Regulatory change has created a growing demand to decrease the hospital costs associated with primary total joint arthroplasty (TJA). Concurrently, the removal of lower extremity TJA from the ...in-patient only list has affected hospital reimbursement. The purpose of this study is to investigate trends in hospital revenue versus costs in primary TJA.
We retrospectively reviewed all patients who underwent primary TJA from June 2011 to May 2021 at our institution. Patient demographics, revenue, total cost, direct cost, and contribution margin were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analysis was used to determine overall trend significance and develop projection models.
Total knee arthroplasty (TKA) insured by government-managed/Medicaid (GMM) plans showed a significant upward trend (P = .013) in total costs. Direct costs of TKA across all insurance providers (P = .001 and P < .001) and total hip arthroplasty (THA) for Medicare (P = .009) and GMM (P = .001) plans demonstrated significant upward trends. Despite this, 2011-2021 modeling found no significant change in contribution margin for TKA and THA covered under all insurance plans. However, models based on 2018-2021 financial data demonstrated a significant downward trend in contribution margin across Medicare (P < .001) and GMM (P < .001) insurers for both TKA and THA.
Physician-led innovation in cost-saving strategies has maintained contribution margin over the past decade. However, the increase in direct costs seen over the past few years could lead to negative contribution margins over time, if further efficiency and cost-saving measures are not developed.
Retrospective Cohort Study.
The influence of anesthetic type on mental health after total hip arthroplasty (THA) is poorly understood. Adverse effects of general anesthesia (GA) on cognition following major non-cardiac surgery ...are well known, but mental health following THA is less well-studied. We hypothesized that neuraxial anesthesia (NA) would provide favorable mental health profiles compared with GA after THA.
Prospectively collected Patient-Reported Outcomes Measurement Information System-10 (PROMIS) Global Mental Health (GMH) scores at preoperative baseline, and 1, 3, and 6 months after THA were accessed on 4,353 patients in the Pulmonary Embolism Prevention After HiP and KneE Replacement (PEPPER) Trial (ClinicalTrials.gov: NCT02810704). Anesthesia was categorized as: general (GA), neuraxial (NA), and neuraxial with peripheral block (NAP). The GMH was assessed longitudinally and compared between groups.
Postoperative GMH improved (P < .05) over preoperative in every anesthetic group. Groups receiving NA had higher baseline GMH scores. Improvement in GMH was diminished after GA alone and plateaued after 1 month. Adding NA or peripheral nerve block to GA conferred additional benefit to GMH improvement.
Patient-perceived mental health improves significantly after THA regardless of anesthetic type. Patients who have higher baseline GMH scores more commonly received NA, likely due to nonsurgical care determinants; these differences in mental wellness persisted at follow-up. Adjunctive NA or peripheral nerve block favored GMH improvement, whereas solitary GA diminished GMH improvement, which plateaued after 1 month. Substantial mental health benefits of THA may overshadow subtle differences in GMH attributable to anesthetic type.
Abstract We retrospectively reviewed 161 revision THAs with diaphyseal fitting, mid-modular femoral components performed by ten surgeons at two academic medical centers. The average follow-up was 6.1 ...years. At final follow-up, 4 patients required re-revision for failure of the femoral component; 3 (2%) for aseptic loosening and 1 for mechanical failure of stem in setting of periprosthetic fracture. There were a total of 24 (14.9%) revisions for any reason, with the most common reason being septic failure (10 of 24). To our knowledge, this is the largest reported series of mid-term survivorship and complications of revision THA with mid-modular femoral components. Our results show that these stems have a low rate of aseptic loosening, subsidence, and mechanical failure.
The optimal fixation method in total hip arthroplasty (THA) remains controversial. Initial concerns related to the long-term performance of cement fixation as well as cement disease led to the ...development of cementless implants, and registry data has indicated that the use of this type of fixation has increased in recent years. However, data from these same registries has not shown any improvement in outcomes when compared to cement fixation. On the contrary, while similar outcomes are seen when comparing these fixation types in younger patients (<70 years of age), cementless fixation has shown increased implant failure and revision rates in elderly patients (>70 years of age). Given the increased projected volume of THA in the United States over the next decade, it is important to utilise available data to make clinical decisions that minimise not only individual patient harm, but also the burden on the healthcare system itself. This review provides an overview of currently available outcomes data comparing cement and cementless fixation, as well as an updated analysis of current trends in fixation use in THA. We furthermore provide a comprehensive technique guide to help surgeons optimise cement fixation of the femoral component for THA and hemiarthroplasty.
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.
Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We ...hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections.
We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups.
We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012).
Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.
Patient-reported outcomes are essential to demonstrate the value of hip and knee arthroplasty, a common target for payment reforms. We compare patient-reported global and condition-specific outcomes ...after hip and knee arthroplasty based on hospital participation in Medicare’s bundled payment programs.
We performed a prospective observational study using the Comparative Effectiveness of Pulmonary Embolism Prevention after Hip and Knee Replacement trial. Differences in patient-reported outcomes through 6 months were compared between bundle and nonbundle hospitals using mixed-effects regression, controlling for baseline patient characteristics. Outcomes were the brief Knee Injury and Osteoarthritis Outcomes Score or the brief Hip Disability and Osteoarthritis Outcomes Score, the Patient-Reported Outcomes Measurement Information System Physical Health Score, and the Numeric Pain Rating Scale, measures of joint function, overall health, and pain, respectively.
Relative to nonbundled hospitals, arthroplasty patients at bundled hospitals had slightly lower improvement in Knee Injury and Osteoarthritis Outcomes Score (−1.8 point relative difference at 6 months; 95% confidence interval −3.2 to −0.4; P = .011) and Hip Disability and Osteoarthritis Outcomes Score (−2.3 point relative difference at 6 months; 95% confidence interval −4.0 to −0.5; P = .010). However, these effects were small, and the proportions of patients who achieved a minimum clinically important difference were similar. Preoperative to postoperative change in the Patient-Reported Outcomes Measurement Information System Physical Health Score and Numeric Pain Rating Scale demonstrated a similar pattern of slightly worse outcomes at bundled hospitals with similar rates of achieving a minimum clinically important difference.
Patients receiving care at hospitals participating in Medicare’s bundled payment programs do not have meaningfully worse improvements in patient-reported measures of function, health, or pain after hip or knee arthroplasty.
Opioids have played an important part in post-operative analgesia, but concerns with associated morbidity and the fate of leftover pills have prompted the creation of opioid-sparing protocols. The ...purpose of this study is to investigate the impact of the implementation of an opioid-sparing protocol on survey-based patient satisfaction scores following total hip arthroplasty (THA).
This study is a retrospective review of prospectively collected data on patients who underwent primary THA between November 2014 and July 2019. Inclusion criteria consisted of primary elective THA with complete Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey information. Cohorts were separated based on their date of surgery relative to the start of an institutional opioid-sparing-protocol in October 2018. Discharge prescriptions and refills were recorded on chart review and converted to milligram morphine equivalents (MME) for comparison between different opioids. HCAHPS results were analyzed for percentage of “top box” ratings for comparison between the 2 groups.
In total, 1003 patients met inclusion criteria: 804 pre-protocol and 199 post-protocol. Mean length of stay decreased from 1.74 ± 1.03 to 1.50 ± 1.11 days (P < .001). Pre-operative Visual Analog Scale pain decreased from 7.00 ± 2.30 to 6.41 ± 2.66 (P = .011) as did the rate of opioid refills (15.6%-9.1%; P = .019). Quantity of opioid medication prescribed upon discharge also decreased from 432 ± 298 to 114 ± 156 MME (P < .001). There was no change in “top box percentages” for satisfaction with pain control (79.7% pre-protocol, 82.1% post-protocol; P = .767). There was a significant increase in proportion of patients reporting top box satisfaction with their overall surgical experience after protocol implementation (88.2%-94.0%; P = .018).
A reduction in opioids prescribed after THA is not associated with a decrease in patient satisfaction with regard to pain control, as measured by the HCAHPS survey, nor is it associated with an increase in post-operative opioid refills.
III.
This study suggests that HCAHP scores are not negatively impacted by a reduction in post-operative opioid analgesics.
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