Abstract Understanding patients' perceived health status, as measured by health state utility, is important when evaluating the societal impact of hip osteoarthritis (OA) and total hip arthroplasty ...(THA). The purpose of this study was to measure health state utility in patients with hip OA and THA. A total of 231 patients from 2 institutions were enrolled into 1 of 6 cohorts: chronic hip OA, successful and failed primary THA, successful and failed revision THA, and infected THA. Average health state utilities were calculated using the time-trade-off method. Health state utilities were highest for primary THA (0.96) and lowest for infected THA (0.46). Our data demonstrate that THA results in substantial improvement in perceived health status in patients with chronic hip OA. However, health state utility is significantly worse after revision THA than primary THA, and failed primary or revision THA results in substantially reduced health state utility, similar to or worse than chronic OA.
Abstract Objectives To evaluate the use of decision aids for hip and knee osteoarthritis (OA) regarding the potential risks and benefits of different treatment options. Methods A prospective, ...randomized controlled trial was conducted of 147 patients with advanced hip or knee OA to compare the effect of two decision aids (booklet-only vs. booklet with DVD). Results Both decision aid programs were well received and demonstrated improvements in patient knowledge and willingness to participate in treatment decisions. The decision aids, however, had a marginal effect on patient willingness to participate in OA management, with an increase of 0.11 and 0.6 on a scale of 2 ( P = 0.58) between groups. Conclusions The decision aids were accepted for most patients and effective in improving patient knowledge and willingness to participate in the decision process. Nevertheless, the addition of a more expensive DVD to the booklet program did not improve patient acceptance or knowledge.
Abstract The purposes of this study were to examine the cost-effectiveness of this technology and to determine improvements in patient outcome needed to make custom total knee cutting blocks ...cost-effective. A Markov decision model was used to evaluate the cost-effectiveness of custom cutting blocks compared with traditional instrumentation in total knee arthroplasty. The analysis demonstrates routine use of custom cutting blocks for total knee arthroplasty will not be cost-effective unless it results in a significantly reduced revision rate. The reduction necessary increases with increasing costs for the custom blocks. Further research will be necessary to determine if this can be achieved using custom cutting blocks. Patients, surgeons, payers, and institutions should consider this when determining their support of this technology in the absence of supportive data.
Abstract A New York State database reported information on all total hip arthroplasty cases between 1990 and 2010 comparing unilateral (242,588 cases) to simultaneous bilateral (4538 cases) ...procedures. Our data showed that the population incidence of this surgery increased 120.2% over twenty years, yet the proportionate number of simultaneous cases has decreased. Simultaneous procedures were found to occur more commonly in younger patients with private insurance. In addition, bilateral procedures showed an increase in PE, DVT, length of stay, and discharge to rehab facilities; whereas mortality and blood transfusions compared to unilateral procedures showed no difference.
Abstract In order to control the unsustainable rise in healthcare costs the Federal Government is experimenting with the bundled payment model for total joint arthroplasty (TJA). In this risk sharing ...model, providers are given one payment, which covers the costs of the TJA, as well as any additional medical costs related to the procedure for up to 90 days. The amount and severity of comorbid conditions strongly influence readmission rates and costs of readmissions in TJA patients. We identified 2026 TJA patients from our database with APR-DRG SOI data for use in this study. Both the costs of readmission and the readmission rate tended to increase as severity of illness increased. The readmission burden also increased as SOI increased, but increased most markedly in the extreme SOI patients.
Abstract The routine use of amoxicillin antibiotic prophylaxis prior to dental procedures for patients with total joint prostheses in place remains controversial. This analysis shows that the ...practice may not be cost-effective for patients in whom the risk of infection with dental work is low. However, specific data quantifying the risk and the impact prophylactic antibiotics can have is needed. Patients and physicians will need to continue to consider their use on an individual basis and should consider the risk of infection as well as the risk of adverse drug reaction when making treatment decisions.
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.
Abstract Little is known about the economic value patients place on effective treatment of osteoarthritis (OA) of the hip. The purpose of this study was to evaluate the value of total hip ...arthroplasty (THA) and hip resurfacing arthroplasty (HRA) to patients with advanced hip OA by measuring their preferences and willingness to pay (WTP) for either procedure. Seventy-three patients younger than 65 years with advanced hip OA reviewed information about the risks and benefits of THA and HRA and were asked which procedure they would choose and how much they would be willing to pay for it. Sixty-nine percent of patients chose THA (average WTP, $69 419) and 31% chose HRA (average WTP, $83 195). There was no correlation between WTP and annual income or total assets. However, patients with modest income and assets could have reported that they were willing and able to pay more than they could actually afford, and WTP dropped and correlation with income rose if we excluded high responses from the poorest respondents. These results may have important policy implications as patients are asked to share a greater burden of the cost of their care for chronic conditions such as OA.
Abstract Rising implant prices and evolving technologies are important factors contributing to the increased cost of arthroplasty. Assessing how patients value arthroplasty, new technologies, and ...their perceived outcomes is critical in planning cost-effective care, as well as evaluating new-technologies. One hundred one patients undergoing arthroplasty took part in the survey. We captured demographics, spending practices, knowledge of implants, patient willingness to pay for implants, and preferences related to implant attributes. When patients were asked if they would be satisfied with “standard of care” prosthesis, 80% replied “no”. When asked if they would pay for a higher than “standard of care” prosthesis, 86% replied “yes”. The study demonstrated that patients, regardless of their socio-economic status, are not satisfied with standard of care implants when newer technologies are available, and they may be willing to share in the cost of their prosthesis. Patients also prefer the option to choose what they perceive to be a higher quality or innovative implant even if the “out of pocket” cost is higher.
As medical management continues to improve, orthopaedic surgeons are likely to encounter a greater proportion of patients who have coinfection with human immunodeficiency virus (HIV) and hepatitis-C ...virus (HCV).
The New York Statewide Planning and Research Cooperative System (SPARCS) database was used to identify patients undergoing total knee arthroplasty between 2010 and 2014. Patients were stratified into 4 groups on the basis of HCV and HIV status. Differences regarding baseline demographics, length of stay, total charges, discharge disposition, in-hospital complications and mortality, and 90-day hospital readmission were calculated.
Between 2010 and 2014, a total of 137,801 patients underwent total knee arthroplasty. Of those, 99.13% (136,604) of the population were not infected, 0.62% (851) had HCV monoinfection, 0.20% (278) had HIV monoinfection, and 0.05% (68) were coinfected with both HCV and HIV. Coinfected patients were more likely to be younger, female, a member of a minority group, homeless, and insured by Medicare or Medicaid, and to have a history of substance abuse. HCV and HIV coinfection was a significant independent risk factor for increased length of hospital stay (odds ratio OR, 2.9; 95% confidence interval CI, 1.75 to 4.81), total hospital charges in the 90th percentile (OR, 2.02; 95% CI, 1.12 to 3.67), ≥2 in-hospital complications (OR, 2.04; 95% CI, 1.04 to 3.97), and 90-day hospital readmission (OR, 3.53; 95% CI, 2.02 to 6.18).
Patients coinfected with both HCV and HIV represent a rare but increasing population of individuals undergoing total knee arthroplasty. Recognition of unique baseline demographics in these patients that may lead to suboptimal outcomes will allow appropriate preoperative management and multidisciplinary coordination to reduce morbidity and mortality while containing costs.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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