Knee arthroplasty (KA) is an effective surgical procedure. However, clinical studies suggest that a considerable number of patients continue to experience substantial pain and functional loss ...following surgical recovery. We aimed to estimate pain and function outcome trajectory types for persons undergoing KA, and to determine the relationship between pain and function trajectory types, and pre-surgery predictors of trajectory types.
Participants were 384 patients who took part in the KA Skills Training randomized clinical trial. Pain and function were assessed at 2-week pre- and 2-, 6-, and 12-months post-surgery. Piecewise latent class growth models were used to estimate pain and function trajectories. Pre-surgery variables were used to predict trajectory types.
There was strong evidence for two trajectory types, labeled as good and poor, for both Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain and Function scores. Model estimated rates of the poor trajectory type were 18% for pain and function. Dumenci's latent kappa between pain and function trajectory types was 0.71 (95% CI: 0.61–0.80). Pain catastrophizing and number of painful body regions were significant predictors of poor pain and function outcomes. Outcome-specific predictors included low income for poor pain and baseline pain and younger age for poor function.
Among adults undergoing KA, approximately one-fifth continue to have persistent pain, poor function, or both. Although the poor pain and function trajectory types tend to go together within persons, a significant number experience either poor pain or function but not both, suggesting heterogeneity among persons who do not fully benefit from KA.
Abstract Background Discharge destination is an important factor to consider in order to maximize care coordination and manage patient expectations after total joint arthroplasty (TJA). It also has ...significant impact on the cost-effectiveness of these procedures given the significant cost of post-acute inpatient care. Therefore, understanding factors that impact discharge destination after TJA is critical. Methods An evaluation of socioeconomic, geographic and racial/ethnic factors associated with discharge destination to either home or institution(i.e. rehabilitation, skilled nursing facility, etc.) following joint arthroplasty of the lower extremity was conducted. We analyzed data on patients admitted between 2011 and 2014 for primary or revision hip or knee arthroplasty at a single institution. Bivariate and multivariate statistical techniques were applied to determine associations. Results Included in the analysis were 7,924cases of lower extremity joint procedures, of which 4836(61%), 785(10%) and 2770(35%) were of female gender, low SES and non-white race/ethnicity respectively. 5088(64%) and 2836(36%) were discharged to home and institution respectively. Significant predictors of discharge to an institution in the multivariate analysis include SESlow and middle SES(OR: 1.3, 95%CI: 1.02-1.57, p=0.029; OR: 1.3, 95%CI: 1.1-1.4, p=0.001); age(OR: 1.05, 95%CI: 1.049-1.060, p<0.001), female gender(OR: 1.7, 95%CI: 1.5-1.9, p<.001), and TKA procedure(OR: 1.5, 95%CI: 1.3-1.6, p<0.001). Non-Black race/ethnicity were more likely to be discharged home(OR: 0.8, 95%CI: 0.7-1.0, p=0.027; OR: 0.8, 95%CI: 0.7-0.9, p=0.009). Conclusion Socioeconomic status and race/ethnicity are important factors related to discharge destination following TJA. Thoroughly understanding and addressing these factors may help increase the rates of discharge to home as opposed to institution.
The effect of surgeon practice and patient care setting have not been studied in the Medicaid population undergoing total knee arthroplasty (TKA). This study aims to evaluate whether point of entry ...and Medicaid status affect outcomes following TKA.
The electronic medical record at our urban, academic, tertiary care hospital system was retrospectively reviewed for all primary, unilateral TKA during January 2016 and January 2018. Outpatient visits within the 6-month preoperative period categorized TKA recipients as either Hospital Ambulatory Clinic Centers patients with Medicaid insurance or private office patients with non-Medicaid insurers.
There were 174 Medicaid patients and 317 non-Medicaid patients for 491 total patients. Medicaid patients were significantly younger (62.6 ± 1.6 vs 65.4 ± 1.1 years, P < .01), of “other’ ethnicity (43.1% vs 25.6%, P < .01), and to be a current smoker (9.3% vs 6.6%, P = .02). There was no difference in gender, body mass index, and American Society of Anesthesiologists score. After controlling for patient factors, the Medicaid effect was insignificant for surgical time (exponentiated β 0.93, 95% confidence interval CI 0.86-1.01, P = .076) and facility discharge (odds ratio 1.58, 95% CI 0.71-3.51, P = .262). Medicaid status had a significant effect on length of stay (LOS) (rate ratio 1.21, 95% CI 1.02-1.43, P = .026).
Multivariable analysis controlling for patient factors demonstrated that Medicaid coverage had minimal effect on surgical time and facility discharge. Medicaid patients had significantly longer LOS by one-half day. These results indicate that comparable outcomes can be achieved for Medicaid patients following TKA provided that the surgeon and care setting are similar. However, increased care coordination and preoperative education may be necessary to normalize disparities in hospital LOS.
III, retrospective observational analysis;
Abstract Introduction Hip Arthroplasty is increasingly performed as a treatment for femoral neck fractures (FNF). However, these cases have higher complication rates than elective total hip ...replacements (THA). The Center for Medicare and Medicaid Services has created the Comprehensive Care for Joint Replacement (CJR) model to increase the value of patient care. This model risk stratifies FNF patients in an attempt to appropriately allocate resources, but the formula has not been disclosed. The goal of this study was to ascertain if patients with FNFs have different readmission rates compared to patients undergoing elective THA so that the resource utilization can be assessed. Methods We analyzed all patients undergoing THA at our institution during a 21-month period. Patients classified by a diagnosis-related group (DRG) of 469 or 470 were included. Multivariate and survival analyses were performed to determine risk of 90-day readmission. Results Patients admitted for FNFs were older, had higher BMIs, longer lengths of stay and were more likely to be discharged to inpatient facilities than patients who underwent elective THA. Increased American Society of Anesthesiologists (ASA) Scores and FNF were also independent risk factors for 90-day readmission, and these patient were more likely to be readmitted during the latter 60-days following admission Conclusion Results suggest that patients who undergo an arthroplasty following urgent or emergent femoral neck fractures have inferior outcomes to those receiving an arthroplasty for a diagnosis of arthritis. Fracture patients should either be risk stratified to allow appropriate resource allocation or be excluded from alternative payment initiatives like CJR.
Abstract Introduction To curb the unsustainable rise in healthcare expenses, healthcare payers are developing programs to incentivize hospitals and physicians to improve the value of care delivered ...to patients. Payers are utilizing various metrics, such as length of stay and unplanned readmissions, to track progression of quality metrics. Relevant to orthopaedic surgeons, the Centers for Medicare and Medicaid Services (CMS) announced in 2015 the Comprehensive Care for Joint Replacement Payment Model (CJR)–a program aimed at improving the quality of healthcare delivered to patients by shifting more of the financial risk of patient care onto providers. Methods We analyzed the medical records of 1,329 consecutive lower extremity total joint patients enrolled in CMS’s Bundled Program for Care Improvement (BPCI) treated over a 21-month period. The goal of this study was to ascertain if hospital length of stay is associated with unplanned readmissions within 90 days of admission for a total hip or knee arthroplasty. Results After controlling for multiple demographic variables including sex, age, comorbidities and discharge location, we found that hospital length of stay greater than 4 days is a significant risk factor for unplanned readmission within 90 days (OR = 1.928, p = 0.010). Total knee arthroplasty and discharge to a location other than home are also independent risk factors for 90-day readmission. Conclusion Our results demonstrate that increased length of stay is a significant risk factor for readmission within 90 days of admission for a hip or knee arthroplasty in the Medicare population.
Abstract Background The post-acute care strategies after lower extremity total joint arthroplasty, including the use of post-acute rehabilitation centers and home therapy services are associated with ...different costs. Providers in Bundled Payment Programs are incentivized to use the most cost-effective strategies. Methods We used decision analysis to examine the impact of extending the inpatient hospital stay in order to avoid discharge of patients to a post-acute rehabilitation facility. Results The results of this decision analysis shows that extended acute hospital care for up to 5.2 extra days to allow for home discharge, rather than discharge to a post-acute inpatient facility can be financially preferable, provided quality is not negatively impacted. Conclusion The data demonstrates that because the cost of additional acute care hospital days are relatively small, and because the cost of an extended post-acute inpatient rehabilitation facility is high, keeping patients in the acute facility for a few extra days and then discharging them directly home may result in an overall lower cost than discharge after a shorter hospital stay to an expensive post-acute facility. However, this approach will have challenges, and future studies are needed to evaluate this change in strategy.
This study examined an early iteration of an inpatient opioid administration-reporting tool, which standardized patient opioid consumption as an average daily morphine milligram equivalence per ...surgical encounter (MME/day/encounter) among total knee arthroplasty (TKA) recipients. The objective was to assess the variability of inpatient opioid administration rates among surgeons after implementation of a multimodal opioid sparing pain protocol. We queried the electronic medical record at our institution for patients undergoing elective primary TKA between January 1, 2016 and June 30, 2018. Patient demographics, inpatient and surgical factors, and inpatient opioid administration were retrieved. Opioid consumption was converted into average MME for each postoperative day. These MME/day/encounter values were used to determine mean and variance of opioids prescribed by individual surgeons. A secondary analysis of regional inpatient opioid consumption was determined by patient zip codes. In total, 23 surgeons performed 4,038 primary TKA. The institutional average opioid dose was 46.24 ± 0.75 MME/day/encounter. Average intersurgeon (IS) opioid prescribing ranged from 17.67 to 59.15 MME/day/encounter. Intrasurgeon variability ranged between ± 1.01 and ± 7.51 MME/day/encounter. After adjusting for patient factors, the average institutional MME/day/encounter was 38.43 ± 0.42, with average IS variability ranging from 18.29 to 42.84 MME/day/encounter, and intrasurgeon variability ranging between ± 1.05 and ± 2.82 MME/day/encounter. Our results suggest that there is intrainstitutional variability in opioid administration following primary TKA even after controlling for potential patient risk factors. TKA candidates may benefit from the implementation of a more rigid standardization of multimodal pain management protocols that can control pain while minimizing the opioid burden. This is a level of evidence III, retrospective observational analysis.
Abstract Background Hospital readmission following total joint arthroplasty accounts for substantial resource consumption. Depression has been shown to impact post-surgical outcomes. We therefore ...aimed to study the association of depression with risk of readmission following total joint arthroplasty. Methods Retrospective cohort data from the population-based California Healthcare Cost and Utilization Project (HCUP) database from 2007-2010 were analyzed using multivariable logistic regression to predict odds of 90-day readmission following hospital discharge for primary total knee (TKA, n=131634) or hip (THA, n=65020) arthroplasty in adults ages 50+. We included the primary exposure of depression and controlled for age, sex, race/ethnicity, Medicaid insurance, comorbidities, and admission year. Results Overall 90-day readmission rates were approximately 17% for TKA and THA. Even after controlling for other chronic conditions and non-modifiable covariates, we found depression predicted higher likelihood of readmission. The odds of readmission for subjects with depression were 21-24% higher overall (OR for TKA: 1.21 95%CI:1.13 - 1.29; OR for THR:1.24, 95%CI:1.13 - 1.35; p<0.01). Subjects with surgery in earlier years were also more likely to be readmitted (p<0.001). Conclusion Depression is associated with a significantly higher risk of readmission after THA and TKA. Hospital readmissions must be minimized to improve care quality, while making these procedures fiscally feasible. Promoting care coordination across disciplines for management of non-orthopedic comorbidities prior to surgery, particularly in higher risk patients with depression, could optimize orthopedic surgery outcomes, patient well-being, and costs of care. Therefore, every effort to address depression prior to surgery is warranted.
Abstract
Background
Existing studies of patient-reported outcomes (PRO) following total knee arthroplasty (TKA) based on fixation methods (cemented vs cementless) are limited to single centers with ...small sample sizes. Using multicentered data,, we compared baseline and early post-operative global and condition-specific PROs between patients undergoing cemented versus cementless TKA.
Methods
With PROs prospectively collected through Comparative Effectiveness Pulmonary Embolism Prevention After Hip and Knee Replacement (PEPPER) trial (ClinicalTrials.gov: NCT02810704), we examined pre- and post-operative (1, 3, and 6-months) outcomes in 5,961 patients undergoing primary TKA enrolled by 28 medical centers between December 2016 and August 2021. Outcomes included the short-form of the Knee Injury and Osteoarthritis Outcome Score (KOOS-Jr.), the Patient-Reported Outcomes Measurement Information System Physical Health (PROMIS-PH), and the Numeric Pain Rating Scale (NPRS). To minimize selection bias, we performed a 1-to-1 propensity score matched analysis to assess relative pre- to post-operative change in outcomes
within
and
between
cemented and cementless TKA groups.
Results
With greater than 90% follow-up, significant pre to- post-operative improvements were observed in both groups. At 6 months, the cemented TKA group achieved a 3.3 point (55% of the Minimum Clinically Important Difference) greater improvement in the mean KOOS-Jr. (95%CI: 0.36, 6.30;
P
= 0.028) than did the cementless group with no significant between-group differences in PROMIS-PH and NPRS.
Conclusions
In a large cohort of primary TKAs, patients with cemented fixation reported early incremental benefit in KOOS-Jr. over those with cementless TKA. Future studies are warranted to capture longer follow-up of PROs.
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