The Role of Patient Education in Arthritis Management Einhorn, Thomas A., MD; Osmani, Feroz A., MD; Sayeed, Yousuf, MD ...
The Orthopedic clinics of North America,
October 2018, Letnik:
49, Številka:
4
Journal Article
Recenzirano
Technologies continue to shape the path of medical treatment. Orthopedic surgeons benefit from becoming more aware of how twenty-first century information technology (IT) can benefit patients. The ...percentage of orthopedic patients utilizing IT resources is increasing, and new IT tools are becoming utilized. These include disease-specific applications. This article highlights the opportunity for developing IT tools applicable to the growing population of patients with osteoarthritis (OA), and presents a potential solution that can facilitate the way OA education and treatment are delivered, and thereby maximize efficiency for the health care system, the physician, and the patient.
Abstract Background The Comprehensive Care for Joint Replacement (CJR) model is designed to minimize costs and improve quality for Medicare patients undergoing joint arthroplasty. The cost of hip ...arthroplasty (HA) episode varies depending on the preoperative diagnosis, and is greater for fracture than for osteoarthritis (OA). Hospitals that perform a higher percentage of HA for OA may therefore have an advantage in the CJR model. The purposes of this study are to: 1) determine the variability in underlying diagnosis for HA in NYS hospitals and 2) determine hospital characteristics, such as volume, associated with this. Methods The New York Statewide Planning and Research Cooperative System (SPARCS) database was used to identify 127,206 primary HA procedures from 2010 to 2014. The data included underlying diagnoses, age, length of stay, and total charges. Hospitals were categorized by volume and descriptive statistics were used. Results OA was the underlying diagnosis for HA for 74.2% of all patients; this was significantly higher for high- (89.30%) and medium-volume (74.9%) hospitals than for low-volume hospitals (58.4%, p<0.05). HA for fracture was significantly more common at low-volume hospitals (32.4%) compared to medium- (18.0%) and high-volume (4.7%) hospitals (p<0.05). Length of stay was significantly greater at low-volume hospitals for all diagnoses. Conclusions High-volume hospitals perform a higher ratio of HA cases for OA compared to fracture, which may lead to advantages in patient outcomes and cost. The variation in underlying diagnosis between hospitals has financial implications and underscores the need for HA’s to be risk stratified by preoperative diagnosis.
The purpose of this study was to evaluate the incidence of lateral trochanteric pain (LTP) following primary total hip arthroplasty (THA) and identify risk factors. From 1993 to 1998, 543 primary ...THAs were performed for osteoarthritis. Lateral trochanteric pain was identified in 24 (4.4%) of 543 patients. The incidence of LTP with the posterior approach was 1.2% (1/82), and the incidence with the direct lateral approach was 4.9% (23/461). Leg length discrepancy, femoral offset, and heterotopic ossification were not correlated with LTP. No patient required operative treatment. Lateral trochanteric pain after primary THA was significantly more common in females (
P < .04) and in patients who had a direct lateral approach (
P < .01). Lateral trochanteric pain in this series was effectively treated with nonoperative modalities.
Abstract This study aims to identify the long-term outcomes of total knee arthroplasty (TKA) treated for deep infection. 3270 consecutive primary and 175 revision TKAs were followed prospectively. ...There were 39 deep infections (1.16%): 29 primary (0.9%) and 10 revision (5.7%) cases. Two-stage resection and re-implantation procedure was performed in 13 primary cases with 10/13 (77%) successfully resolved. Early (< 1 month) Irrigation and Debridement (I&D) was performed in 16 primary cases with 100% success. Late (> 4 months) I&D was performed in 6 cases with 5/6 (83.3%) successful. Infection following revision TKA resulted in poor outcomes with both two-stage (2/4 successful) and I&D (2/6 successful). Deep infection after primary TKA can be successfully resolved with I&D and appropriate antibiotic treatment in the early postoperative course.
Multimodal pain control strategies are crucial in reducing opioid use and delivering effective pain management to facilitate improved surgical outcomes. The utility of liposomal bupivacaine in ...enabling effective pain control in multimodal strategies has been demonstrated in several studies, but others have found the value of liposomal bupivacaine in such approaches to be insignificant. At New York University Langone Medical Center, liposomal bupivacaine injection and femoral nerve block were compared in their delivery of efficacious and cost-effective multimodal analgesia among patients undergoing total joint arthroplasty (TJA). Retrospective analysis revealed that including liposomal bupivacaine in a multimodal pain control protocol for TJA resulted in improved quality and efficiency metrics, decreased narcotic use, and faster mobilization, all relative to femoral nerve block, and without a significant increase in admission costs. In addition, liposomal bupivacaine use was associated with elimination of the need for patient-controlled analgesia in TJA. Thus, at Langone Medical Center, the introduction of liposomal bupivacaine to TJA has been instrumental in achieving adequate pain control, delivering high-level quality of care, and controlling costs.
Abstract The Centers for Medicare and Medicaid (CMS) have continued to explore ways to decrease cost and increase quality in the provision of medical services. There is increasing concern that the ...current “fee for service” payment structure of American medicine may do neither. CMS has developed several programs aimed at incentivizing better quality at a lower spend, termed Alternative Payment Models (APMs). CJR is the largest, being implemented in 67 metropolitan regions. This is a mandated bundle payment where providers initially are not at risk, but hospitals control the bundle and are at risk. Clearly, in any program designed to curtail spending there will be losers and winners, “musical chairs” if you will. This article reviews the scope of services within the bundle, and predicts how specific stakeholders will do.
In January 2013, a large, tertiary, urban academic medical center began participation in the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty, a program ...implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011. Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 were included. We participated in BPCI Model 2, by which an episode of care includes the inpatient and all post-acute care costs through 90 days following discharge. The goal for this initiative is to improve patient care and quality through a patient-centered approach with increased care coordination supported through payment innovation.
Length of stay (LOS), readmissions, discharge disposition, and cost per episode of care were analyzed for year 3 compared with year 1 of the initiative. Multiple programs were implemented after the first year to improve performance metrics: a surgeon-directed preoperative risk-factor optimization program, enhanced care coordination and home services, a change in venous thromboembolic disease (VTED) prophylaxis to a risk-stratified protocol, infection-prevention measures, a continued emphasis on discharge to home rather than to an inpatient facility, and a quality-dependent gain-sharing program among surgeons.
There were 721 Medicare primary total joint arthroplasty patients in year 1 and 785 in year 3; their data were compared. The average hospital LOS decreased from 3.58 to 2.96 days. The rate of discharge to an inpatient facility decreased from 44% to 28%. The 30-day all-cause readmission rate decreased from 7% to 5%; the 60-day all-cause readmission rate decreased from 11% to 6%; and the 90-day all-cause readmission rate decreased from 13% to 8%. The average 90-day cost per episode decreased by 20%.
Mid-term results from the implementation of Medicare BPCI Model 2 for primary total joint arthroplasty demonstrated decreased LOS, decreased discharges to inpatient facilities, decreased readmissions, and decreased cost of the episode of care in year 3 compared with year 1, resulting in increased value to all stakeholders involved in this initiative and suggesting that continued improvement over initial gains is possible.
Tranexamic acid (TXA) is used to reduce blood loss in orthopedic total joint arthroplasty (TJA). This study evaluates the effectiveness of TXA in reducing transfusions and hospital cost in TJA. ...Participants undergoing elective TJA were stratified into 2 cohorts: those not receiving and those receiving intravenous TXA. TXA decreased total hip arthroplasty (THA) transfusions from 22.7% to 11.9%, and total knee arthroplasty (TKA) from 19.4% to 7.0%. The average direct hospital cost reduction for THA and TKA was $3083 and $2582, respectively. Implementation of a TJA TXA protocol significantly reduced transfusions in a safe and cost-effective manner.
Background
Periprosthetic joint infections (PJIs) are associated with increased morbidity and cost. It would be important to identify any modifiable patient- and surgical-related factors that could ...be modified before surgery to decrease the risk of PJI.
Questions/purposes
We sought to identify and quantify the magnitude of modifiable risk factors for deep PJIs after primary hip arthroplasty.
Methods
A series of 3672 primary and 406 revision hip arthroplasties performed at a single specialty hospital over a 3-year period were reviewed. All deep PJIs were identified using the Centers for Disease Control and Prevention case definitions (ie, occurs within 30–90 days postoperatively, involves deep soft tissues of the incision, purulent drainage, dehiscence and fever, localized pain or tenderness). Univariate and multivariate analyses determined the association between patient and surgical risk factors and PJIs. For the elective patients, the procedure was performed on the day of admission (“same-day procedure”), whereas for the fracture and nonelective patients, the procedure was performed 1 or more days postadmission (“nonsame-day procedure”).
Staphylococcus aureus
colonization, tobacco use, and body mass index (BMI) were defined as patient-related modifiable risk factors.
Results
Forty-seven (1.3%) deep PJIs were identified. Infection developed in 20 of 363 hips of nonsame-day procedures and 27 of 3309 same-day procedures (p = 0.006). There were eight (2%) infections in the revision group. After controlling for confounding variables, our multivariate analysis showed that BMI ≧ 40 kg/m
2
(odds ratio OR, 4.13; 95% confidence interval CI, 1.3–12.88; p = 0.01), operating time > 115 minutes (OR, 3.38; 95% CI, 1.23–9.28; p = 0.018), nonsame-day surgery (OR, 4.16; 95% CI, 1.44–12.02; p = 0.008), and revision surgery (OR, 4.23; 95% CI, 1.67–10.72; p < 0.001) are significant risk factors for PJIs. Tobacco use and
S aureus
colonization were additive risk factors when combined with other significant risk factors (OR, 12.76; 95% CI, 2.47–66.16; p = 0.017).
Conclusions
Nonsame-day hip and revision arthroplasties have higher infection rates than same-day primary surgeries. These characteristics are not modifiable and should be categorized as a separate cohort for complication-reporting purposes. Potentially modifiable risk factors in our patient population include operating time, elevated BMI, tobacco use, and
S aureus
colonization. Modifying risk factors may decrease the incidence of PJIs. When reporting deep PJI rates, stratification into preventable versus nonpreventable infections may provide a better assessment of performance on an institutional and individual surgeon level.
Level of Evidence
Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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