review was performed on new patients presenting to an orthopedic reconstructive-service clinic. New patients aged 18 years or older with osteoarthritis of the hip or knee who presented over a 1-year period and underwent total knee arthroplasty or total hip arthroplasty were included. The Arkansas prescription monitoring program was then used to determine recent narcotic and benzodiazepine prescriptions filled within 3 months of surgery, and this was converted into morphine milligram equivalents (MME).
One hundred seventy-nine patients met the inclusion criteria. When compared with patients who did not take any preoperative opioids, narcotic- and tramadol-only users filled an average of 86% and 38% more MME, respectively. Benzodiazepine users required an average of 81% more MME postoperative than nonusers, and smokers required an average of 90% more MME postoperative than nonsmokers. Subjects with body mass index >40 kg/m2 had 82% higher average postoperative MME than subjects with body mass index <25 kg/m2. Age and sex had no significant correlation with postoperative narcotic use.
This study suggests that a patient's preoperative narcotic, tramadol, benzodiazepine, and tobacco use are correlated to the amount of postoperative narcotic prescriptions filled in the 3 months following surgery. Predisposition to substance abuse may be a characteristic which leads to increased postoperative narcotic use.
Abstract Poor tibial component fit can lead to issues including pain, loosening and subsidence. Morphometric data, from 30 patients undergoing UKA were utilized; comparing size, match and fit between ...patient-specific and off-the-shelf implants. CT images were prospectively obtained and implants modeled in CAD, utilizing sizing templates with off-the-shelf and CAD designs with patient-specific implants. Virtual surgery was performed, maximizing tibial plateau coverage while minimizing implant overhang. Each implant evaluated to examine tibial fit. Patient-specific implants provided significantly greater cortical rim surface area coverage versus off-the-shelf implants: 77% v. 43% medially and 60% v. 37% laterally. Significantly less cortical rim overhang and undercoverage were observed with patient-specific implants. Patient-specific implants provide superior cortical bone coverage and fit while minimizing overhang and undercoverage seen in off-the-shelf implants.
Osteoarthritis (OA) of the knee is thought to lead to a loss of lumbar lordosis (LL) as a compensation for knee flexion contracture. Changes in sagittal alignment are not limited to the lumbar spine ...and involve a complex interplay of alignment of the hip, pelvis, and spine. While spine-hip interactions have been previously explored, the influence of knee OA sagittal alignment parameters on spinopelvic alignment and global sagittal balance remains unexplored. Standing radiological examination using EOS biplanar radiography was examined in 108 patients with knee OA. Whole-body sagittal alignment parameters (thoracic kyphosis, LL, pelvic incidence, pelvic tilt PT, femoropelvic angle FPA, femoral tilt angle FTA, tibial tilt angle, and knee flexion angle KFA) and global balance parameters (sagittal vertical axis SVA and odontoid hip axis OD-HA angle) were measured three dimensionally (3D). The correlation coefficients among all parameters were assessed. A multiple stepwise linear regression model was built to investigate the direct association between SVA or OD-HA angle (dependent variables) and sagittal alignment parameters and demographic data (independent variables). Significant correlations between KFA, FPA, FTA, SVA, and OD-HA angle were found. FTA was correlated with LL and FPA. The FTA was the most influential predictor of both global sagittal balance parameters (
< 0.001). Knee OA leads to changes in global sagittal balance with effects at the hip, knee, pelvis, and spine. FTA (forward flexion of the femur vs. the vertical plane) is the largest driver of global sagittal plane balance in patients with knee OA.
Predicting the length of stay (LOS) after total joint arthroplasty (TJA) has become more important with their recent removal from inpatient-only designation. The American College of Surgeons (ACS) ...National Surgical Quality Improvement Program surgical risk calculator and the CMS’ diagnosis-related group (DRG) calculator are two common LOS predictors. The aim of our study was to determine how our actual LOS compared with those predicted by both the ACS and DRG.
99 consecutive TJA (49 hips and 50 knee procedures) were reviewed in Medicare-eligible patients from four fellowship-trained arthroplasty surgeons. Predicted LOS was calculated using the DRG and ACS risk calculators for each patient using demographics, medical histories, and comorbidities. LOS was compared between the predicted and the actual LOS for both total hip arthroplasty (THA) and total knee arthroplasty (TKA) using paired t-tests.
Actual LOS was shorter in the THA group vs the TKA group (1.29 days vs 1.46 days, P < .05). The actual LOS of patients at our institution was significantly shorter than both DRG and ACS predictions for both THA and TKA (P < .05). In both the THA and TKA patients, the actual LOS (1.29 and 1.46 day) was significantly shorter than the DRG-predicted LOS (2.15 and 2.15 days) which was significantly shorter than the ACS-predicted LOS (2.9 and 3.14 days).
We found the actual LOS was significantly shorter than that predicted by both the DRG and ACS risk calculators. Current risk calculators may not be accurate for contemporary fast-track protocols and newer tools should be developed.
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