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
Abstract Introduction The Bundled Payment for Care Improvement (BPCI) Initiative is a Centers for Medicare and Medicaid services (CMS) program designed to promote coordinated and efficient care. This ...study seeks to report costs of readmissions within a 90-day episode of care for BPCI Initiative patients receiving total knee or hip arthroplasty (TKA or THA). Methods From January 2013 through December 2013 one urban, tertiary, academic orthopaedic hospital admitted 664 patients undergoing either primary TKA or THA through the BPCI Initiative. All patients readmitted to our hospital or an outside hospital (OSH) within 90-days from the index episode were identified. The diagnosis and cost for each readmission was analyzed. Results Eighty readmissions in 69 patients (11%) were identified within 90-days. There were 53 readmissions (45 patients) following THA, and 27 readmissions (24 patients) following TKA. Surgical complications accounted for 54% of THA readmissions and 44% TKA readmissions. These complications had an average cost of $36,038 (range $6,375-$60,137) for THA and $38,953 (range $4,790-$104,794) for TKA. Eliminating the TKA outlier of greater than $100,000 yields an average cost of $27,979. Medical complications of THA and TKA had an average cost of $22,775 (range $5,678-$82,940) for THA and $24,183 (range $3,306-$186,069) for TKA. Eliminating the TKA outlier of greater than $100,000 yields an average cost of $11,682. Conclusion Hospital readmissions following THA and TKA are common and costly. Identifying the causes for readmission and assessing the cost will guide quality improvement efforts.
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.
Abstract Higher PJI rates may be related to identifiable risk factors, which may or may not be modifiable. Identifying risk factors preoperatively provides opportunities for modification and ...potentially decreasing the incidence of PJI. The purposes of this study were to: (1) retrospectively identify and quantify risk factors for PJI following primary TKA, and (2) to classify those significant risk factors as either non-modifiable or modifiable for intervention prior to surgery. Optimization of modifiable risk factors such as Staphylococcus aureus colonization, and tobacco use prior to primary TKA may decrease the incidence of periprosthetic joint infection after primary TKA, thereby reducing morbidity and the costs associated with treating those infections.
Abstract Previous studies have demonstrated no significant difference in overall functional outcomes of patients discharged to a sub acute setting versus home with health services after total joint ...arthroplasty. These findings coupled with pressure to reduce health care costs and the implementation of a prospective payment system under Medicare have supported the use of home rehabilitation services and the trend towards earlier discharge after hospitalization. While the overall functional outcome of patients discharged to various settings has been studied, there is a relative dearth of investigation comparing postoperative complications and readmission rates between various discharge dispositions. Our study demonstrated patients discharged home with health services had a significantly lower 30 day readmission rate compared to those discharged to inpatient rehab facilities. Patients discharged to rehab facilities have a higher incidence of comorbidity and this association could be responsible for their higher rate of readmission.
Abstract We aimed to examine and quantify the combined association of patient sociodemographic, preoperative comorbidities and intraoperative factors with extended and prolonged length of stay (LOS) ...following primary total hip arthroplasty. Longer LOS was associated with Age (≥ 65 years), BMI ≥ 30 kg/m2 , ASA score > 2, minority race/ethnicity, low SES, general anesthesia, comorbidities of the Circulatory, Genitourinary and Respiratory systems, and operating time. Collectively, being of low SES, advanced age (≥ 65 years) and minority race/ethnicity was most significantly associated with prolonged LOS (> 7 days). The combined associations of lower SES, female gender, advanced age, non-Caucasian race/ethnicity and certain comorbidities presented a synergistically elevated risk for longer LOS and may warrant the need to consider sociodemographic status when allocating resources to hospitals serving such patients.
Abstract This study investigated the impact of metabolic syndrome (MetS) on perioperative and postoperative complication rates: the results of a cohort of 168 total hip and knee arthroplasties, 63 of ...normal weight, 105 with obesity without risk factors for metabolic syndrome and 39 with obesity and other factors that classify them with metabolic syndrome. Patients with metabolic syndrome were more likely to have complications than those without metabolic syndrome ( P = 0.0156). Perioperative and postoperative complication rates for the MetS and control groups were 35.9% and 16.3%, respectively. Elevated BMI was the element of MetS that had the largest impact on post-surgical complication rates, and this was statistically significant ( P = 0.0028). The presence of MetS in patients undergoing total joint arthroplasty has a significant impact on surgical complication rates. This cannot be attributed to the BMI component alone, and may help guide efforts of patient optimization prior to total joint arthroplasty.
Abstract The effect of obesity on the outcomes of total joint arthroplasties is an ongoing concern. As obesity becomes more endemic, new categories emerge, such as the “super-obese.” We conducted a ...retrospective study to determine the difference in outcomes among the super-obese. When categorized according to body mass index (BMI), the overall rate of complications was higher for patients with BMI of 45 or higher. Super-obese patients had an odds ratio (OR) of 8.44 for developing inhospital complications. Most importantly, each incremental 5-U increase in BMI above 45 was associated with an increased risk of inhospital (OR, 1.69) and outpatient complications (OR, 2.71), and readmission (OR, 2.0), compared with patients with BMI of 45 to 50. Length of stay was increased by 13.8% for each 5-U increase in BMI above 45. There is a significant increased risk for complications in the super-obese population, and this continues to increase with BMI increases above 45. These data are important when counseling super-obese patients and should be accounted for in reporting quality outcome measures in this population.
Abstract Reducing the cost of total joint implants can significantly reduce the cost of an episode of care without affecting the quality. In 2011 we began a program to decrease and standardize the ...pricing of total joint implants. In the first year of the intervention we preformed 1,090 and 1,022 unilateral total knee and total hip arthroplasties respectively. Based on our volume and pricing data, our institution saved over $2 million during the first year of this intervention. It is clear that our initiative to negotiate lower implant cost with our vendors has lead to a significant reduction in the cost of joint arthroplasties and a reduction in the variability in costs between physicians.
Abstract Background Significant attempts have been made to adopt practices to minimize blood transfusion after total joint arthroplasty (TJA) because of transfusion cost and potential negative ...clinical consequences including allergic reactions, transfusion-related lung injuries, and immunomodulatory effects. We aimed to evaluate risk factors for blood transfusion in a large cohort of TJA patients. Methods We used the all-payer California Healthcare Cost and Utilization Project data from 2006 to 2011 to examine the trends in utilization of blood transfusion among arthroplasty patients (n = 320,746). We performed descriptive analyses and multivariate logistic regression clustered by hospital, controlling for Deyo-Charlson comorbidity index, age, insurance type (Medicaid vs others), gender, procedure year, and race/ethnicity. Results Eighteen percent (n = 59,038) of TJA patients underwent blood transfusion during their surgery, from 15% with single knee to 45% for bilateral hip arthroplasty. Multivariate analysis indicated that compared with the referent category of single knee arthroplasty, single hip had a significantly higher odds of blood transfusion (odds ratio OR, 1.76; 95% confidence interval CI, 1.68-1.83), as did bilateral knee (OR, 3.57; 95% CI, 3.20-3.98) and bilateral hip arthroplasty (OR, 6.17; 95% CI, 4.85-7.85). Increasing age (eg, age ≥80 years; OR, 2.99; 95% CI, 2.82-3.17), Medicaid insurance (OR, 1.36; 95% CI, 1.27-1.45), higher comorbidity index (eg, score of ≥3; OR, 2.33; 95% CI, 2.22-2.45), and females (OR, 1.75; 95% CI, 1.70-1.80) all had significantly higher odds of blood transfusion after TJA. Conclusion Primary hip arthroplasties have significantly greater risk of transfusion than knee arthroplasties, and bilateral procedures have even greater risk, especially for hips. These factors should be considered when evaluating the risk for blood transfusions.
