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Murphy MP, Boubekri AM, Eikani CK, Brown NM. Inpatient Hospital Costs, Emergency Department Visits, and Readmissions for Revision Hip and Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00355-3. [PMID: 38640968 DOI: 10.1016/j.arth.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) tremendously burden hospital resources. This study evaluated factors influencing perioperative costs, including emergency department (ED) visits, readmissions, and total costs-of-care within 90 days following revision surgery. METHODS A retrospective analysis of 772 revision TKAs and THAs performed on 630 subjects at a single center between January 2007 and December 2019 was conducted. Cost data were available from January 2015 to December 2019 for 277 patients. Factors examined included comorbidities, demographic information, preoperative Anesthesia Society of Anesthesiologists score, implant selection, and operative indication using mixed-effects linear regression models. RESULTS Among 772 revisions (425 THAs and 347 TKAs), 213 patients required an ED visit, and 90 required hospital readmission within 90 days. There were 22.6% of patients who underwent a second procedure after their initial revision. Liver disease was a significant predictor of ED readmission for THA patients (multivariable odds ratio [OR]: 3.473, P = .001), while aseptic loosening, osteolysis, or instability significantly reduced the odds of readmission for TKA patients (OR: 0.368, P = .014). In terms of ED visits, liver disease increased the odds for THA patients (OR: 1.845, P = .100), and aseptic loosening, osteolysis, or instability decreased the odds for TKA patients (OR: 0.223, P < .001). Increased age was associated with increased costs in both THA and TKA patients, with significant cost factors including congestive heart failure for TKA patients (OR: $7,308.17, P = .004) and kidney disease for THA patients. Revision surgeries took longer than primary ones, with TKA averaging 3.0 hours (1.6 times longer) and THA 2.8 hours (1.5 times longer). CONCLUSIONS Liver disease increases ED readmission risk in revision THA, while aseptic loosening, osteolysis, or instability decreases it in revision TKA. Increased age and congestive heart failure are associated with increased costs. These findings inform postoperative care and resource allocation in revision arthroplasty. LEVEL OF EVIDENCE Economic and Decision Analysis, Level IV.
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Affiliation(s)
- Michael P Murphy
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
| | - Amir M Boubekri
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
| | - Carlo K Eikani
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
| | - Nicholas M Brown
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
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Swenson R, Paull T, Moua G, Weatherby D, Azzam K, Wojahn R, Anderson S, Cole PA, Nguyen M. Does Transparency of Ankle Implant Costs Influence Surgeon Behavior? FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241247826. [PMID: 38659719 PMCID: PMC11041529 DOI: 10.1177/24730114241247826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Background Ankle fractures are a common injury treated by orthopaedic surgeons. Unstable, displaced ankle fractures are often fixed with open reduction internal fixation (ORIF) using different implant constructs at various cost. No study to date has looked at transparency in ankle implant costs to surgeon behavior. Our surgeons self-identified that the biggest barrier for lowering implant cost was the lack of cost transparency. This was a surgeon-led-study to evaluate whether increased transparency in implant costs affected surgeon behavior. Methods Monthly operative logs from December 2021 to September 2022 were reviewed at our level 1 trauma center for operative fixation of ankle fractures. The cost data of each fixation construct was reported to trauma-trained surgeons at the end of each month from March 2022 to June 2022. Average costs of implants were compared before and after education. A linear mixed model was used to explore what factors were associated with changes in costs. Surgeons also participated in a poststudy survey. Results The implant costs of 110 ankle fracture fixations were reviewed over the period before education (n = 60), during education (n = 30), and after education (n = 20). The mean implant cost difference for unimalleolar fractures was -$204.80 (P = .68), whereas the mean cost difference for bimalleolar fractures was -$9.82 (P = .98). Trimalleolar fractures had a mean cost difference of +$94.47 (P = .84). Linear mixed model demonstrated fracture pattern as the only factor significantly associated with implant costs (P < .01). Post-education surgeon survey revealed that 6 of 7 surgeons felt that monthly updates affected their implant selection. However, only 2 surgeons demonstrated a change in practice with decreased implant costs during the study. Conclusion The majority of surgeons self-reported being influenced by the implant cost education, but the detected change in implant cost was only observed in less than one-third of surgeons. Our results suggest implant selection and related costs are not influenced by increased cost transparency education alone. Level of Evidence Level III, case control study.
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Affiliation(s)
| | - Thomas Paull
- University of Minnesota, Minneapolis, MN, USA
- Regions Hospital, Saint Paul, MN, USA
| | - Gaonhia Moua
- University of Minnesota, Minneapolis, MN, USA
- Regions Hospital, Saint Paul, MN, USA
| | - David Weatherby
- University of Minnesota, Minneapolis, MN, USA
- Regions Hospital, Saint Paul, MN, USA
| | - Khalid Azzam
- University of Minnesota, Minneapolis, MN, USA
- Regions Hospital, Saint Paul, MN, USA
| | - Robert Wojahn
- University of Minnesota, Minneapolis, MN, USA
- Regions Hospital, Saint Paul, MN, USA
| | - Sarah Anderson
- University of Minnesota, Minneapolis, MN, USA
- Regions Hospital, Saint Paul, MN, USA
| | - Peter A. Cole
- University of Minnesota, Minneapolis, MN, USA
- Regions Hospital, Saint Paul, MN, USA
| | - Mai Nguyen
- University of Minnesota, Minneapolis, MN, USA
- Regions Hospital, Saint Paul, MN, USA
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Ong CB, Buchan GBJ, Hecht Ii CJ, Lawrie CM, DeCook CA, Sculco PK, Kamath AF. Robotic-assisted total hip arthroplasty utilizing a fluoroscopy-guided system resulted in improved intra-operative efficiency relative to a computerized tomography-based platform. J Robot Surg 2023; 17:2841-2847. [PMID: 37770721 DOI: 10.1007/s11701-023-01723-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/17/2023] [Indexed: 09/30/2023]
Abstract
Robotic-assisted total hip arthroplasty (THA) using a computerized-tomography (CT) based workflow increases surgical time relative to traditional manual technique. The purpose of this investigation was to compare the intra-operative efficiencies of two robotic THA systems: a fluoroscopy-based platform (FL-RTHA) and a contemporary, CT-based (CT-RTHA) platform. A review of 107 consecutive FL-RTHA and 159 CT-RTHA primary, direct anterior approach (DAA) THA procedures was conducted. All cases were performed by one of two surgeons operating at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Primary outcome variables included averages and consistencies (variances) for surgical times and operating room (OR) times. A secondary outcome was to quantify the duration of robot-active phases in the FL-RTHA workflow. The FL-RTHA cohort experienced shorter surgical times (38.71 min ± 7.00 vs. 75.33 min ± 11.38; p < 0.001) and OR times (101.35 min ± 12.22 vs. 156.74 min ± 17.79; p < 0.001) compared to the CT-RTHA cohort. Surgical times and OR times were both more consistent in the FL-RTHA cohort compared to the CT-RTHA cohort (p < 0.001). Patients who underwent DAA THA with the assistance of a fluoroscopy-based robotic system experienced shorter and more consistent surgical times and OR times compared to patients who underwent similar DAA THA procedures with a contemporary, CT-based robotic platform.
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Affiliation(s)
- Christian B Ong
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Graham B J Buchan
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Christian J Hecht Ii
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Charles M Lawrie
- Department of Orthopaedic Surgery, Baptist Health South Florida, 8940 N Kendall Dr Suite 601E, Miami, FL, 33176, USA
| | - Charles A DeCook
- Arthritis and Total Joint Specialists, 2000 Howard Farm Drive, Suite 200, Cumming, GA, 30041, USA
| | - Peter K Sculco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 541 E 71St St 6th Floor, New York, NY, 10021, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Blackburn CW, Tanenbaum JE, Knapik DM, Voos JE, Gillespie RJ, Wetzel RJ. Trends in Orthopedic Device Innovation: An Analysis of 510(k) Clearances and Premarket Approvals From 2000 to 2019. Orthopedics 2023; 46:e98-e104. [PMID: 36476242 DOI: 10.3928/01477447-20221129-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The objective of this study was to characterize recent trends in orthopedic device development across different subspecialty areas. Orthopedic 510(k) clearances, premarket approvals (PMAs; together, "authorizations"), and new market entrants from 2000 to 2019 were analyzed as markers of research and development activity. Data were extracted from the US Food and Drug Administration website and stratified into one of 9 "subspecialty" groups: spine, trauma, hip arthroplasty, knee arthroplasty, shoulder, hand/elbow, foot/ankle, cement/filler/graft, and other. Descriptive statistics were used to analyze the data. Growth rates were calculated from trailing 3-year averages. During the study period, there were 9906 orthopedic 510(k) clearances and 1409 PMAs, of which 61 were for original PMA submissions. The preponderance of 510(k) clearances were for devices used in spine (36%) and trauma (30%) surgery, followed by hip (11%) and knee (8%) arthroplasty. Annual 510(k) clearances for spine and trauma devices grew by 232% and 44%, respectively, whereas annual hip and knee arthroplasty clearances declined. Paralleling these findings, the influx of new manufacturers of orthopedic devices was greatest for the trauma surgery (438), spine surgery (383), and cement/filler/graft (181) markets. Spinal surgery and orthopedic trauma have become leading priorities in orthopedic product development during the past two decades. Meanwhile, hip and knee arthroplasty products have proportionally become a smaller category of new devices over time. These findings demonstrate changing priorities within orthopedic innovation. [Orthopedics. 2023;46(2):e98-e104.].
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Alter T, Fitch A, Bailey Terhune E, Williams JC. The economics of patients undergoing periacetabular osteotomy for hip dysplasia: the financial relationship between physicians and hospitals. J Hip Preserv Surg 2022; 9:225-231. [PMID: 36908555 PMCID: PMC9993450 DOI: 10.1093/jhps/hnac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/08/2022] [Indexed: 03/14/2023] Open
Abstract
Periacetabular osteotomy (PAO) is the gold standard for treating hip dysplasia in patients with preserved articular cartilage. The aim of this study is to evaluate the financial relationship between facility and professional revenue for patients undergoing PAO for hip dysplasia and acetabular version abnormalities. All patients who underwent PAO for hip dysplasia by a single surgeon at a tertiary academic medical center between December 2016 and November 2020 were identified. Financial records for facility and professional services were reviewed and analyzed. The orthopedic charge multiplier, the dollars of facility charge created by a single dollar of orthopedic professional charge, and orthopedic net revenue multiplier, the dollars collected by the hospital for facility services generated for each dollar collected by the orthopedic surgeon, were calculated. A total of 36 patients were included in the study. The mean total charge for all patients was $144 939.35 ± $23 726.48 (range $109 002.71 to $227 290.20), and the average total revenue for all patients was $44 218.79 ± $12 352.97 (range $29 397.39 to $90,830.62). The mean orthopedic charge multiplier was 2.47 ± 1.32 (range 0.78-6.53), and the net revenue collection multiplier was 8.62 ± 10.69 (range, 1.20-57.80). The majority of charges and revenue related to care of patients undergoing PAO return to the hospital. The significant mean orthopedic charge multiplier for this procedure increases the value of the service and the surgeon to hospital profitability. This information can help shape the relationship between the hospital and the surgeon and create a firm platform to advocate for program advancement.
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Affiliation(s)
- Thomas Alter
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612, USA
| | - Ashlyn Fitch
- School of Medicine, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, USA
| | - E Bailey Terhune
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612, USA
| | - Joel C Williams
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612, USA
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Thornburg DA, Gupta N, Chow N, Haglin J, Noland S. An Analysis of Procedural Medicare Reimbursement Rates in Hand Surgery: 2000 to 2019. Hand (N Y) 2022; 17:1207-1213. [PMID: 33631979 PMCID: PMC9608280 DOI: 10.1177/1558944721990807] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Medicare reimbursement trends across multiple surgical subspecialties have been analyzed; however, little has been reported regarding the long-term trends in reimbursement of hand surgery procedures. The aim of this study is to analyze trends in Medicare reimbursement for commonly performed hand surgeries. METHODS Using the Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File, we determined the 20 hand surgery procedure codes most commonly billed to Medicare in 2016. Reimbursement rates were collected and analyzed for each code from The Physician Fee Schedule Look-Up Tool for years 2000 to 2019. We compared the change in reimbursement rate for each procedure to the rate of inflation in US dollars, using the Consumer Price Index (CPI) over the same time period. RESULTS The reimbursement rate for each procedure increased on average by 13.9% during the study period while the United States CPI increased significantly more by 46.7% (P < .0001). When all reimbursement data were adjusted for inflation to 2019 dollars, the average reimbursement for all included procedures in this study decreased by 22.6% from 2000 to 2019. The average adjusted reimbursement rate for all procedures decreased by 21.92% from 2000 to 2009 and decreased by 0.86% on average from 2009 to 2019 (P < .0001). CONCLUSION When adjusted for inflation, Medicare reimbursement for hand surgery has steadily decreased over the past 20 years. It will be important to consider the implications of these trends when evaluating healthcare policies and the impact this has on access to hand surgery.
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Ackerman SJ, Deol GS, Polly DW. Cost-Utility Analysis of Sacroiliac Joint Fusion in High-Risk Patients Undergoing Multi-Level Lumbar Fusion to the Sacrum. CLINICOECONOMICS AND OUTCOMES RESEARCH 2022; 14:523-535. [PMID: 35966399 PMCID: PMC9374202 DOI: 10.2147/ceor.s377132] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Multi-level lumbar fusion to the sacrum (MLF) can lead to increased stress and angular motion across the sacroiliac joint (SIJ), with an incidence of post-operative SIJ pain estimated at 26–32%. SIJ fusion (SIJF) can help obviate the need for revisions by reducing range of motion and screw stresses. We aimed to evaluate the cost-utility of MLF + SIJF compared to MLF alone among high-risk patients from a payer perspective, where high risk is defined as high body mass index and high pelvic incidence. Methods A Markov process decision-analysis model was developed to evaluate cumulative 5-year costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) of MLF + SIJF compared to MLF alone using published data; costs from Medicare claims data analyses and health state utility values (derived from EQ-5D) informed by three prospective, multicenter, clinical trials. The base case assumed a reduction in post-operative SIJ pain from 30% to 10% (relative risk reduction [RRR] of 67%). Costs and utilities were discounted 3% annually. The ICER is reported in 2020 US dollars. One-way, multi-way, and probabilistic sensitivity analyses were performed. Results With an assumed 30% incidence of SIJ pain after MLF alone, stabilizing with SIJF was associated with an additional 5-year cost of $2421 and a gain of 0.14 QALYs, resulting in an ICER of $17,293 per QALY gained (similar to total knee arthroplasty and more favorable than open discectomy). ICERs were most sensitive to the RRR of post-operative SIJ pain conferred by SIJF, time horizon, and probability of successful treatment with MLF alone. At a willingness-to-pay threshold of $50,000/QALY gained, MLF + SIJF has a 97.7% probability of being cost-effective in the target patient population. Conclusion Fusing the SIJ in high-risk patients undergoing MLF was cost-effective when the incidence of post-operative SIJ pain after MLF alone exceeds approximately 25%, providing value-based healthcare from a payer perspective.
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Affiliation(s)
- Stacey J Ackerman
- Department of Biomedical Engineering, Johns Hopkins University, San Diego, CA, USA
| | | | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
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Muchiri S, Pakdil F, Beazoglou H. The length of stay and readmissions of THA and TKA patients: A longitudinal analysis using a nationwide readmissions data. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2022. [DOI: 10.1080/20479700.2022.2099337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Steve Muchiri
- Department of Economics and Finance, Eastern Connecticut State University, Willimantic, CT, USA
| | - Fatma Pakdil
- Department of Marketing and Management, Eastern Connecticut State University, Willimantic, CT, USA
| | - Hannah Beazoglou
- Department of Marketing and Management, Eastern Connecticut State University, Willimantic, CT, USA
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Effects of Preoperative Carbohydrate-rich Drinks on Immediate Postoperative Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial. J Am Acad Orthop Surg 2022; 30:e833-e841. [PMID: 35312650 DOI: 10.5435/jaaos-d-21-00960] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/11/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study investigates the effects of preoperative carbohydrate-rich drinks on postoperative outcomes after primary total knee arthroplasty. METHODS We prospectively randomized 153 consecutive patients undergoing primary total knee arthroplasty at one institution. Patients were assigned to one of three groups: group A (50 patients) received a carbohydrate-rich drink; group B (51 patients) received a placebo drink; and group C (52 patients) did not receive a drink (control). All healthcare personnel and patients were blinded to group allocation. Controlling for demographics, we analyzed the rate of postoperative nausea and vomiting, length of stay, opiate consumption, pain scores, serum glucose, adverse events, and intraoperative and postoperative fluid intake. RESULTS Demographics and comorbidities were similar among the groups. There were no significant differences in surgical interventions or experience. Surgical fluid intake and total blood loss were similar among the three groups (P = 0.47, P = 0.23). Furthermore, acute postoperative outcomes (ie, pain, episodes of nausea, and length of stay) were similar across all three groups. There were no significant differences in adverse events between the three groups (P = 0.13). There was a significant difference in one-time postoperative bolus between the three groups (P = 0.02), but after multivariate analysis, it did not demonstrate significance. None of the intervention group were readmitted, whereas 5.9% and 11.5% were readmitted in the placebo and control groups, respectively (P = 0.047). The chance of 90-day readmission was reduced in group A compared with group C (odds ratio, 0.08; 95% confidence interval, 0.01 to 0.72; P = 0.02). There were no differences in other postoperative outcome measurements. CONCLUSION This randomized controlled trial demonstrated that preoperative carbohydrate loading does not improve immediate postoperative outcomes, such as nausea and vomiting; however, it demonstrated that consuming fluid preoperatively proved no increased risk of adverse outcomes and there was a trend toward decrease of one-time boluses postoperatively. CLINICAL TRIALS REGISTRY NCT03380754.
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Fang CJ, Shaker JM, Ward DM, Jawa A, Mattingly DA, Smith EL. Financial Burden of Revision Hip and Knee Arthroplasty at an Orthopedic Specialty Hospital: Higher Costs and Unequal Reimbursements. J Arthroplasty 2021; 36:2680-2684. [PMID: 33840537 DOI: 10.1016/j.arth.2021.03.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/06/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND As demand for primary total joint arthroplasty (TJA) continues to grow, a proportionate increase in revision TJA (rTJA) is expected. It is essential to understand costs and reimbursement of rTJA as our country moves to bundled payment models. We aimed (1) to characterize implant and total hospital costs, (2) assess reimbursement, and (3) determine revenue for rTJA in comparison with primary TJA. METHODS The average implant and total hospital cost of all primary and rTJA procedures by diagnosis-related group (DRG) was calculated using time-driven activity-based costing at an orthopedic hospital from 2018 to 2020. Average reimbursement and payer type were assessed by DRG. Revenue was calculated by deducting average time-driven activity-based costing total costs from reimbursement. RESULTS 13,946 arthroplasties were included in the study. Implant cost comprised 55.8% of total hospital costs for rTJA DRG 468, compared with 43.6% of total hospital costs for primary TJA DRG 470. Total hospital costs for DRG 468 were 61.1% more than DRG 470. Reimbursement for rTJA was 1.23x more than primary TJA. Private payers paid 23.2% more than Medicare for rTJA. Margin for DRG 468 was 1.5% less than primary DRG 470. CONCLUSION rTJA requires more hospital resources and costs than primaries, yet hospital reimbursement may be inadequate with the additional expenditures necessary to provide optimal care. If hospitals cannot perform revision services under the current reimbursement model, patient access may be limited. Implant costs are a major contributor to overall rTJA cost. Strategies are needed to reduce revision implant costs to improve value of care. LEVEL OF EVIDENCE Level III, economic and decision analysis.
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Affiliation(s)
- Christopher J Fang
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA
| | - Jonathan M Shaker
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA
| | - Daniel M Ward
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA
| | - Andrew Jawa
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA
| | - David A Mattingly
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA
| | - Eric L Smith
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, MA
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Bernstein DN, Hanna P, Merchan N, Rodriguez EK, Appleton PT, Kwon JY, Wixted JJ. Lack of Surgeon Standardization on Implant Selection in Ankle Fracture Fixation May Increase Costs and Decrease Contribution Margin. Foot Ankle Spec 2021; 16:129-134. [PMID: 34142591 DOI: 10.1177/19386400211009357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Surgical standardization has been shown to decrease costs without impacting quality; however, there is limited literature on this subject regarding ankle fracture fixation. Methods. Between October 5, 2015 and September 27, 2017, a total of 168 patients with isolated ankle fractures who underwent open reduction, internal fixation (ORIF) were analyzed. Financial data were analyzed across ankle fracture classification type, implant characteristics, and surgeons. Bivariate analyses were conducted. One-way analysis of variance was used to compare hardware costs across all 5 surgeons. Linear regression analysis was used to determine if hardware cost differed by surgeon when accounting for fracture type. RESULTS The mean contribution margin was $4853 (SD $6446). There was a significant difference in implant costs by surgeon (range, lowest-cost surgeon: $471 [SD $283] to $1609 [SD $819]; P < .001). There was no difference in the use of a suture button or locking plate by fracture type (P = .13); however, the cost of the implant was significantly higher if a suture button or locking plate was used ($1014 [SD $666] vs $338 [SD $176]; P < .001). There was an association between surgeon 3 (β = 200.32 [95% CI 6.18-394.47]; P = .043) and surgeon 4 (β = 1131.07 [95% CI 906.84-1355.30]; P < .001) and higher hardware costs. CONCLUSIONS Even for the same ankle fracture type, a wide variation in implant costs exists. The lack of standardization among surgeons accounted for a nearly 3.5-fold difference, on average, between the lowest- and highest-cost surgeons, negatively affecting contribution margin. LEVELS OF EVIDENCE Level IV.
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Affiliation(s)
- David N Bernstein
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Philip Hanna
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nelson Merchan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Edward K Rodriguez
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Paul T Appleton
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - John Y Kwon
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - John J Wixted
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Marrache M, Harris AB, Puvanesarajah V, Raad M, Hassanzadeh H, Srikumaran U, Ficke JR, Levy JF, Jain A. Hospital Payments Increase as Payments to Surgeons Decrease for Common Inpatient Orthopaedic Procedures. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e20.00026. [PMID: 32377615 PMCID: PMC7188271 DOI: 10.5435/jaaosglobal-d-20-00026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 11/18/2022]
Abstract
As healthcare costs continue to increase in the United States, it is important to understand the trends in the allocation of healthcare spending for common orthopaedic surgical procedures. We investigated the recent trends in (1) total net payments (for episode of care), (2) payments to hospitals, (3) payments to physicians, (4) payments to physicians as a percentage of total net payments, and (5) regional variation in hospital and physician payments for four common orthopaedic procedures. Methods Using a private insurance claims database, we analyzed the payments to US hospitals and physicians from 2010 to 2016 for primary total hip arthroplasty (THA) (n = 128,269), total knee arthroplasty (TKA) (n = 223,319), 1-level anterior cervical diskectomy and fusion (ACDF) (n = 51,477), and 1-level lumbar-instrumented posterior spinal fusion (PSF) (n = 45,680). Regional variations in payments were also assessed. Trends were analyzed using linear regression models adjusting for age, sex, comorbidities, duration of hospital stay, and inflation (alpha = 0.05). Results Inflation-adjusted total net payments for the episode of care increased by the following percentages per year: 5.2% for ACDF, 3.2% for PSF, 2.9% for TKA, and 2.6% for THA. Annual inflation-adjusted hospital payments increased significantly for all 4 procedures, whereas annual inflation-adjusted physician payments decreased by -2.2%/year for PSF, -1.5%/year for TKA, -1.1%/year for THA, and -0.4%/year for ACDF (all, P < 0.001). As a percentage of total net payments, physician payments decreased markedly for ACDF (-4.6%), PSF (-3.1%), TKA (-2.1%), and THA (-1.8%). Hospital and physician payments varied significantly by region and were both highest in the West (P < 0.001). Conclusions From 2010 to 2016, inflation-adjusted total net payments for 4 common orthopaedic surgical procedures increased markedly, as did payments to the US hospitals for these procedures. Payments to orthopaedic surgeons for these procedures decreased markedly during the same period.
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Affiliation(s)
- Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - James R Ficke
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Joseph F Levy
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Marrache, Mr. Harris, Dr. Puvanesarajah, Dr. Raad, Dr. Srikumaran, Dr. Ficke, Dr. Jain); the Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA (Dr. Hassanzadeh); and the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr. Levy)
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Garbarino LJ, Gold PA, Sodhi N, Anis HK, Ehiorobo JO, Boraiah S, Danoff JR, Rasquinha VJ, Higuera-Rueda CA, Mont MA. The effect of operative time on in-hospital length of stay in revision total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:66. [PMID: 30963061 DOI: 10.21037/atm.2019.01.54] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Revision total knee arthroplasty (TKA) is associated with increased rates of infections, readmissions, longer operative times, and lengths-of-stay (LOS) compared to primary TKA. Additionally, increasing operative times and prolonged postoperative LOS are independent risk factors for these postoperative complications in lower extremity total joint arthroplasty (TJA). This has led to an increased effort to reduce these risk factors in order to improve patient outcomes and reduce cost. However, the relationship between operative time and LOS has not been well assessed in revision arthroplasty. Therefore, the purpose of this study was to: (I) identify predictors of longer operative times; (II) identify predictors of longer LOS; and (III) evaluate the effects of operative time, treated as both a categorical variable and a continuous variable, on LOS after revision TKA. Methods The NSQIP database was queried for all revision TKA cases (CPT code 27487) between 2008 and 2016 which yielded 10,604 cases. Mean operative times were compared between patient demographics including age groups, sex, and body mass indexes (BMIs). To determine predictors of LOS, mean LOS were also compared between patient demographics in the same groups. To assess the correlation of operative time on LOS, the mean LOS for 30-minute operative time intervals were compared. Univariate analysis was performed with one-way analysis of variance (ANOVA) and t-tests. A multivariate analysis with a multiple linear regression model was performed to evaluate the association of LOS with operative times after adjusting for patient age, sex, and BMI. Results The mean LOS for revision TKA was 4 (±3) days. Further analysis showed that young age is associated with increased LOS (P<0.01). An analysis of operative times showed positive correlations with young age, BMI greater than 30 and male sex (P<0.05). The mean LOS of revision TKA patients was found to increase with increasing operative time in 30-minute intervals (P<0.001). Multivariate analysis showed that longer operative times had significant associations with longer LOS even after adjusting for patient factors (β=0.102, SE =0.001, P<0.001). These results also showed that out of all of the study covariates, operative times had the greatest effect on LOS after revision TKA. Conclusions Revision TKA is a complex procedure, often requiring increased operative times compared to primary TKA. This study provides unique insight by correlating operative times to LOS in over 10,000 revision TKAs from a nationwide database. Our results demonstrate that out of all the study covariates (age, sex, and BMI), operative times had the greatest effect on LOS. The results from this study indicate that less time spent in the operating room can lead to shorter LOS for revision TKA patients. This relationship further underscores the need for improved preoperative planning and intra-operative efficiency in an effort to decrease LOS and improve patient outcomes.
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Affiliation(s)
- Luke J Garbarino
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
| | - Peter A Gold
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph O Ehiorobo
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Sreevathsa Boraiah
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
| | - Jonathan R Danoff
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
| | - Vijay J Rasquinha
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
| | | | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
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Novikov D, Cizmic Z, Feng JE, Iorio R, Meftah M. The Historical Development of Value-Based Care: How We Got Here. J Bone Joint Surg Am 2018; 100:e144. [PMID: 30480607 DOI: 10.2106/jbjs.18.00571] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The original architects of Medicare modeled the payment system on the existing fee-for-service (FFS) structure that historically dominated the health-insurance market. Under the FFS paradigm, health-care expenditures experienced an exponential rise. In response, the managed care and capitation models of health-care delivery were developed. However, changes in Medicare reimbursement, along with an increasing volume of orthopaedic procedures and escalating implant costs, call into question the cost-effectiveness of this service line. The success of the Medicare Acute Care Episode (ACE) Demonstration Project proved the feasibility of value-based care and ushered in a new era of bundled payment initiatives.
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Affiliation(s)
- David Novikov
- Division of Adult Reconstructive Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Zlatan Cizmic
- Division of Adult Reconstructive Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - James E Feng
- Division of Adult Reconstructive Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Richard Iorio
- Division of Adult Reconstructive Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Morteza Meftah
- Division of Adult Reconstructive Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
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15
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Kildow BJ, Howell EP, Karas V, Baumgartner WT, Cunningham DJ, Green CL, Bolognesi MP, Seyler TM. When Should Complete Blood Count Tests Be Performed in Primary Total Hip Arthroplasty Patients? J Arthroplasty 2018; 33:3211-3214. [PMID: 29908797 DOI: 10.1016/j.arth.2018.05.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/09/2018] [Accepted: 05/21/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Routine laboratory studies are often obtained following total hip arthroplasty (THA). Moreover, laboratory studies are often continued daily until the patient is discharged regardless of medical management. The purpose of this study was to investigate the use of routine complete blood count (CBC) tests following THA. Secondarily, the purpose was to identify patient factors associated with abnormal postoperative lab values. METHODS This retrospective review identified 352 patients who underwent primary THA at a single institution from 2012 to 2014. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were used to identify factors associated with an abnormal postoperative lab and risk of transfusion. RESULTS Of the 352 patients, 54 patients were transfused (15.3%). Patients who underwent transfusion had a significantly lower preoperative hemoglobin (Hb; 12.0 g/dL) compared to patients who did not undergo transfusion (13.5 g/dL; P < .001). Patients who did not receive TXA were 3.7 times more likely to receive a transfusion. No patients received medical intervention based on the outcome of postoperative platelet or white blood counts. A Hb value below 11.94 g/dL for patients who are anemic preoperative or did not receive TXA predicted transfusion after postoperative day 1. CONCLUSION Under value-based care models, cost containment while maintaining high-quality patient care is critical. Routine postoperative CBC tests in patients with a normal preoperative Hb who receive TXA do not contribute to actionable information. Patients who are anemic before THA or do not receive TXA should at minimum obtain a CBC on postoperative day 1.
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Affiliation(s)
- Beau J Kildow
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Elizabeth P Howell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vasili Karas
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - William T Baumgartner
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Cynthia L Green
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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16
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Kildow BJ, Karas V, Howell E, Green CL, Baumgartner WT, Penrose CT, Bolognesi MP, Seyler TM. The Utility of Basic Metabolic Panel Tests After Total Joint Arthroplasty. J Arthroplasty 2018; 33:2752-2758. [PMID: 29858101 DOI: 10.1016/j.arth.2018.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/04/2018] [Accepted: 05/02/2018] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Routine laboratory studies are often obtained daily after total joint arthroplasty (TJA) regardless of medical management. The purpose of this study was to investigate the utility of routine basic metabolic panel (BMP) tests after TJA. Furthermore, the goal was to identify factors that may predispose patients to abnormal laboratory values that require medical intervention. METHODS A retrospective review was performed on 767 patients who underwent primary TJA at a single institution. Preoperative and postoperative potassium, sodium, creatinine, and glucose values were collected along with demographic data, comorbidities, and procedural characteristics. Multivariable logistic regression models were used to determine independent risk factors for abnormal postoperative laboratory values. RESULTS Diabetes was associated with abnormal glucose (odds ratio [OR] 23.4, 95% confidence interval [CI] 10.7-51.0, P < .001), while chronic kidney disease was associated with abnormal creatinine (OR 3.1, 95% CI 1.7-5.8, P < .001) and potassium (OR 1.8, 95% CI 1.1-2.8, P = .014) requiring medical intervention. An abnormal preoperative laboratory value was also associated with medical treatment for each of sodium, potassium, and creatinine (all P < .001). Average number of BMP tests collected for patients who did not receive medical intervention was 2.8. This equated to $472,372.56 in total hospital charges. CONCLUSION Cost containment while maintaining high-quality patient care is critical. Routine postoperative BMP tests in patients with normal preoperative values without major medical comorbidities do not contribute to actionable information. Patients with diabetes, chronic kidney disease, or with abnormal preoperative values should obtain a BMP after TJA.
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Affiliation(s)
- Beau J Kildow
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vasili Karas
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Elizabeth Howell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Cynthia L Green
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - William T Baumgartner
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Colin T Penrose
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Performance milestones in postoperative physical therapy after total hip arthroplasty: impact on length of stay and discharge destination. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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18
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Gagné OJ, Veljkovic A, Glazebrook M, Daniels TR, Penner MJ, Wing KJ, Younger ASE. Prospective Cohort Study on the Employment Status of Working Age Patients After Recovery From Ankle Arthritis Surgery. Foot Ankle Int 2018; 39:657-663. [PMID: 29506397 DOI: 10.1177/1071100718757722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND People who are affected by end-stage ankle arthritis are as disabled as those suffering from arthritis in other main articulations of the lower extremity. Once these patients become unable to perform their job duties, they leave the workforce and require financial aid from government agencies, which represents a considerable economic burden. Regardless of whether arthrodesis or arthroplasty is performed, we hypothesized that patients younger than 55 years at the time of surgery should be able to return to work within 2 years and require less social assistance. METHODS Patients from 2002 to 2014 included in the nationwide prospective Ankle Reconstruction Database treated for end-stage ankle arthritis with a total ankle replacement or an ankle arthrodesis and younger than 55 years at the time of surgery were included. This study used a standard preoperative survey (AAOS, SF-36) along with the same survey filled by patients in intervals up to 2 years postoperatively. Their employment status was determined at each time point. Participation in third-party wage assistance programs was recorded. This cohort had 194 patients with an average age of 47.0 ± 7.2 years and was balanced in terms of sex (104 female) and side (94 left). RESULTS The employment rate prior to surgery was 56%, which increased to 62% at the 2-year postoperative mark. With regards to worker's compensation, disability, and social security, 20% of patients left all subsidized programs whereas 4% entered at least 1 which is significant (P < .05). CONCLUSION The 2-year follow-up after tibiotalar arthrodesis/arthroplasty in patients younger than 55 years showed that significantly more people were able to leave subsidized work assistance programs than enroll in them. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Oliver J Gagné
- 1 University of British Columbia Orthopedics, Vancouver, BC, Canada
| | - Andrea Veljkovic
- 2 Saint-Paul's Hospital Department of Orthopedics, Vancouver, BC, Canada
| | - Mark Glazebrook
- 3 Queen Elizabeth Health Science Center, Halifax, NS, Canada
| | | | | | - Kevin J Wing
- 2 Saint-Paul's Hospital Department of Orthopedics, Vancouver, BC, Canada
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Jang S, Mandabach M, Aburjania Z, Balentine CJ, Chen H. Racial disparities in the cost of surgical care for parathyroidectomy. J Surg Res 2018; 221:216-221. [DOI: 10.1016/j.jss.2017.08.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 08/13/2017] [Accepted: 08/16/2017] [Indexed: 10/18/2022]
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Swenson ER, Bastian ND, Nembhard HB, Davis Iii CM. Reducing cost drivers in total joint arthroplasty: understanding patient readmission risk and supply cost. Health Syst (Basingstoke) 2017; 7:135-147. [PMID: 31214344 DOI: 10.1080/20476965.2017.1397237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/03/2017] [Accepted: 10/15/2017] [Indexed: 10/28/2022] Open
Abstract
Introduction: Understanding and planning for the factors that impact supply cost and unplanned readmission risk for total joint arthroplasty (TJA) patients is helpful for hospitals at financial risk under bundled payments. Readmission and operating room supply costs are two of the biggest expenses. Methods: Logistic and linear regressions are used to measure the impacts of TJA patient attributes on readmission risk and supply costs, respectively. Results: Patients' health market segment and the number/type of comorbidity impacts 30/90-day readmission rates. Surgeon implant preference and type of surgery impact supply costs. Discharge location and two of the five health market segments increase the odds of 30-day readmission. Arrhythmia and lymphoma are the primary comorbidities that impact the odds of readmission at 90 days. Conclusions: Preoperatively identifying TJA patients likely to have large supply costs and higher readmission risk allows hospitals to invest in low-cost interventions to reduce risk and improve healthcare value.
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Affiliation(s)
- Eric R Swenson
- Center for Health Organization Transformation, Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
| | - Nathaniel D Bastian
- Center for Health Organization Transformation, Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
| | - Harriet B Nembhard
- Center for Health Organization Transformation, Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
| | - Charles M Davis Iii
- Penn State Hershey Medical Center, Bone and Joint Institute, Hershey, PA, USA
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Wasterlain AS, Bello RJ, Vigdorchik J, Schwarzkopf R, Long WJ. Surgeons' Perspectives on Premium Implants in Total Joint Arthroplasty. Orthopedics 2017; 40:e825-e830. [PMID: 28662250 DOI: 10.3928/01477447-20170619-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/03/2017] [Indexed: 02/03/2023]
Abstract
Declining total joint arthroplasty reimbursement and rising implant prices have led many hospitals to restrict access to newer, more expensive total joint arthroplasty implants. The authors sought to understand arthroplasty surgeons' perspectives on implants regarding innovation, product launch, costs, and cost-containment strategies including surgeon gain-sharing and patient cost-sharing. Members of the International Congress for Joint Reconstruction were surveyed regarding attitudes about implant technology and costs. Descriptive and univariate analyses were performed. A total of 126 surgeons responded from all 5 regions of the United States. Although 76.9% believed new products advance technology in orthopedics, most (66.7%) supported informing patients that new implants lack long-term clinical data and restricting new implants to a small number of investigators prior to widespread market launch. The survey revealed that 66.7% would forgo gain-sharing incentives in exchange for more freedom to choose implants. Further, 76.9% believed that patients should be allowed to pay incremental costs for "premium" implants. Surgeons who believed that premium products advance orthopedic technology were more willing to forgo gain-sharing (P=.040). Surgeons with higher surgical volume (P=.007), those who believed implant companies should be allowed to charge more for new technology (P<.001), and those who supported discussing costs with patients (P=.004) were more supportive of patient cost-sharing. Most arthroplasty surgeons believe technological innovation advances the field but support discussing the "unproven" nature of new implants with patients. Many surgeons support alternative payment models permitting surgeons and patients to retain implant selection autonomy. Most respondents prioritized patient beneficence and surgeon autonomy above personal financial gain. [Orthopedics. 2017; 40(5):e825-e830.].
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Okike K, Pollak R, O'Toole RV, Pollak AN. "Red-Yellow-Green": Effect of an Initiative to Guide Surgeon Choice of Orthopaedic Implants. J Bone Joint Surg Am 2017; 99:e33. [PMID: 28375897 DOI: 10.2106/jbjs.16.00271] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Orthopaedic procedures are expensive, and devices account for a large proportion of the overall costs. Hospitals have employed a variety of strategies to decrease implant costs, but many center on restricting surgeon choice. At our institution, we developed an implant selection tool that guides surgeons toward more cost-effective implants, while minimally restricting choice. The purpose of this study was to assess the effect of this tool on preferred implant usage rates, vendor attitudes toward pricing structure, and hospital implant expenditures. METHODS For 6 commonly used orthopaedic trauma devices, similar constructs were created for the 4 vendors used at our hospital, and the costs were determined. On the basis of these costs, the available options for each device type were categorized as "green" (preferred vendor), "yellow" (midrange), or "red" (used for patient-specific requirements). The "Red-Yellow-Green" chart was posted on the wall of each orthopaedic trauma operating room. To assess the effect of the tool, we compared implant usage patterns before and after implementation of the implant selection tool. We also assessed changes in vendor contract prices, as well as overall savings to our institution. RESULTS Implant usage changed significantly from 30% "red," 56% "yellow," and 14% "green" prior to the intervention, to 9% "red," 21% "yellow," and 70% "green" after the intervention (p < 0.0001). As a result of price renegotiation with vendors following implementation, we observed average price decreases that ranged from 1.1% to 22.4%. Average expenditures on these 6 implants decreased 20% during the study period, which represented a savings of $216,495 per year. CONCLUSIONS At our institution, we designed and implemented "Red-Yellow-Green," a simple tool that guides surgeons toward the selection of lower-cost implants without violating vendor confidentiality clauses, limiting the implants from which surgeons can choose, or requiring surgeons to discern the prices of complex constructs. Following implementation, hospital implant expenditures decreased as a result of a combination of increased preferred vendor usage by surgeons, as well as increased competition among vendors, which resulted in lower overall prices.
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Affiliation(s)
- Kanu Okike
- 1Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland 2Case Western Reserve University, Cleveland, Ohio
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Schwartz AJ, Fraser JF, Shannon AM, Jackson NT, Raghu TS. Patient Perception of Value in Bundled Payments for Total Joint Arthroplasty. J Arthroplasty 2016; 31:2696-2699. [PMID: 27378636 DOI: 10.1016/j.arth.2016.05.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A central concern for providers in a bundled payment model is determining how the bundle is distributed. Prior studies have shown that current reimbursement rates are often not aligned with patients' values. While willingness-to-pay (WTP) surveys are perhaps useful in a fee-for-service arrangement to determine overall reimbursement, the percentage of payment distribution might be as or more important in a bundled payment model. METHODS All patients undergoing primary total joint arthroplasty by a single surgeon were offered participation in a preoperative WTP survey. At a minimum 3 months postoperatively, patients were mailed instructions for an online follow-up survey asking how they would allocate a hypothetical bonus payment. RESULTS From January through December 2014, 45 patients agreed to participate in the preoperative WTP survey. Twenty patients who were minimum 3 months postoperative also completed the follow-up survey. Patients valued total knee and hip arthroplasty at $28,438 (95% confidence interval [CI]: $20,551-36,324) and $39,479 (95% CI: $27,848-$51,112), respectively. At 3 months postoperatively, patients distributed a hypothetical bonus payment 55.5% to the surgeon (95% CI: 47.8%-63.1%), 38% to the hospital (95% CI: 30.3%-45.7%), and 6.5% (95% CI: -1.2% to 14.2%) to the implant manufacturer (P < .001). CONCLUSION The data suggest that total joint arthroplasty patients have vastly different perceptions of payment distributions than what actually exists. In contrast to the findings of this study, the true distribution of payments for an episode of care averages 65% to the hospital, 27% to the implant manufacturer, and 8% to the surgeon. While many drivers of payment distribution exist, this study suggests that patients would allocate a larger proportion of a bundled payment to surgeons than is currently disbursed. This finding may also provide a plausible explanation for patients' consistent overestimation of surgeon reimbursements.
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Affiliation(s)
- Adam J Schwartz
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - James F Fraser
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Nikki T Jackson
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - T S Raghu
- W. P. Carey School of Business, Arizona State University, Tempe, Arizona
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Goldstein JP, Babikian GM, Rana AJ, Mackenzie JA, Millar A. The Cost and Outcome Effectiveness of Total Hip Replacement: Technique Choice and Volume-Output Effects Matter. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:703-718. [PMID: 27484490 DOI: 10.1007/s40258-016-0260-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Total hip replacement (THR) must be managed in a more sustainable manner. More cost-effective surgical techniques and the centralization/regionalization of services are two solutions. The former requires an assessment of newer minimally invasive and muscle-sparing surgical techniques. The latter necessitates an effective volume-outcome (VO) relationship. Prior studies have failed to evaluate and control for the VO relation. OBJECTIVE The objective of this study was to evaluate the relative cost and outcome effectiveness of two minimally invasive and one muscle-sparing techniques while evaluating and controlling for a potentially endogenous VO relation. METHODS An all payer claims database for all THR performed in Maine in 2011 was used. The cost and outcome effectiveness of newer minimally invasive (modified Hardinge) and muscle-sparing (modified Watson-Jones) techniques were compared with the standard bearer posterior minimally invasive method. Using regression analysis, the outcomes analyzed were as follows: total costs, length of hospital stay, nursing care and home discharges, and use of physical therapy. Regression analysis was also used to evaluate and control for VO effects. RESULTS (1) Newer muscle-sparing and minimally invasive approaches are substantially more effective; (2) irrespective of technique, higher volume surgeons are more effective; (3) technique-specific VO effects for more complex techniques exist and show substantial savings when yearly volume exceeds 30-50; and (4) the anterolateral muscle-sparing technique is accessible to the average surgeon. CONCLUSION Reliance on newer surgical techniques and centralization/regionalization of THR services can reduce costs.
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Affiliation(s)
- Jonathan P Goldstein
- Department of Economics, Bowdoin College, 9700 College Station, Brunswick, ME, 04011, USA.
| | - George M Babikian
- Department of Surgery, Division of Joint Replacement Maine Medical Center, Portland, ME, USA
- , 5 Bucknam Rd., Suite 1D, Falmouth, ME, 04105, USA
| | - Adam J Rana
- Department of Surgery, Division of Joint Replacement Maine Medical Center, Portland, ME, USA
- , 5 Bucknam Rd., Suite 1D, Falmouth, ME, 04105, USA
| | - Johanna A Mackenzie
- Department of Surgery, Division of Joint Replacement Maine Medical Center, Portland, ME, USA
- , 5 Bucknam Rd., Suite 1D, Falmouth, ME, 04105, USA
| | - Andrew Millar
- Department of Economics, Bowdoin College, 9700 College Station, Brunswick, ME, 04011, USA
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Clement RC, Soo AE, Kheir MM, Derman PB, Flynn DN, Levin LS, Fleisher LA. What Incentives Are Created by Medicare Payments for Total Hip Arthroplasty? J Arthroplasty 2016; 31:69-72. [PMID: 27184466 DOI: 10.1016/j.arth.2015.09.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 09/25/2015] [Accepted: 09/28/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Differences in profitability and contribution margin (CM) between various patient populations may make certain patients particularly attractive (or unattractive) to providers. This study seeks to identify patient characteristics associated with increased profit and CM among Medicare patients undergoing total hip arthroplasty (THA). METHODS The expected Medicare reimbursement for consecutive patients of Medicare-eligible age (65+ years) undergoing primary unilateral elective THA (n = 498) was calculated in accordance with Center for Medicare and Medicaid Services policy. Costs were derived from the hospital's cost accounting system. Profit and CM were calculated for each patient as reimbursement less total and variable costs, respectively. Patients were compared based on clinical and demographic factors by univariate and multivariate analyses. RESULTS Medicare patients undergoing THA generated negative average profits but substantial positive CMs. Lower profit and CM were associated with higher American Society of Anesthesiologists Physical Status Classification (P < .01, P = .03), older age (P < .01), and longer length of stay (P < .01, P = .03). No association was found with gender, body mass index, or race. CONCLUSION If our results are generalizable, Medicare patients requiring THA are currently financially attractive, but institutions have a long-term incentive to shift resources to more profitable patients and service lines, which may eventually restrict access to care for this population. THA providers have a financial incentive to favor Medicare patients with younger age, lower American Society of Anesthesiologists Physical Status Classification, and those who can be expected to require relatively short admissions. The Center for Medicare and Medicaid Services must strive to accurately match reimbursement rates to provider costs to avoid inequitable payments to providers and financial incentives discouraging treatment of high-risk patients or other patient subpopulations.
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Affiliation(s)
- R Carter Clement
- Department of Orthopaedics, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Adrianne E Soo
- Department of Orthopaedics, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Michael M Kheir
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter B Derman
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | - David N Flynn
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - L Scott Levin
- Department of Orthopaedics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Kim CY, Wiznia DH, Roth AS, Walls RJ, Pelker RR. Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act. Foot Ankle Int 2016; 37:776-81. [PMID: 27026727 DOI: 10.1177/1071100716642015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to foot and ankle surgeons for total ankle arthroplasty. METHODS We called 240 foot and ankle surgeons who performed total ankle arthroplasty in 8 representative states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for a fictitious patient to be evaluated for a total ankle arthroplasty. Each office was called 3 times to assess the responses for Medicaid, Medicare, and BlueCross. From each call, we recorded appointment success or failure and any barriers to an appointment, such as need for a referral. RESULTS Patients with Medicaid were less likely to receive an appointment compared to patients with Medicare (19.8% vs 92.0%, P < .0001) or BlueCross (19.8% vs 90.4%, P < .0001) and experienced more requests for referrals compared to patients with Medicare (41.9% vs 1.6%, P < .0001) or BlueCross (41.9% vs 4%, P < .0001). Waiting periods were longer for patients with Medicaid compared to those with Medicare (22.6 days vs 11.7 days, P = .004) or BlueCross (22.6 days vs 10.7 days, P = .001). Reimbursement rates did not correlate with appointment success rate or waiting period. CONCLUSION Despite the passage of the PPACA, patients with Medicaid continue to have difficulty finding a surgeon who will provide care, increased need for a primary care referral, and longer waiting periods for appointments. LEVEL OF EVIDENCE Level II, prognostic study.
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Affiliation(s)
- Chang-Yeon Kim
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Daniel H Wiznia
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Alexander S Roth
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Raymond J Walls
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Richard R Pelker
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
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27
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Hanstein T, Kumpe O, Mittelmeier W, Skripitz R. [Hybrid and uncemented hip arthroplasty: Contribution margin in the German lump sum reimbursement system]. DER ORTHOPADE 2016. [PMID: 26215628 DOI: 10.1007/s00132-015-3139-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The economization of inpatient care began when lump sum reimbursement was introduced into the hospital sector. Since then, total hip arthroplasty (THA) has experienced a rapid development in terms of annual procedures and the optimization of the clinical pathway. Therefore, it is obvious to highlight THA as one of the most common procedures in the German health care system. In this work, the two most common techniques for the fixation of THA are investigated with regard to their cost structure and their influence on the clinical result. OBJECTIVES In Germany, uncemented and hybrid fixation are used for THA. In this study we investigated the differences in material costs, the duration of surgery, and the length of stay. MATERIALS AND METHODS For each fixation technique a retrospective cost analysis was carried out, based on the data from the treatment documentation of the University Hospital for Orthopedics, Rostock (OUK). The mean values of the parameters and expenses have been reviewed with descriptive statistics for differences. RESULTS With regard to total costs and the contribution margin there was no statistically significant difference. CONCLUSIONS Although there are differences in individual cost areas, in total costs, cost advantages and disadvantages cancel each other out. Thus, from an economic perspective no particular technique can be recommended.
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Affiliation(s)
- Tim Hanstein
- Hochschule Ludwigshafen am Rhein, Ernst-Boehe-Str. 4, 67059, Ludwigshafen am Rhein, Deutschland,
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Chin G, Wright DJ, Snir N, Schwarzkopf R. Primary vs Conversion Total Hip Arthroplasty: A Cost Analysis. J Arthroplasty 2016; 31:362-7. [PMID: 26387923 PMCID: PMC5863729 DOI: 10.1016/j.arth.2015.08.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 08/24/2015] [Accepted: 08/26/2015] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Increasing hip fracture incidence in the United States is leading to higher occurrences of conversion total hip arthroplasty (THA) for failed surgical treatment of the hip. In spite of studies showing higher complication rates in conversion THA, the Centers for Medicare and Medicaid services currently bundles conversion and primary THA under the same diagnosis-related group. We examined the cost of treatment of conversion THA compared with primary THA. Our hypothesis is that conversion THA will have higher cost and resource use than primary THA. METHODS Fifty-one consecutive conversion THA patients (Current Procedure Terminology code 27132) and 105 matched primary THA patients (Current Procedure Terminology code 27130) were included in this study. The natural log-transformed costs for conversion and primary THA were compared using regression analysis. Age, gender, body mass index, American Society of Anesthesiologist, Charlson comorbidity score, and smoker status were controlled in the analysis. Conversion THA subgroups formed based on etiology were compared using analysis of variance analysis. RESULTS Conversion and primary THAs were determined to be significantly different (P<.05) and greater in the following costs: hospital operating direct cost (29.2% greater), hospital operating total cost (28.8% greater), direct hospital cost (24.7% greater), and total hospital cost (26.4% greater). CONCLUSIONS Based on greater hospital operating direct cost, hospital operating total cost, direct hospital cost, and total hospital cost, conversion THA has significantly greater cost and resource use than primary THA. In order to prevent disincentives for treating these complex surgical patients, reclassification of conversion THA is needed, as they do not fit together with primary THA.
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Affiliation(s)
- Garwin Chin
- University of California Irvine Medical School, Irvine, California
| | - David J Wright
- University of California Irvine Medical School, Irvine, California
| | - Nimrod Snir
- Department of Orthopaedic Surgery, Sorasky Medical Center, Tel-Aviv, Israel
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
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29
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Abstract
PURPOSE total joint replacement is one of the most successful procedures in medicine and cost reimbursements to hospitals for the joint arthroplasty diagnosis-related group are among the largest payments made by a Regional Health Service. Despite the popularity of these procedures, there are few high-quality cost-effectiveness studies on this topic. This study evaluates the cost of total joint arthroplasty performed in a district hospital. METHODS direct and indirect costs have been measured and patient procedure pathway was analyzed subdivided into three stages: surgical procedure, inpatient care and outpatient clinic. RESULTS the cost of the surgical procedure stage was calculated as 3,798 euros, while that of the inpatient stage was 2,924 euros. The mean hospital costs per procedure amounted to 6,952 euros. CONCLUSIONS although the Health Service tariffs fully reimburse the cost of providing a joint replacement, our data contribute to point out the role of hospital staff's organization to support sustainable improvements on health care for joint replacement surgery. LEVEL OF EVIDENCE Level VI, single economic evaluation.
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Affiliation(s)
- Filippo Boniforti
- UO Ortopedia e Traumatologia, Fondazione San Raffaele Giglio, Cefalù, Italy
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Kamath AF, Courtney PM, Bozic KJ, Mehta S, Parsley BS, Froimson MI. Bundled Payment in Total Joint Care: Survey of AAHKS Membership Attitudes and Experience with Alternative Payment Models. J Arthroplasty 2015; 30:2045-56. [PMID: 26077149 DOI: 10.1016/j.arth.2015.05.036] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/13/2015] [Accepted: 05/22/2015] [Indexed: 02/01/2023] Open
Abstract
The goal of alternative payment models (APMs), particularly bundling of payments in total joint arthroplasty (TJA), is to incentivize physicians, hospitals, and payers to deliver quality care at lower cost. To study the effect of APMs on the field of adult reconstruction, we conducted a survey of AAHKS members using an electronic questionnaire format. Of the respondents, 61% are planning to or participate in an APM. 45% of respondents feel that a bundled payment system will be the most effective model to improve quality and to reduce costs. Common concerns were disincentives to operate on high-risk patients (94%) and uncertainty about revenue sharing (79%). While many members feel that APMs may improve value in TJA, surgeons continue to have reservations about implementation.
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Affiliation(s)
- Atul F Kamath
- Department of Orthopedic Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Paul M Courtney
- Department of Orthopedic Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Kevin J Bozic
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Samir Mehta
- Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian S Parsley
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, Texas
| | - Mark I Froimson
- Trinity Health Unified Clinical Organization, Chief Clinical Officer, Trinity Health, Livonia, Michigan
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Clarke A, Pulikottil-Jacob R, Grove A, Freeman K, Mistry H, Tsertsvadze A, Connock M, Court R, Kandala NB, Costa M, Suri G, Metcalfe D, Crowther M, Morrow S, Johnson S, Sutcliffe P. Total hip replacement and surface replacement for the treatment of pain and disability resulting from end-stage arthritis of the hip (review of technology appraisal guidance 2 and 44): systematic review and economic evaluation. Health Technol Assess 2015; 19:1-668, vii-viii. [PMID: 25634033 DOI: 10.3310/hta19100] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Total hip replacement (THR) involves the replacement of a damaged hip joint with an artificial hip prosthesis. Resurfacing arthroplasty (RS) involves replacement of the joint surface of the femoral head with a metal surface covering. OBJECTIVES To undertake clinical effectiveness and cost-effectiveness analysis of different types of THR and RS for the treatment of pain and disability in people with end-stage arthritis of the hip, in particular to compare the clinical effectiveness and cost-effectiveness of (1) different types of primary THR and RS for people in whom both procedures are suitable and (2) different types of primary THR for people who are not suitable for hip RS. DATA SOURCES Electronic databases including MEDLINE, EMBASE, The Cochrane Library, Current Controlled Trials and UK Clinical Research Network (UKCRN) Portfolio Database were searched in December 2012, with searches limited to publications from 2008 and sample sizes of ≥ 100 participants. Reference lists and websites of manufacturers and professional organisations were also screened. REVIEW METHODS Systematic reviews of the literature were undertaken to appraise the clinical effectiveness and cost-effectiveness of different types of THR and RS for people with end-stage arthritis of the hip. Included randomised controlled trials (RCTs) and systematic reviews were data extracted and risk of bias and methodological quality were independently assessed by two reviewers using the Cochrane Collaboration risk of bias tool and the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A Markov multistate model was developed for the economic evaluation of the technologies. Sensitivity analyses stratified by sex and controlled for age were carried out to assess the robustness of the results. RESULTS A total of 2469 records were screened of which 37 were included, representing 16 RCTs and eight systematic reviews. The mean post-THR Harris Hip Score measured at different follow-up times (from 6 months to 10 years) did not differ between THR groups, including between cross-linked polyethylene and traditional polyethylene cup liners (pooled mean difference 2.29, 95% confidence interval -0.88 to 5.45). Five systematic reviews reported evidence on different types of THR (cemented vs. cementless cup fixation and implant articulation materials) but these reviews were inconclusive. Eleven cost-effectiveness studies were included; four provided relevant cost and utility data for the model. Thirty registry studies were included, with no studies reporting better implant survival for RS than for all types of THR. For all analyses, mean costs for RS were higher than those for THR and mean quality-adjusted life-years (QALYs) were lower. The incremental cost-effectiveness ratio for RS was dominated by THR, that is, THR was cheaper and more effective than RS (for a lifetime horizon in the base-case analysis, the incremental cost of RS was £11,284 and the incremental QALYs were -0.0879). For all age and sex groups RS remained clearly dominated by THR. Cost-effectiveness acceptability curves showed that, for all patients, THR was almost 100% cost-effective at any willingness-to-pay level. There were age and sex differences in the populations with different types of THR and variations in revision rates (from 1.6% to 3.5% at 9 years). For the base-case analysis, for all age and sex groups and a lifetime horizon, mean costs for category E (cemented components with a polyethylene-on-ceramic articulation) were slightly lower and mean QALYs for category E were slightly higher than those for all other THR categories in both deterministic and probabilistic analyses. Hence, category E dominated the other four categories. Sensitivity analysis using an age- and sex-adjusted log-normal model demonstrated that, over a lifetime horizon and at a willingness-to-pay threshold of £20,000 per QALY, categories A and E were equally likely (50%) to be cost-effective. LIMITATIONS A large proportion of the included studies were inconclusive because of poor reporting, missing data, inconsistent results and/or great uncertainty in the treatment effect estimates. This warrants cautious interpretation of the findings. The evidence on complications was scarce, which may be because of the absence or rarity of these events or because of under-reporting. The poor reporting meant that it was not possible to explore contextual factors that might have influenced study results and also reduced the applicability of the findings to routine clinical practice in the UK. The scope of the review was limited to evidence published in English in 2008 or later, which could be interpreted as a weakness; however, systematic reviews would provide summary evidence for studies published before 2008. CONCLUSIONS Compared with THR, revision rates for RS were higher, mean costs for RS were higher and mean QALYs gained were lower; RS was dominated by THR. Similar results were obtained in the deterministic and probabilistic analyses and for all age and sex groups THR was almost 100% cost-effective at any willingness-to-pay level. Revision rates for all types of THR were low. Category A THR (cemented components with a polyethylene-on-metal articulation) was more cost-effective for older age groups. However, across all age-sex groups combined, the mean cost for category E THR (cemented components with a polyethylene-on-ceramic articulation) was slightly lower and the mean QALYs gained were slightly higher. Category E therefore dominated the other four categories. Certain types of THR appeared to confer some benefit, including larger femoral head sizes, use of a cemented cup, use of a cross-linked polyethylene cup liner and a ceramic-on-ceramic as opposed to a metal-on-polyethylene articulation. Further RCTs with long-term follow-up are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42013003924. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Aileen Clarke
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Amy Grove
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karoline Freeman
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Hema Mistry
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Martin Connock
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Matthew Costa
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Gaurav Suri
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - David Metcalfe
- Warwick Orthopaedics, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Michael Crowther
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sarah Morrow
- Oxford Medical School, University of Oxford, Oxford, UK
| | - Samantha Johnson
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Sutcliffe
- Warwick Evidence, Warwick Medical School, University of Warwick, Coventry, UK
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El Bitar YF, Illingworth KD, Scaife SL, Horberg JV, Saleh KJ. Hospital Length of Stay following Primary Total Knee Arthroplasty: Data from the Nationwide Inpatient Sample Database. J Arthroplasty 2015; 30:1710-5. [PMID: 26009468 DOI: 10.1016/j.arth.2015.05.003] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 04/13/2015] [Accepted: 05/05/2015] [Indexed: 02/01/2023] Open
Abstract
Demand and cost of total knee arthroplasty (TKA) has increased significantly over the past decade resulting in decreased hospital length of stay (LOS) to counterbalance increasing cost of health care. The purpose of this study was to determine the factors that influence LOS following primary TKA. Discharge data from the 2009-2011 Nationwide Inpatient Sample were used. Patients included underwent primary TKA and were grouped based on LOS; 3 days or less, and 4 days or more. Majority of patients had a hospital LOS of 3 or less (74.8%). The most significant predictors of increased hospital LOS (≥ 4 days) were age ≥ 80 years, Hispanic race, Medicaid payer status, lower median household income, weekend admission, rural non-teaching hospital, discharge to another facility and any complication.
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Affiliation(s)
- Youssef F El Bitar
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Kenneth D Illingworth
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Steven L Scaife
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, Illinois
| | - John V Horberg
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Khaled J Saleh
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
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Oren J, Hutzler LH, Hunter T, Errico T, Zuckerman J, Bosco J. Decreasing spine implant costs and inter-physician cost variation. Bone Joint J 2015. [DOI: 10.1302/0301-620x.97b8.35333] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre. Cite this article: 2015; 97-B:1102–5.
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Affiliation(s)
- J. Oren
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, 10003, USA
| | - L. H. Hutzler
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
| | - T. Hunter
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
| | - T. Errico
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
| | - J. Zuckerman
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
| | - J. Bosco
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
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Mohan R, Yi PH, Hansen EN. Evaluating online information regarding the direct anterior approach for total hip arthroplasty. J Arthroplasty 2015; 30:803-7. [PMID: 25697892 DOI: 10.1016/j.arth.2014.12.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 12/15/2014] [Accepted: 12/28/2014] [Indexed: 02/01/2023] Open
Abstract
We evaluated the quality of information available on the Internet regarding the direct anterior approach (DAA). The top 50 Web sites from three major search engines (Google, Yahoo!, and Bing) were tabulated utilizing the search term direct anterior hip replacement. Of these, only 22% were authored by a hospital/university, while 60% were by a private physician/clinic. Most Web sites presented the DAA as "better" than other surgical approaches describing benefits, such as accelerated recovery though only 35% described risks of the approach. While only 39% of sites presented patient eligibility criteria, greater than 75% had the ability to make an appointment. Web sites regarding the DAA provide patients with a limited perspective and may be focused on attracting new patients, as opposed to accurately educating them.
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Affiliation(s)
- Rohith Mohan
- Boston University School of Medicine, Boston, Massachusetts; University of California, San Francisco, Department of Orthopaedic Surgery, San Francisco, California
| | - Paul H Yi
- University of California, San Francisco, Department of Orthopaedic Surgery, San Francisco, California
| | - Erik N Hansen
- University of California, San Francisco, Department of Orthopaedic Surgery, San Francisco, California
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35
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Kallala RF, Vanhegan IS, Ibrahim MS, Sarmah S, Haddad FS. Financial analysis of revision knee surgery based on NHS tariffs and hospital costs: does it pay to provide a revision service? Bone Joint J 2015; 97-B:197-201. [PMID: 25628282 DOI: 10.1302/0301-620x.97b2.33707] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Revision total knee arthroplasty (TKA) is a complex procedure which carries both a greater risk for patients and greater cost for the treating hospital than does a primary TKA. As well as the increased cost of peri-operative investigations, blood transfusions, surgical instrumentation, implants and operating time, there is a well-documented increased length of stay which accounts for most of the actual costs associated with surgery. We compared revision surgery for infection with revision for other causes (pain, instability, aseptic loosening and fracture). Complete clinical, demographic and economic data were obtained for 168 consecutive revision TKAs performed at a tertiary referral centre between 2005 and 2012. Revision surgery for infection was associated with a mean length of stay more than double that of aseptic cases (21.5 vs 9.5 days, p < 0.0001). The mean cost of a revision for infection was more than three times that of an aseptic revision (£30 011 (sd 4514) vs £9655 (sd 599.7), p < 0.0001). Current NHS tariffs do not fully reimburse the increased costs of providing a revision knee surgery service. Moreover, especially as greater costs are incurred for infected cases. These losses may adversely affect the provision of revision surgery in the NHS.
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Affiliation(s)
- R F Kallala
- University College London Hospitals, 235 Euston Rd, London NW1 2BU, UK
| | - I S Vanhegan
- Royal National Orthopaedic Hospital Stanmore, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - M S Ibrahim
- University College London Hospitals, 235 Euston Rd, London NW1 2BU, UK
| | - S Sarmah
- University College London Hospitals, 235 Euston Rd, London NW1 2BU, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Rd, London NW1 2BU, UK
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Younger ASE, MacLean S, Daniels TR, Penner MJ, Wing KJ, Dunbar M, Glazebrook M. Initial hospital-related cost comparison of total ankle replacement and ankle fusion with hip and knee joint replacement. Foot Ankle Int 2015; 36:253-7. [PMID: 25367250 DOI: 10.1177/1071100714558844] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total hip and knee arthroplasty (THA and TKA) are accessible to patients with end-stage hip and knee arthritis in most health care systems. The availability of total ankle arthroplasty (TAA) to patients with end-stage ankle arthritis is often restricted because of prosthesis cost. Ankle fusion (AF) is often offered as the only alternative. Patients should have equal access to procedures that are equivalent in total cost. We compared total costs of TAA, AF, THA, and TKA for similar cohorts in a government-funded teaching hospital. METHODS A subset of 13 TAA and 13 AF patients were selected from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database, and 13 THA and 13 TKA patients were randomly selected from the Canadian Joint Replacement Registry. Total cost was estimated from operating room time, hospital stay, surgeon billing, and equipment used. RESULTS Mean total cost associated with TAA was $13,500 ± 1000 and was the same as THA ($14,500 ± 1500) and TKA ($12,500 ± 1000). Mean total cost associated with AF was significantly less at $5500 ± 500. Mean operating room time was longer, but mean hospital stay was shorter for the ankle procedures compared with THA and TKA. CONCLUSION All arthroplasties had similar total costs. Total ankle arthroplasty should not be denied based on prosthetic cost alone, as total procedure cost is equivalent to THA and TKA. We believe ankle fusion is a less expensive and preferable alternative for some patient groups.
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Affiliation(s)
- Alastair S E Younger
- Division of Distal Extremities, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada BC's Foot and Ankle Clinic, St Paul's Hospital, Vancouver, BC, Canada
| | - Scott MacLean
- Division of Orthopaedics, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada
| | - Timothy R Daniels
- Division of Orthopaedic Surgery, St Michael's Hospital and University of Toronto, Toronto, ON, Canada
| | - Murray J Penner
- Division of Distal Extremities, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada BC's Foot and Ankle Clinic, St Paul's Hospital, Vancouver, BC, Canada
| | - Kevin J Wing
- Division of Distal Extremities, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada BC's Foot and Ankle Clinic, St Paul's Hospital, Vancouver, BC, Canada
| | - Michael Dunbar
- Division of Orthopaedics, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada
| | - Mark Glazebrook
- Division of Orthopaedics, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada
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Rana AJ, Bozic KJ. Bundled payments in orthopaedics. Clin Orthop Relat Res 2015; 473:422-5. [PMID: 24554458 PMCID: PMC4294917 DOI: 10.1007/s11999-014-3520-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 02/07/2014] [Indexed: 01/31/2023]
Affiliation(s)
- Adam J. Rana
- Division of Joint Replacements, Department of Orthopedics, Maine Medical Partners, Portland, ME USA
| | - Kevin J. Bozic
- Department of Orthopaedic Surgery and Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 500 Parnassus Ave. MU320 W, San Francisco, CA 94143 USA
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Zuckerman JD, Koli EN, Inneh I, Iorio R. Can a hip and knee adult reconstruction orthopaedic surgeon sustain a practice comprised entirely of Medicare patients? J Arthroplasty 2014; 29:132-4. [PMID: 24973932 DOI: 10.1016/j.arth.2014.02.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 01/28/2014] [Accepted: 02/06/2014] [Indexed: 02/01/2023] Open
Abstract
Reimbursement continues to decrease for orthopaedic surgeons specializing in total joint arthroplasty (TJA). Practice information from the Medical Group Management Association (MGMA) Cost Survey and Private practice Compensation Survey and CMS locality reimbursement data was used to develop a practice model for a TJA specialist performing 300 TJA per year (66% knees, 33% hips, 15% revision surgery), evaluating 3000 outpatient visits per year based on, current Medicare reimbursement rates. Our model shows that the anticipated physician compensation is well below the mean compensation reported for a TJA specialist irrespective of geographic location. When MGMA practice expense data are applied to the Medicare-only model, the salary level is unsustainable. Further decreases in Medicare Part B reimbursement will only worsen the disparity.
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Affiliation(s)
- Joseph D Zuckerman
- Department of Orthopaedic Surgery, Division of Adult Reconstructive Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
| | - Emmanuel N Koli
- Department of Orthopaedic Surgery, Division of Adult Reconstructive Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
| | - Ifeoma Inneh
- Department of Orthopaedic Surgery, Division of Adult Reconstructive Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
| | - Richard Iorio
- Department of Orthopaedic Surgery, Division of Adult Reconstructive Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
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Raphael DR, Cannesson M, Schwarzkopf R, Garson LM, Vakharia SB, Gupta R, Kain ZN. Total joint Perioperative Surgical Home: an observational financial review. Perioper Med (Lond) 2014; 3:6. [PMID: 25177486 PMCID: PMC4149757 DOI: 10.1186/2047-0525-3-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 07/25/2014] [Indexed: 12/01/2022] Open
Abstract
Background The numbers of people requiring total arthroplasty is expected to increase substantially over the next two decades. However, increasing costs and new payment models in the USA have created a sustainability gap. Ad hoc interventions have reported marginal cost reduction, but it has become clear that sustainability lies only in complete restructuring of care delivery. The Perioperative Surgical Home (PSH) model, a patient-centered and physician-led multidisciplinary system of coordinated care, was implemented at UC Irvine Health in 2012 for patients undergoing primary elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). This observational study examines the costs associated with this initiative. Methods The direct cost of materials and services (excluding professional fees and implants) for a random index sample following the Total Joint-PSH pathway was used to calculate per diem cost. Cost of orthopedic implants was calculated based on audit-verified direct cost data. Operating room and post-anesthesia care unit time-based costs were calculated for each case and analyzed for variation. Benchmark cost data were obtained from literature search. Data are presented as mean ± SD (coefficient of variation) where possible. Results Total per diem cost was $10,042 ± 1,305 (13%) for TKA and $9,952 ± 1,294 (13%) for THA. Literature-reported benchmark per diem cost was $17,588 for TKA and $16,267 for THA. Implant cost was $7,482 ± 4,050 (54%) for TKA and $9869 ± 1,549 (16%) for THA. Total hospital cost was $17,894 ± 4,270 (24%) for TKA and $20,281 ± 2,057 (10%) for THA. In-room to incision time cost was $1,263 ± 100 (8%) for TKA and $1,341 ± 145 (11%) for THA. Surgery time cost was $1,558 ± 290 (19%) for TKA and $1,930 ± 374 (19%) for THA. Post-anesthesia care unit time cost was $507 ± 187 (36%) for TKA and $557 ± 302 (54%) for THA. Conclusions Direct hospital costs were driven substantially below USA benchmark levels using the Total Joint-PSH pathway. The incremental benefit of each step in the coordinated care pathway is manifested as a lower average length of stay. We identified excessive variation in the cost of implants and post-anesthesia care.
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Affiliation(s)
- Darren R Raphael
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, University of California, 101 The City Drive South Pavilion III, Building 29A Orange, Irvine, California 92868, USA
| | - Leslie M Garson
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
| | - Shermeen B Vakharia
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
| | - Ranjan Gupta
- Department of Orthopedic Surgery, University of California, 101 The City Drive South Pavilion III, Building 29A Orange, Irvine, California 92868, USA
| | - Zeev N Kain
- Department of Anesthesiology and Perioperative Care, University of California, 333 The City Boulevard West, Suite 2150, Orange, Irvine, California 92868, USA
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Belatti DA, Pugely AJ, Phisitkul P, Amendola A, Callaghan JJ. Total joint arthroplasty: trends in medicare reimbursement and implant prices. J Arthroplasty 2014; 29:1539-44. [PMID: 24736291 DOI: 10.1016/j.arth.2014.03.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/11/2014] [Accepted: 03/18/2014] [Indexed: 02/01/2023] Open
Abstract
Total joint arthroplasty (TJA) continues to be a popular target of cost control efforts. In order to provide a unique overview of financial trends facing TJA, we analyzed Medicare databases including 100% of beneficiaries, as well as industry surveys of implant list prices. Although there was a substantial increase in TJA utilization over the period 2000-2011 (+26.9%), growth has been stagnant since 2005. New coding schemes have made complicated cases more lucrative for hospitals (+2.5% to 6.5% per year), while reimbursements for uncomplicated cases have fallen (-0.7% to -0.6%). Physician reimbursements have declined on all case types (-2.5% to -2.1% per year), while list prices of orthopedic implants have risen (+4.8% to 5.5%). These trends should be kept in mind while contemplating future changes to TJA payment.
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Affiliation(s)
- Daniel A Belatti
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Andrew J Pugely
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Phinit Phisitkul
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Annunziato Amendola
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - John J Callaghan
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA
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Derman PB, Fabricant PD, David G. The Role of Overweight and Obesity in Relation to the More Rapid Growth of Total Knee Arthroplasty Volume Compared with Total Hip Arthroplasty Volume. J Bone Joint Surg Am 2014; 96:922-928. [PMID: 24897740 DOI: 10.2106/jbjs.l.01731] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The volume of primary joint replacements performed in the United States increased rapidly over the past twenty years, but the growth rate of total knee arthroplasties exceeded that of total hip arthroplasties. The aim of this study was to identify the key contributing factors behind this differential growth rate. METHODS We compiled longitudinal data on total hip arthroplasty and total knee arthroplasty volume, length of hospital stay, and in-hospital mortality from the Nationwide Inpatient Sample; we calculated reimbursement using information available in the Federal Register and Centers for Medicare & Medicaid Services databases; we determined trends in body mass index from Behavioral Risk Factor Surveillance System findings; and we estimated the size of the surgical workforce based on membership data from the American Academy of Orthopaedic Surgeons. These sources each contained at least ten years of data, ending in 2009. Data sources were analyzed and were compared to identify supply-side and demand-side factors contributing to the more rapid growth observed in total knee arthroplasty. RESULTS Of the factors examined, body mass index played the most substantial role in increasing demand for total knee arthroplasty above that of total hip arthroplasty, with younger individuals affected to a greater degree. More rapid growth in utilization of total knee arthroplasty over total hip arthroplasty in individuals with a body mass index of ≥25 kg/m2 was responsible for 95% of the differential increase in total knee arthroplasty over total hip arthroplasty volumes. Hospital and physician reimbursement, length of stay, and in-hospital mortality did not improve more for total knee arthroplasty than total hip arthroplasty. The surgical community responded to additional demand primarily by increasing per-physician output. CONCLUSIONS Growth in total knee arthroplasty volume has far outpaced that of total hip arthroplasty among those with a body mass index of ≥25 kg/m2 but not for those with a body mass index of <25 kg/m2. The magnitude of this effect will continue to expand if the proportion of Americans with a body mass index of ≥25 kg/m2 continues to increase. Changes in hospital and physician reimbursement, length of stay, and in-hospital mortality did not contribute to this differential growth rate.
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Affiliation(s)
- Peter B Derman
- Department of Orthopaedics, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for P.B. Derman:
| | - Peter D Fabricant
- Department of Orthopaedics, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for P.B. Derman:
| | - Guy David
- Health Care Management Department, The Wharton School, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104
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Ackerman SJ, Polly DW, Knight T, Schneider K, Holt T, Cummings J. Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States commercial payer population: potential economic implications of a new minimally invasive technology. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:283-96. [PMID: 24904218 PMCID: PMC4041287 DOI: 10.2147/ceor.s63757] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Introduction Low back pain is common and treatment costly with substantial lost productivity and lost wages in the working-age population. Chronic low back pain originating in the sacroiliac (SI) joint (15%–30% of cases) is commonly treated with nonoperative care, but new minimally invasive surgery (MIS) options are also effective in treating SI joint disruption. We assessed whether the higher initial MIS SI joint fusion procedure costs were offset by decreased nonoperative care costs from a US commercial payer perspective. Methods An economic model compared the costs of treating SI joint disruption with either MIS SI joint fusion or continued nonoperative care. Nonoperative care costs (diagnostic testing, treatment, follow-up, and retail pharmacy pain medication) were from a retrospective study of Truven Health MarketScan® data. MIS fusion costs were based on the Premier’s Perspective™ Comparative Database and professional fees on 2012 Medicare payment for Current Procedural Terminology code 27280. Results The cumulative 3-year (base-case analysis) and 5-year (sensitivity analysis) differentials in commercial insurance payments (cost of nonoperative care minus cost of MIS) were $14,545 and $6,137 per patient, respectively (2012 US dollars). Cost neutrality was achieved at 6 years; MIS costs accrued largely in year 1 whereas nonoperative care costs accrued over time with 92% of up front MIS procedure costs offset by year 5. For patients with lumbar spinal fusion, cost neutrality was achieved in year 1. Conclusion Cost offsets from new interventions for chronic conditions such as MIS SI joint fusion accrue over time. Higher initial procedure costs for MIS were largely offset by decreased nonoperative care costs over a 5-year time horizon. Optimizing effective resource use in both nonoperative and operative patients will facilitate cost-effective health care delivery. The impact of SI joint disruption on direct and indirect costs to commercial insurers, health plan beneficiaries, and employers warrants further consideration.
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Affiliation(s)
| | - David W Polly
- University of Minnesota, Orthopaedic Surgery, Minneapolis, MN, USA
| | - Tyler Knight
- Covance Market Access Services Inc., Gaithersburg, MD, USA
| | | | - Tim Holt
- Montgomery Spine Center, Orthopedic Surgery, Montgomery, AL, USA
| | - John Cummings
- Community Health Network, Neurosurgery, Indianapolis, IN, USA
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Bosco JA, Alvarado CM, Slover JD, Iorio R, Hutzler LH. Decreasing total joint implant costs and physician specific cost variation through negotiation. J Arthroplasty 2014; 29:678-80. [PMID: 24134928 DOI: 10.1016/j.arth.2013.09.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 09/03/2013] [Accepted: 09/13/2013] [Indexed: 02/01/2023] Open
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.
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Abstract
BACKGROUND Developing a high-efficiency operating room (OR) for total joint arthroplasty (TJA) in an academic setting is challenging given the preexisting work cultures, bureaucratic road blocks, and departmental silo mentalities. Also, academic institutions and aligned surgeons must have strategies to become more efficient and productive in the rapidly changing healthcare marketplace to ensure future financial viability. QUESTIONS/PURPOSES We identified specific resources and personnel dedicated to our OR for TJA, assessed the typical associated work process delays, and implemented changes and set goals to improve OR efficiencies, including more on-time starts and shorter turnover times, to perform more TJA cases per OR. We then compared these variables before and after project initiation to determine whether our goals were achieved. METHODS We gathered 1 year of retrospective TJA OR time data (starting, completion, turnover times) and combined these data with 1 month of prospective observations of the workflow (patient check-in, patient processing and preparation, OR setup, anesthesia, surgeon behaviors, patient pathway). The summarized information, including delays and inefficiencies, was presented to a multidisciplinary committee of stakeholders; recommendations were formulated, implemented, and revised quarterly. Key strategies included dedicated OR efficiency teams, parallel processing, dedicated hospital resources, and modified physician behavior. OR data were gathered and compared 3 years later. RESULTS After project changes, on-time OR starts increased from less than 60% to greater than 90% and average turnover time decreased from greater than 60 minutes to 35 minutes. Our average number of TJA cases per OR increased by 29% during the course of this project. CONCLUSIONS Our project achieved improved OR efficiency and productivity using strategies such as process and resource analysis, improved communication, elimination of silo mentalities, and team work.
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Blood management and transfusion strategies in 600 patients undergoing total joint arthroplasty: an analysis of pre-operative autologous blood donation. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 11:370-6. [PMID: 23736922 DOI: 10.2450/2013.0197-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 02/04/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Blood loss during total joint arthroplasty strongly influences the time to recover after surgery and the quality of the recovery. Blood conservation strategies such as pre-operative autologous blood donation and post-operative cell salvage are intended to avoid allogeneic blood transfusions and their associated risks. Although widely investigated, the real effectiveness of these alternative transfusion practices remains controversial. MATERIALS AND METHODS The surgery reports of 600 patients undergoing total joint arthroplasty (312 hip and 288 knee replacements) were retrospectively reviewed to assess transfusion needs and related blood management at our institute. Evaluation parameters included post-operative blood loss, haemoglobin concentration measured at different time points, ASA score, and blood transfusion strategies. RESULTS Autologous blood donation increased the odds of receiving a red blood cell transfusion. Reinfusion by a cell salvage system of post-operative shed blood was found to limit adverse effects in cases of severe post-operative blood loss. The peri-operative net decrease in haemoglobin concentration was higher in patients who had predeposited autologous blood than in those who had not. DISCUSSION The strengths of this study are the high number of cases and the standardised procedures, all operations having been performed by a single orthopaedic surgeon and a single anaesthesiologist. Our data suggest that a pre-operative autologous donation programme may often be useless, if not harmful. Conversely, the use of a cell salvage system may be effective in reducing the impact of blood transfusion on a patient's physiological status. Basal haemoglobin concentration emerged as a useful indicator of transfusion probability in total joint replacement procedures.
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Blum MA, Singh JA, Lee GC, Richardson D, Chen W, Ibrahim SA. Patient race and surgical outcomes after total knee arthroplasty: an analysis of a large regional database. Arthritis Care Res (Hoboken) 2013; 65:414-20. [PMID: 22933341 DOI: 10.1002/acr.21834] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 08/13/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To examine racial differences in surgical complications, mortality, and revision rates after total knee arthroplasty. METHODS We studied patients undergoing primary total knee arthroplasty using 2001-2007 Pennsylvania Health Care Cost Containment Council data. We conducted bivariate analyses to assess the risk of complications such as myocardial infarction, venous thromboembolism, wound infections, and failure of prosthesis, as well as 30-day and 1-year overall mortality after elective total knee arthroplasty, between racial groups. We estimated Kaplan-Meier 1- and 5-year surgical revision rates, and fit multivariable Cox proportional hazards models to compare surgical revision by race, incorporating 5 years of followup. We adjusted for patient age, sex, length of hospital stay, surgical risk of death, type of health insurance, hospital surgical volume, and hospital teaching status. RESULTS In unadjusted analyses, there were no significant differences by racial group for either overall 30-day or in-hospital complication rates, or 30-day and 1-year mortality rates. Adjusted Cox models incorporating 5 years of followup showed an increased risk of revisions for African American patients (hazard ratio [HR] 1.39, 95% confidence interval [95% CI] 1.08-1.80), younger patients (HR 2.30, 95% CI 1.96-2.69), and lower risk for female patients (HR 0.81, 95% CI 0.71-0.92). CONCLUSION In this sample of patients who underwent knee arthroplasty, we found no significant racial differences in major complication rates or mortality. However, African American patients, younger patients, and male patients all had significantly higher rates of revision based on 5 years of followup.
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Affiliation(s)
- Marissa A Blum
- Temple University School of Medicine, Philadelphia, Pennsylvania, USA.
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Röttger J, Scheller-Kreinsen D, Busse R. Patient-level hospital costs and length of stay after conventional versus minimally invasive total hip replacement: a propensity-matched analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:999-1004. [PMID: 23244800 DOI: 10.1016/j.jval.2012.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 06/05/2012] [Accepted: 06/15/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES A current trend in total hip replacement (THR) is the use of minimally invasive surgery. Little is known, however, about the impact of minimally invasive THR on resource use and length of stay. This study analyzed the effect of minimally invasive surgery on hospital costs and length of stay in German hospitals compared with conventional treatment in THR. METHODS We used patient-level administrative hospital data from three German hospitals participating in the national cost data study. We conducted a propensity score matching to account for baseline differences between minimally invasively and conventionally treated patients. Subsequently, we estimated the treatment effect on costs and length of stay by conducting group comparisons, via paired t tests and Wilcoxon signed-rank tests, and regression analyses. RESULTS The three hospitals provided data from 2886 THR patients. The propensity score matching led to 812 matched pairs. Length of stay was significantly higher for conventionally treated patients (11.49 days vs. 10.90 days; P < 0.05), but total costs did not differ significantly (€6018 vs. €5986; P = 0.67). We found a difference in the allocation of costs, with significantly higher implant costs for minimally invasively treated patients (€1514 vs. €1375; P < 0.001) in contrast to significantly higher staff and overhead costs for conventionally treated patients. CONCLUSIONS Minimally invasive surgery was compared with conventional THR and was found to be associated with a reduced length of stay. Total hospital costs, however, did not differ between the two treatment groups, because of higher implant costs for minimally invasively treated patients.
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Affiliation(s)
- Julia Röttger
- Department of Health Care Management, Berlin University of Technology, Germany, Berlin, Germany.
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[Economic impact of infected total hip arthroplasty in the German diagnosis-related groups system]. DER ORTHOPADE 2012; 41:467-76. [PMID: 22653328 DOI: 10.1007/s00132-012-1939-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The treatment of an infected total hip arthroplasty is becoming an increasing economic problem. The additional costs of treatment are insufficiently represented in the diagnosis-related groups (DRG) categories. The aim of this study was to clarify whether the costs can be covered under the German DRG system and to identify the extent of the surplus or negative balance. PATIENTS AND METHODS A retrospective analysis of the treatment costs of total hip arthroplasty was carried out. Data from all patients treated at the orthopedic clinic of the University Hospital in Rostock were collected from patient records and from the hospital information system and calculation of the personnel and material costs using data from the central pharmacy and control centre of the University of Rostock. RESULTS In this study a total of 49 patients were included. The average treatment costs were 29,331.36 EUR per patient for an infected and 6,263.59 EUR for a primarily non-infected total hip arthroplasty. A comparison between the calculated and compensated costs resulted in an average deficit of 12,685.60 EUR per patient and an average surplus of 781.41 EUR per patient in the control group. CONCLUSIONS An economically viable treatment of infected total hip arthroplasty was not possible mostly due to the increased personnel and material costs but also to the lack of inclusion of the procedures in the DRG system. Further multicenter cost analysis studies and extensive quality assurance measures are necessary with respect to a comprehensive medical standard for a medically meaningful and economically reasonable treatment of periprosthetic infections.
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Warth LC, Callaghan JJ, Wells CW, Liu SS, Klaassen A, Gao Y, Johnston RC. Demographic and comorbid disparities based on payer type in a total joint arthroplasty cohort: implications in a changing health care arena. THE IOWA ORTHOPAEDIC JOURNAL 2011; 31:64-68. [PMID: 22096422 PMCID: PMC3215116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION The purpose of this study was to compare differences in demographic, functional, access to care, and comorbidity data between a Medicaid and Iowa Care (state Medicaid) insured patient cohort and Medicare and a Commercial Payer patient cohort undergoing lower extremity total joint arthroplasty (TJA). MATERIAL & METHODS A retrospective review of 874 primary TKAs and THAs by a single surgeon at an academic institution between January, 2004 and June, 2008 was performed. Data on the primary insurance payer was used to stratify the cohort into two groups; Medicaid and Iowa Care (state Medicaid) insured and Medicare and commercial payer. Demographic, functional, access to care, and comorbidity data obtained from a standard preoperative survey were compared. RESULTS Of 874 primary TKAs and THAs, 18.3 % of patients were Medicaid and Iowa Care insured, while 81.7 % were insured by Medicare and commercial payer. Average age was 53.7 and 62.3 respectively, while average BMI was 35.2 and 32.9 respectively. The Medicaid and Iowa Care group was found to be 3 times more likely to smoke tobacco (25.2% v. 8.3%). Preoperative WOMAC Function scores were 33.9 and 46.8, respectively. Self reported diabetes was used as a general surrogate for health comorbidities and occurred in 12.3 % and 11.5%, respectively. Distance traveled was used as a general surrogate for access to care with averages of 92.5 miles and 62.8 miles, respectively. CONCLUSION The Medicaid and Iowa Care (state Medicaid) group had significantly higher rates of smoking, were significantly younger, and had significantly lower WOMAC scores (p<0.05) preoperatively. BMI comparison showed a trend to greater obesity in the Medicaid and Iowa Care cohort (p=0.056). Diabetes rates were comparable between the two cohorts. Medicaid and Iowa Care patients traveled 29.7 miles farther, suggesting they had less access to local orthopaedic care. There are major differences in comorbidities and patient demographics between payer types.
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