The unsustainable rising costs of healthcare, a greater portion of which is being borne by the federal government, has resulted in the government’s development of programs aimed to control costs ...without adversely affecting outcomes.
Alternative Payment Models, the shift from inpatient to outpatient and ambulatory surgery centers’ surgical venues, and Relative Value Update Committee coding and reimbursement strategies are all designed to achieve the aforementioned goal. These programs will continue to influence our practice patterns.
It is clear that we must continue to advocate for access to high quality care reimbursed at a fair price. It is also clear that the successful adult reconstructive surgeon will understand these programs and adjust his/her practice to take full advantage of the opportunities that these programs present.
To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes.
Prospective cohort study.
Seven ...musculoskeletal care centers within New York City and Long Island.
One hundred thirty-eight recent and 115 historical hip fracture patients.
Patients with hip fractures occurring between February 1, 2020, and April 15, 2020, or between February 1, 2019, and April 15, 2019, were prospectively enrolled in an orthopaedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs), or COVID negative (C-).
Hospital quality measures, inpatient complications, and mortality rates.
Seventeen (12.2%) patients were confirmed C+ by testing, and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared with Cs and C- cohorts, had an increased mortality rate (35.3% vs. 7.1% vs. 0.9%), increased length of hospital stay, a greater major complication rate, and a greater incidence of ventilator need postoperatively.
COVID-19 had a devastating effect on the care of patients with hip fracture during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in patients with hip fracture complicated by COVID-19.
Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
Abstract Background In 2011 Medicare initiated a Bundled Payment for Care Improvement (BPCI) program with the goal of introducing a payment model that would “lead to higher quality, more coordinated ...care at a lower cost to Medicare.” Methods A Model 2 bundled payment initiative for Total Joint Replacement (TJR) was implemented at a large, tertiary, urban academic medical center. The episode of care includes all costs through 90 days following discharge. After one year, data on 721 Medicare primary TJR patients were available for analysis. Results Average length of stay (LOS) was decreased from 4.27 days to 3.58 days (Median LOS 3 days). Discharges to inpatient facilities decreased from 71% to 44%. Readmissions occurred in 80 patients (11%), which is slightly lower than before implementation. The hospital has seen cost reduction in the inpatient component over baseline. Conclusion Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings. Level of Evidence IV economic and decision analyses—developing an economic or decision model
Core muscle injuries are being diagnosed with increasing frequency in athletes. Knowledge of the anatomy is key to understanding the pathology. Notably, the origin on the pubis of the majority of ...adductor long muscles is via direct insertion of the muscle to the bone and not via a tendon, thus making direct repair difficult.
Abstract The Centers for Medicare and Medicaid Services has proposed bundling of payments for acute care episodes for certain procedures, including total joint arthroplasty. The purpose of this study ...is to quantify the readmission burden of TJA as a function of readmission rate and reimbursement for the bundled payment. Using the hospital’s administrative database, we identified all unplanned 30-day readmissions following index admissions for total hip and total knee arthroplasty, and revision hip and knee arthroplasty among Medicare beneficiaries from 2009 to 2012. For each group, we determined 30-day readmission rates and direct costs of each readmission. The hospital cost margins for Medicare TJAs are small and any decrease in these margins can potentially make performing these procedures economically unfeasible potentially decreasing Medicare patient access.
Surgery and the Aging Orthopaedic Surgeon Bosco, Joseph A; Papalia, Aidan; Zuckerman, Joseph D
Journal of bone and joint surgery. American volume,
2024-Feb-07, Letnik:
106, Številka:
3
Journal Article
Recenzirano
➤ Aging is associated with well-documented neurocognitive and psychomotor changes.➤ These changes can be expected to impact the skill with which orthopaedic surgeons continue to perform surgical ...procedures.➤ Currently, there is no standardized approach for assessing the changes in surgical skills and clinical judgment that may occur with aging.➤ Oversight by the U.S. Equal Employment Opportunity Commission, the impact of the Age Discrimination in Employment Act, and the current legal climate make it difficult to institute a mandatory assessment program.➤ The regularly scheduled credentialing process that occurs at each institution can be the most effective time to assess for these changes because it utilizes an established process that occurs at regularly scheduled intervals.➤ Each department of orthopaedic surgery and institution should determine an approach that can be utilized when there is concern that a surgeon's surgical skills have shown signs of deterioration.
Retrospective review of medical records.
We reviewed all early readmissions after elective spine surgery at a single orthopedic specialty hospital to analyze the causes of unplanned readmissions.
...Recent advances in techniques and instrumentation have made more complex spinal surgeries possible, although sometimes with more complications. Early readmission rate is being used as a marker to evaluate quality of care. There is little data available regarding the causes of early readmissions after spine surgery.
Using the hospital's administrative database of patient records from 2007 to 2009, all patients who underwent spine surgery and were readmitted to the hospital within 30 days were identified and broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Analysis was focused on 12 common spine procedures based on the principle procedure International Classification of Diseases, Ninth Revision, Clinical Modification code for the patient's initial admission. The readmission rate was calculated for each procedure.
A total of 156 early readmissions were identified, of which 141 were unplanned. Of the unplanned readmissions, the most common causes were infection or a concern for an infection (45 patients, 32% of unplanned readmissions), nonsurgical complications (31 patients, 22% of readmissions), complications requiring surgical revision (21 patients, 15% of readmissions), and wound drainage (12 patients, 9% of readmissions). Fifty-seven percent of unplanned readmissions required a return to the operating room (76% of infections or concern for infection). The average length of stay for the unplanned readmissions was 6.5 days. When using the 12 most common procedures based on the International Classification of Diseases, Ninth Revision, Clinical Modification, the early readmission rate was 3.8% (141 early readmissions in 3673 procedures).
Infection, medical complications after surgery, and surgical complications requiring revision of implants are the primary causes of unplanned early readmissions and spine surgery. Further studies are necessary to identify patients and procedures most associated with readmission.
Introduction
Operating room air quality can be affected by several factors including temperature, humidity, and airborne particle burden. Our study examines the role of operating room (OR) size on ...air quality and airborne particle (ABP) count in primary total knee arthroplasty (TKA).
Materials and methods
We analyzed all primary, elective TKAs performed within two ORs measuring 278 sq ft. (small) and 501 sq ft. (large) at a single academic institution in the United States from April 2019 to June 2020. Intraoperative measurements of temperature, humidity, and ABP count were recorded.
p
values were calculated using
t
test for continuous variables and chi-square for categorical values.
Results
91 primary TKA cases were included in the study, with 21 (23.1%) in the small OR and 70 (76.9%) in the large OR. Between-groups comparisons revealed significant differences in relative humidity (small OR 38.5% ± 7.24% vs. large OR 44.4% ± 8.01%,
p
= 0.002). Significant percent decreases in ABP rates for particles measuring 2.5 μm (− 43.9%,
p
= 0.007) and 5.0 μm (− 69.0%,
p
= 0.0024) were found in the large OR. Total time spent in the OR was not significantly different between the two groups (small OR 153.09 ± 22.3 vs. large OR 173 ± 44.6,
p
= 0.05).
Conclusions
Although total time spent in the room did not differ between the large and small OR, there were significant differences in humidity and ABP rates for particles measuring 2.5 μm and 5.0 μm, suggesting the filtration system encounters less particle burden in larger rooms. Larger studies are required to determine the impact this may have on OR sterility and infection rates.
Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this ...study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty.
We reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-squared tests.
Among Medicare patients receiving THA, CM was 96.1% lower for the inpatient cohort when compared to outpatient (P < .001), although the difference between groups for TKA was not significant (P = .163). For patients covered by Medicaid or Government-managed plans, CM was 807% higher for THA inpatients (P < .001), and 143.7% higher for TKA inpatients (P < .001).
Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care.
Retrospective Cohort Study.
The opioid epidemic in the United States is a public health crisis. As a result, regulatory agencies, including state governments, have enacted initiatives to decrease the use of opioids in the ...perioperative setting. The purpose of this study was to compare opioid utilization in orthopaedic surgery patients at discrete points after implementation of State regulatory and institution/physician-led initiatives to decrease opioid utilization in the perioperative period.
We reviewed the electronic medication orders for all patients who underwent orthopaedic surgery procedures between September 2015 and June 2018 at our urban academic medical center. The outcome measures were the number of patients who were prescribed opioid medications, duration of prescription (days), and average milligram morphine equivalents prescribed. Patients were divided into three time cohorts to assess the effect of the NY State (NYS) policy and institutional initiatives to decrease opioid utilization.
A total of 20,483 patients met the inclusion criteria over all three time cohorts. After the initiation of the NYS 7-day supply legislation, there was a decrease in the average supply of opioids prescribed from 10.1 to 7.6 days and the average daily milligram morphine equivalent decreased from 67.9 to 56.7 mg (P < 0.0001). However, with the combination of physician education and surgeon-led institutional initiatives, the percentage of patients who were prescribed opioids decreased by over 10% (96% to 84%), with continued decrease in duration of prescription by 1.0 to 6.4 days (P < 0.0001).
The addition of institution-led initiatives and education programs to previously established government-led prescription limits produced a substantial reduction in the amount of opioids prescribed to orthopaedic surgery patients in the perioperative period. Although mandatory limits set by the state government resulted in a decreased amount of opioid medications being prescribed per patient, it was only after the introduction of educational programs and institution- and physician-led programs that perioperative patient exposure to opioids decreased.
Level III.
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