Strategies and tactics for successful implementation of bundled payments: bundled payment for care improvement at a large, urban, academic medical center

Total Hip and Total Knee Arthroplasty Outpatient Case Volume During the 2020 COVID-19 Pandemic in New York and California

BACKGROUND

Inpatient total hip and total knee arthroplasty were substantially impacted by the SARS-CoV-2 (COVID-19) pandemic. We sought to characterize the transition of total joint arthroplasty (TJA) to the outpatient setting in 2 large state health systems during this pandemic.

METHODS

Adult patients who underwent primary elective TJA between January 1, 2016 and December 31, 2020 were retrospectively reviewed using the New York Statewide Planning and Research Cooperative System and California Department of Health Care Access and Information datasets. Yearly inpatient and outpatient case volumes and patient demographics, including age, sex, race, and payer coverage, were recorded. Continuous and categorical variables were compared using descriptive statistics. Significance was set at P < .05.

RESULTS

In New York during 2020, TJA volume decreased 16% because 22,742 fewer inpatient TJAs were performed. Much of this lost volume (46.6%) was offset by a 166% increase in outpatient TJA. In California during 2020, TJA volume decreased 20% because 34,114 fewer inpatient TJAs were performed. Much of this lost volume (37%) was offset by a 47% increase in outpatient TJA.

CONCLUSIONS

This present study demonstrates a marked increase in the proportion of TJA being performed on an outpatient basis in both California and New York. In both states, despite a decrease in overall TJA volume in 2020, outpatient TJA volume increased markedly.

LEVEL OF EVIDENCE

Therapeutic Level IV, Retrospective Cohort Study.

Early Discharge for Revision Total Knee and Hip Arthroplasty: Predictors of Success

BACKGROUND

The rate of revision total joint arthroplasties is expected to increase drastically in the near future. Given the recent pandemic, there has been a general push toward early discharge. This study aimed to assess for predictors of early postoperative discharge after revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA).

METHODS

There were 77 rTKA and 129 rTHA collected between January 1, 2019 and December 31, 2021. Demographic data, comorbidities, a comorbidity index, the modified frailty index (mFI-5), and surgical history were collected. The Common Procedural Terminology codes for each case were assessed. Patients were grouped into 2 cohorts, early discharge (length of stay [LOS] <24 hours) and late discharge (LOS >24 hours).

RESULTS

In the rTHA cohort, age >65 years, a history of cardiac or liver disease, an mFI-5 of >1, a comorbidity index of >2.7, a surgical time >122 minutes, and the need for a transfusion were predictors of prolonged LOS. Only the presence of a surgical time of >63 minutes or an mFI-5 >1 increased patient LOS in the rTKA cohort. In both rTHA and rTKA patients, periprosthetic joint infection resulted in a late discharge for all patients, mean 4.8 and 7.1 days, respectively. Dual component revision was performed in 70.5% of rTHA. Only 27.6% of rTKA were 2-component revisions or placements of an antibiotic spacer.

CONCLUSIONS

Several patient and surgical factors preclude early discharge candidacy. For rTHA, an mFI-5 of >2/5, comorbidity index of >4, or a surgical time of >122 minutes is predictive of prolonged LOS. For rTKA, an mFI-5 of >2/5, Charlson Comorbidity Index of >5, or a surgical time of >63 minutes predicts prolonged LOS.

Marginalization Influences Access, Outcomes, and Discharge Destination Following Total Joint Arthroplasty in Canada's Universal Healthcare System

BACKGROUND

The influence of socioeconomic status on outcomes following total joint arthroplasty (TJA) in the Canadian single-payer healthcare system is yet to be elucidated. The objective of the present study was to evaluate the impact of socioeconomic status on TJA outcomes.

METHODS

This was a retrospective review of 7,304 consecutive TJA (4,456 knees and 2,848 hips) performed between January 1, 2001 and December 31, 2019. The primary independent variable was the average census marginalization index. The primary dependent variable was functional outcome scores.

RESULTS

The most marginalized patients in both the hip and knee cohorts had significantly worse preoperative and postoperative functional scores. Patients in the most marginalized quintile (V) showed a decreased odds of achieving a minimal important difference in functional scores at 1-year follow-up (odds ratio [OR] 0.44; 95% confidence interval [CI] [0.20, 0.97], P = .043). Patients in the knee cohort in the most marginalized quintiles (IV and V) had increased odds of being discharged to an inpatient facility with an OR of 2.07 (95% CI [1.06, 4.04], P = .033) and OR of 2.57 (95% CI [1.26, 5.22], P = .009), respectively. Patients in the hip cohort in V quintile (most marginalized) had increased odds of being discharged to an inpatient facility with an OR of 2.24 (95% CI [1.02, 4.96], P = .046).

CONCLUSION

Despite being a part of the Canadian universal single-payer healthcare system, the most marginalized patients had worse preoperative and postoperative function, and had increased odds of being discharged to another inpatient facility.

LEVEL OF EVIDENCE

IV.

Trends in Single-Level Lumbar Fusions Over the Past Decade Using a National Database

OBJECTIVE

To compare rates of different fusion techniques using a nationwide database over the last decade and identify differences in complications and readmissions based on fusion technique.

METHODS

All elective, single-level lumbar fusions performed by orthopaedic surgeons from 2011 to 2020 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Rates of lumbar fusion technique posterolateral decompression and fusion [PLDF], combined transforaminal lumbar interbody fusion and PLDF, anterior lumbar or lateral lumbar interbody fusion [ALIF/LLIF], and combined ALIF/LLIF and PLDF were recorded, and 30-day complications and readmissions were compared. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome.

RESULTS

Inclusion criteria were met by 28,413 fusions: 8749 (30.8%) PLDFs, 11,973 (42.1%) transforaminal lumbar interbody fusions, 4769 (16.8%) ALIF/LLIFs, and 2922 (10.3%) combined ALIF/LLIF and PLDFs. The number of fusions increased over time with 1227 fusions performed in 2011 and 3958 fusions performed in 2019. Interbody fusions also increased over time with a subsequent decrease in PLDFs (39.0% in 2011, 25.2% in 2020). Patients were more likely to be discharged home over the course of the decade (85.4% in 2011, 95.0% in 2020). No difference was observed between the techniques regarding complications or readmissions. The modified 5-item frailty index was predictive of complications (odds ratio, 2.05; P = 0.001) and readmissions (odds ratio, 2.61; P < 0.001).

CONCLUSIONS

Lumbar fusions have continued to increase over the last decade with an increasing proportion of interbody fusions. Complications and readmissions appear to be driven by patient comorbidity and not fusion technique.

Neural network models accurately predict discharge disposition after revision total knee arthroplasty?

PURPOSE

Based on the rising incidence of revision total knee arthroplasty (TKA), bundled payment models may be applied to revision TKA in the near future. Facility discharge represents a significant cost factor for those bundled payment models; however, accurately predicting discharge disposition remains a clinical challenge. The purpose of this study was to develop and validate artificial intelligence algorithms to predict discharge disposition following revision total knee arthroplasty.

METHODS

A retrospective review of electronic patient records was conducted to identify patients who underwent revision total knee arthroplasty. Discharge disposition was defined as either home discharge or non-home discharge, which included rehabilitation and skilled nursing facilities. Four artificial intelligence algorithms were developed to predict this outcome and were assessed by discrimination, calibration and decision curve analysis.

RESULTS

A total of 2228 patients underwent revision TKA, of which 1405 patients (63.1%) were discharged home, whereas 823 patients (36.9%) were discharged to a non-home facility. The strongest predictors for non-home discharge following revision TKA were American Society of Anesthesiologist (ASA) score, Medicare insurance type and revision surgery for peri-prosthetic joint infection, non-white ethnicity and social status (living alone). The best performing artificial intelligence algorithm was the neural network model which achieved excellent performance across discrimination (AUC = 0.87), calibration and decision curve analysis.

CONCLUSION

This study developed four artificial intelligence algorithms for the prediction of non-home discharge disposition for patients following revision total knee arthroplasty. The study findings show excellent performance on discrimination, calibration and decision curve analysis for all four candidate algorithms. Therefore, these models have the potential to guide preoperative patient counselling and improve the value (clinical and functional outcomes divided by costs) of revision total knee arthroplasty patients.

LEVEL OF EVIDENCE

IV.

Surgeon and Facility Volumes Are Associated With Social Disparities and Post-Operative Complications After Total Hip Arthroplasty

BACKGROUND

The purpose of this study is to further characterize the volume dependence of facilities and surgeons on morbidity and mortality after total hip arthroplasty (THA).

METHODS

Adults who underwent THA from 2009 to 2014 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Complication rates were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression controlling for factors such as the Social Deprivation Index. Surgeon and facility volumes were compared between the low and high volume using cutoffs established by prior research.

RESULTS

In total, 99,832 patients were included. Low volume facilities had higher rates of readmission, urinary tract infection (UTI), acute renal failure, pneumonia, surgical site infection (SSI), cellulitis, wound complications, deep vein thrombosis (DVT), in-hospital mortality, and revision. Low volume surgeons had higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, acute respiratory failure, pulmonary embolism, cellulitis, wound complications, in-hospital mortality, cardiorespiratory arrest, DVT, and revision. African Americans, Hispanics, and those with federal insurance had increased rates of readmission. Those with ≥1 Charlson comorbidities or from areas of higher social deprivation had increased incidence of treatment by low volume surgeons and facilities.

CONCLUSION

Both low volume facilities and surgeons performing primary THA have higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, cellulitis, wound complications, DVT, in-hospital mortality, and revision. Demographic disparities exist between who is treated at low vs high volume surgeons and facilities placing those groups at higher risks for complications.

Patient-reported Outcomes Among Vulnerable Populations in the Medicare Bundled Payments for Care Improvement Initiative

BACKGROUND

The Centers for Medicare & Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative tested whether episode-based payment models could reduce Medicare payments without harming quality. Among patients with vulnerabilities, BPCI appeared to effectively reduce payments while maintaining the quality of care. However, these findings could overlook potential adverse patient-reported outcomes in this population.

RESEARCH DESIGN

We surveyed beneficiaries with 4 characteristics (Medicare-Medicaid dual eligibility; dementia; recent institutional care; or racial/ethnic minority) treated at BPCI-participating or comparison hospitals for congestive heart failure, sepsis, pneumonia, or major joint replacement of the lower extremity. We estimated risk-adjusted differences in patient-reported outcomes between BPCI and comparison respondents, stratified by clinical episode and vulnerable characteristic.

MEASURES

Patient care experiences during episodes of care and patient-reported functional outcomes assessed roughly 90 days after hospitalization.

RESULTS

We observed no differences in self-reported functional improvement between BPCI and comparison respondents with vulnerable characteristics. Patient-reported care experience was similar between BPCI and comparison respondents in 11 of 15 subgroups of clinical episode and vulnerability. BPCI respondents with congestive heart failure, sepsis, and pneumonia were less likely to indicate positive care experiences than comparison respondents for at least 1 subgroup with vulnerabilities.

CONCLUSIONS

As implemented by hospitals, BPCI Model 2 was not associated with adverse effects on patient-reported functional status among beneficiaries who may be vulnerable to reductions in care. Hospitals participating in heart failure, sepsis or pneumonia bundled payment episodes should focus on patient care experience while implementing changes in care delivery.

Is There An Association Between Bundled Payments and "Cherry Picking" and "Lemon Dropping" in Orthopaedic Surgery? A Systematic Review

BACKGROUND

The goal of bundled payments-lump monetary sums designed to cover the full set of services needed to provide care for a condition or medical event-is to provide a reimbursement structure that incentivizes improved value for patients. There is concern that such a payment mechanism may lead to patient screening and denying or providing orthopaedic care to patients based on the number and severity of comorbid conditions present associated with complications after surgery. Currently, however, there is no clear consensus about whether such an association exists.

QUESTIONS/PURPOSES

In this systematic review, we asked: (1) Is the implementation of a bundled payment model associated with a change in the sociodemographic characteristics of patients undergoing an orthopaedic procedure? (2) Is the implementation of a bundled payment model associated with a change in the comorbidities and/or case-complexity characteristics of patients undergoing an orthopaedic procedure? (3) Is the implementation of a bundled payment model associated with a change in the recent use of healthcare resources characteristics of patients undergoing an orthopaedic procedure?

METHODS

This systematic review was registered in PROSPERO before data collection (CRD42020189416). Our systematic review included scientific manuscripts published in MEDLINE, Embase, Web of Science, Econlit, Policyfile, and Google Scholar through March 2020. Of the 30 studies undergoing full-text review, 20 were excluded because they did not evaluate the outcome of interest (patient selection) (n = 8); were editorial, commentary, or review articles (n = 5); did not evaluate the appropriate intervention (introduction of a bundled payment program) (n = 4); or assessed the wrong patient population (not orthopaedic surgery patients) (n = 3). This led to 10 studies included in this systematic review. For each study, patient factors analyzed in the included studies were grouped into the following three categories: sociodemographics, comorbidities and/or case complexity, or recent use of healthcare resources characteristics. Next, each patient factor falling into one of these three categories was examined to evaluate for changes from before to after implementation of a bundled payment initiative. In most cases, studies utilized a difference-in-difference (DID) statistical technique to assess for changes. Determination of whether the bundled payment initiative required mandatory participation or not was also noted. Scientific quality using the Adapted Newcastle-Ottawa Scale had a median (range) score of 8 (7 to 8; highest possible score: 9), and the quality of the total body of evidence for each patient characteristic group was found to be low using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. We could not assess the likelihood of publication using funnel plots because of the variation of patient factors analyzed in each study and the heterogeneity of data precluded a meta-analysis.

RESULTS

Of the nine included studies that reported on the sociodemographic characteristics of patients selected for care, seven showed no change with the implementation of bundled payments, and two demonstrated a difference. Most notably, the studies identified a decrease in the percentage of patients undergoing an orthopaedic operative intervention who were dual-eligible (range DID estimate -0.4% [95% CI -0.75% to -0.1%]; p < 0.05 to DID estimate -1.0% [95% CI -1.7% to -0.2%]; p = 0.01), which means they qualified for both Medicare and Medicaid insurance coverage. Of the 10 included studies that reported on comorbidities and case-complexity characteristics, six reported no change in such characteristics with the implementation of bundled payments, and four studies noted differences. Most notably, one study showed a decrease in the number of treated patients with disabilities (DID estimate -0.6% [95% CI -0.97% to -0.18%]; p < 0.05) compared with before bundled payment implementation, while another demonstrated a lower number of Elixhauser comorbidities for those treated as part of a bundled payment program (before: score of 0-1 in 63.6%, 2-3 in 27.9%, > 3 in 8.5% versus after: score of 0-1 in 50.1%, 2-3 in 38.7%, > 3 in 11.2%; p = 0.033). Of the three included studies that reported on the recent use of healthcare resources of patients, one study found no difference in the use of healthcare resources with the implementation of bundled payments, and two studies did find differences. Both studies found a decrease in patients undergoing operative management who recently received care at a skilled nursing facility (range DID estimate -0.50% [95% CI -1.0% to 0.0%]; p = 0.04 to DID estimate: -0.53% [95% CI -0.96% to -0.10%]; p = 0.01), while one of the studies also found a decrease in patients undergoing operative management who recently received care at an acute care hospital (DID estimate -0.8% [95% CI -1.6% to -0.1%]; p = 0.03) or as part of home healthcare (DID estimate -1.3% [95% CI -2.0% to -0.6%]; p < 0.001).

CONCLUSION

In six of 10 studies in which differences in patient characteristics were detected among those undergoing operative orthopaedic intervention once a bundled payment program was initiated, the effect was found to be minimal (approximately 1% or less). However, our findings still suggest some level of adverse patient selection, potentially worsening health inequities when considered on a large scale. It is also possible that our findings reflect better care, whereby the financial incentives lead to fewer patients with a high risk of complications undergoing surgical intervention and vice versa for patients with a low risk of complications postoperatively. However, this is a fine line, and it may also be that patients with a high risk of complications postoperatively are not being offered surgery enough, while patients at low risk of complications postoperatively are being offered surgery too frequently. Evaluation of the longer-term effect of these preliminary bundled payment programs on patient selection is warranted to determine whether adverse patient selection changes over time as health systems and orthopaedic surgeons become accustomed to such reimbursement models.

The Hospital Frailty Risk Score is Not an Accurate Predictor of Treatment Costs for Total Joint Replacement Patients in a Medicare Bundled Payment Population

BACKGROUND

Medically complex patients require more resources and experience higher costs within total joint arthroplasty (TJA) bundled payment models. While risk adjustment would be beneficial for such patients, no tool currently exists which can reliably identify these patients preoperatively. The purpose of this study is to determine if the Hospital Frailty Risk Score (HFRS) is a valid predictor of high-TJA treatment costs.

METHODS

Retrospective analysis was performed on patients who underwent primary TJA between 2015 and 2020 from a single large orthopedic practice. ICD-10 codes from an institutional database were used to calculate HFRS. Cost data including inpatient, postacute, and episode of care (EOC) costs were collected. Charlson comorbidity index, demographics, readmissions, and complications were analyzed.

RESULTS

4936 patients had a calculable HFRS and those with intermediate and high scores experienced more frequent readmissions/complications after TJA, as well as higher EOC costs. However, HFRS did not reliably predict EOC costs, yielding a sensitivity of 49% and specificity of 66%. Multivariate analysis revealed that both patient age and sex are superior individual cost predictors when compared with HFRS. Secondary analyses indicated that HFRS more effectively predicts TJA complications and readmissions but is still nonideal for clinical applications.

CONCLUSION

HFRS has poor sensitivity as a predictor of high-EOC costs for TJA patients but has adequate specificity for predicting postoperative readmissions and complications. Further research is needed to develop a scale that can appropriately predict orthopedic cost outcomes.

Comorbidity Burden Contributing to Racial Disparities in Outpatient Versus Inpatient Total Knee Arthroplasty

INTRODUCTION

Outpatient total knee arthroplasty (TKA) is increasingly common in the setting of early-recovery protocols, value-based care, and removal from the inpatient-only list by the Centers for Medicare & Medicaid Services. Given the established racial disparities that exist in different aspects of total joint arthroplasty, we aimed to investigate whether racial and ethnic disparities exist in outpatient compared with inpatient TKA.

METHODS

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program. We queried TKAs done in 2018. Demographics, inpatient (≥2 midnights) versus outpatient (≤1 midnight) status, comorbidities, and perioperative events/complications were recorded. We analyzed differences between racial/ethnic groups and predictors of inpatient versus outpatient surgery, and outcomes.

RESULTS

A total of 54,582 patients were included (83.2% Caucasian, 9.2% African American [AA], 4.5% Hispanic, 2.4% Asian, and 0.6% Native American). AA had the highest mean body mass index, American Society of Anesthesiologists score, and comorbidity burden. AA had the lowest rate of outpatient TKA (18.3%) and Asians the highest rate of outpatient TKA (31.4%, P < 0.0001). AA had the highest postoperative transfusion rate (1.8%, P < 0.0001) and highest rate of discharge to acute rehab (8.4%). Asians had the highest rate of postoperative cardiac arrest and urinary tract infection. AA had the highest rate of acute kidney injury within 30 days. Regression analyses revealed that AAs were more likely to undergo inpatient surgery (odds ratio [OR], 2.58; confidence interval [CI], 1.57-4.23; P = 0.001) and discharge to rehab/skilled nursing facility [SNF] (OR, 2.86; CI, 1.66-4.92; P = 0.001). Asian patients were more likely to undergo outpatient surgery (OR, 2.48, CI, 1.47-4.18, P = 0.001) and discharged to rehab/SNF (OR, 2.41, CI, 1.36-4.25, P = 0.001). Caucasians were more likely to undergo outpatient surgery (OR, 1.62, CI, 1.34-1.97, P = 0.001) and less likely discharged to rehab/SNF (OR, 0.73, CI, 0.60-0.88, P = 0.001). When controlling for comorbidities, race was not an independent risk factor for 30-day complications or inpatient versus outpatient surgery.

DISCUSSION

Differences in indications for outpatient TKA between races/ethnicities seem to be highly associated with comorbidity burden and preoperative baseline differences, not race alone. Appropriate patient optimization for either outpatient or inpatient TKA may reduce disparities between groups in either care setting.

Metric Selection, Metric Targets, and Risk Adjustment Should be Considered in the Design of Gainsharing Models for Bundled Payment Programs in Total Joint Arthroplasty

BACKGROUND

Under bundled payment models, gainsharing presents an important mechanism to ensure engagement and reward innovation. We hypothesized that metric selection, metric targets, and risk adjustment would impact surgeons' performance in gainsharing models.

METHODS

Patients undergoing total joint arthroplasty at an urban health system from 2017 to September 2018 were included. Gainsharing metrics included the following: length of stay, % discharge-to-home, 90-day readmission rate, % of patients with episode spend under target price, and % of patients with patient-reported outcomes (PROs) collected. Four scenarios were created to evaluate how metric selection/adjustment impacted surgeons' performance designation: scenario 1 used "aspirational targets" (>60th percentile), scenario 2 used "acceptable targets" (>50th percentile), scenario 3 risk-adjusted surgeon performance prior to comparing aspirational targets, and scenario 4 included a PRO collection metric. Number of metrics achieved determined performance tier, with higher tiers getting a greater share of the gainsharing pool.

RESULTS

In total, 2776 patients treated by 12 surgeons met inclusion criteria (mean length of stay 3.0 days, readmission rate 4.0%, discharge-to-home 74%, episode spend under target price 85%, PRO collection 56%). Lowering of metric targets (scenario 1 vs. 2) resulted in a 75% increase in the number of high performers and 98% of the gainsharing pool being eligible for distribution. Risk adjustment (scenario 3) caused 50% of providers to move to higher performance tiers and potential payments to increase by 28%. Adding the PRO metric did not change performance.

CONCLUSION

Quality metric/target selection and risk adjustment profoundly impact surgeons' performance in gainsharing contracts. This impacts how successful these contracts can be in driving innovation and dis-incentivizing the "cherry picking" of patients.

LEVEL OF EVIDENCE

Level III.

Robotic total knee arthroplasty: A missed opportunity for cost savings in Bundled Payment for Care Improvement initiatives?

BACKGROUND

The use of robotic total knee arthroplasty has become increasingly prevalent. Proponents of robotic total knee arthroplasty tout its potential to not only improve outcomes, but also to reduce costs compared with traditional total knee arthroplasty. Despite its potential to deliver on the value proposition, whether robotic total knee arthroplasty has led to improved outcomes and cost savings within Medicare's Bundled Payment for Care Improvement initiative remains unexplored.

METHODS

Medicare beneficiaries who underwent total knee arthroplasty designated under Medicare severity diagnosis related group 469 or 470 in the year 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals participating in the Bundled Payment for Care Improvement were identified using the Bundled Payment for Care Improvement analytic file. We calculated risk-adjusted, price-standardized payments for the surgical episode from admission through 90-days postdischarge. Outcomes, utilization, and spending were assessed relative to variation between robotic and traditional total knee arthroplasty.

RESULTS

Overall, 198,371 patients underwent total knee arthroplasty (traditional total knee arthroplasty: n= 194,020, 97.8% versus robotic total knee arthroplasty: n = 4,351, 2.2%). Among the 3,272 hospitals that performed total knee arthroplasty, only 300 (9.3%) performed robotic total knee arthroplasty. Among the 183 participating in the Bundled Payment for Care Improvement, only 40 (19%) hospitals performed robotic total knee arthroplasty. Risk-adjusted 90-day episode spending was $14,263 (95% confidence interval $14,231-$14,294) among patients who underwent traditional total knee arthroplasty versus $13,676 (95% confidence interval $13,467-$13,885) among patients who had robotic total knee arthroplasty. Patients who underwent robotic total knee arthroplasty had a shorter length of stay (traditional total knee arthroplasty: 2.3 days, 95% confidence interval: 2.3-2.3 versus robotic total knee arthroplasty: 1.9 days, 95% confidence interval: 1.9-2.0), as well as a lower incidence of complications (traditional total knee arthroplasty: 3.3%, 95% confidence interval: 3.2-3.3 versus robotic total knee arthroplasty: 2.7%, 95% confidence interval: 2.3-3.1). Of note, patients who underwent robotic total knee arthroplasty were less often discharged to a postacute care facility than patients who underwent traditional total knee arthroplasty (traditional total knee arthroplasty: 32.4%, 95% confidence interval: 32.3-32.5 versus robotic total knee arthroplasty: 16.8%, 95% confidence interval 16.1-17.6). Both Bundled Payment for Care Improvement and non-Bundled Payment for Care Improvement hospitals with greater than 50% robotic total knee arthroplasty utilization had lower spending per episode of care versus spending at hospitals with less than 50% robotic total knee arthroplasty utilization.

CONCLUSION

Overall 90-day episode spending for robotic total knee arthroplasty was lower than traditional total knee arthroplasty (Δ $-587, 95% confidence interval: $-798 to $-375). The decrease in spending was attributable to shorter length of stay, fewer complications, as well as lower utilization of postacute care facility. The cost savings associated with robotic total knee arthroplasty was only realized when robotic total knee arthroplasty volume surpassed 50% of all total knee arthroplasty volume. Hospitals participating in the Bundled Payment for Care Improvement may experience cost-saving with increased utilization of robotic total knee arthroplasty.

Which Patients Require Unexpected Admission to Postacute Care Facilities After Total Hip Arthroplasty?

BACKGROUND

Many surgeons prefer to discharge patients home due to patient preferences, improved outcomes, and decreased costs. Despite an institutional protocol to send total hip arthroplasty (THA) patients home, some patients still required postacute care (PAC) facilities. This study aimed to create two predictive models based on preoperative and postoperative risk factors to identify which patients require PAC facilities.

METHODS

A retrospective review of 2,372 patients undergoing primary unilateral THA at a single institution from 2012 to 2017 was done. An electronic query followed by manual review identified discharge disposition, demographic factors, comorbidities, and other patient factors. Of the 2,372 patients, 6.2% were discharged to skilled nursing facilities or inpatient rehabilitation facilities and 93.8% discharged home. Univariate and multivariate analysis were conducted to create two predictive models for patient discharge: preoperative visit and postoperative hospital course.

RESULTS

Of 45 variables evaluated, 7 were found to be notable predictors for PAC facility discharge. In descending order, these included age 65 years or greater, non-Caucasian race, history of depression, female sex, and greater comorbidities. In addition to preoperative factors, in-hospital complications and surgical duration of 90 minutes or greater led to a higher likelihood of PAC facility discharge. Both models had excellent predictive assessments with area under curve values of 0.77 and 0.80 for the preoperative visit and postoperative models, respectively.

DISCUSSION

This study identifies both preoperative and postoperative risk factors that predispose patients to nonroutine discharges after THA. Orthopaedic surgeons may use these models to better predict which patients are predisposed to discharge to PAC facilities.

Are current DRG-based bundled payment models for revision total joint arthroplasty risk-adjusting adequately?

Aims

Currently, the US Center for Medicaid and Medicare Services (CMS) has been testing bundled payments for revision total joint arthroplasty (TJA) through the Bundled Payment for Care Improvement (BPCI) programme. Under the BPCI, bundled payments for revision TJAs are defined on the basis of diagnosis-related groups (DRGs). However, these DRG-based bundled payment models may not be adequate to account appropriately for the varying case-complexity seen in revision TJAs.

Methods

The 2008-2014 Medicare 5% Standard Analytical Files (SAF5) were used to identify patients undergoing revision TJA under DRG codes 466, 467, or 468. Generalized linear regression models were built to assess the independent marginal cost-impact of patient, procedural, and geographic characteristics on 90-day costs.

Results

A total of 9,263 patients (DRG-466 = 838, DRG-467 = 4,573, and DRG-468 = 3,842) undergoing revision TJA from 2008 to 2014 were included in the study. Undergoing revision for a dislocation (+$1,221), periprosthetic fracture (+$4,454), and prosthetic joint infection (+$5,268) were associated with higher 90-day costs. Among comorbidities, malnutrition (+$10,927), chronic liver disease (+$3,894), congestive heart failure (+$3,292), anaemia (+$3,149), and coagulopathy (+$2,997) had the highest marginal cost-increase. The five US states with the highest 90-day costs were Alaska (+$14,751), Maryland (+$13,343), New York (+$7,428), Nevada (+$6,775), and California (+$6,731).

Conclusion

Under the proposed DRG-based bundled payment methodology, surgeons would be reimbursed the same amount of money for revision TJAs, regardless of the indication (periprosthetic fracture, prosthetic joint infection, mechanical loosening) and/or patient complexity. Cite this article: Bone Joint J 2020;102-B(7):959–964.

A systematic review and meta-synthesis of policy intervention characteristics that influence the implementation of government-directed policy in the hospital setting: implications for infection prevention and control

Background

Government-directed policy plays an important role in the regulation and supervision of healthcare quality. Effective implementation of these policies has the potential to significantly improve clinical practice and patient outcomes, including the prevention of healthcare-associated infections. A systematic review of research describing the implementation of government-directed policy in the hospital setting was performed with the aim to identify policy intervention characteristics that influence implementation.

Methods

A systematic search of four electronic databases was undertaken to identify eligible articles published between 2007 and 2017. Studies were included if published in the English language and described the implementation of government-directed policy in a high-income country hospital setting. Data on policy and implementation were extracted for each article and interpretive syntheses performed.

Results

A total of 925 articles were retrieved and titles and abstracts reviewed, with 69 articles included after review of abstract and full text. Qualitative synthesis of implementation data showed three overarching themes related to intervention characteristics associated with implementation: clarity; infrastructure; and alignment.

Conclusion

Better understanding and consideration of policy intervention characteristics during development and planning will facilitate more effective implementation although research describing implementation of government-directed policy in the hospital setting is limited and of variable quality. The findings of this study provide guidance to staff tasked with the development or implementation of government-directed policy in the hospital setting, infection prevention and control professionals seeking to maximise the impact of policy on practice and improve patient outcomes.

Factors Associated With Extended Length of Stay and 90-Day Readmission Rates Following ACDF

STUDY DESIGN

Retrospective.

OBJECTIVE

Identify patient risk factors for extended length of stay (LOS) and 90-day hospital readmissions following elective anterior cervical discectomy and fusion (ACDF).

METHODS

Included ACDF patients from 2013 to 2017 at a single institution. Eligible patients were subset into LOS <2 and LOS ≥2 days, and no 90-day hospital readmission and yes 90-day hospital readmission. Patient and surgical factors were compared between the LOS and readmission groups. Multivariable logistic regression analysis was utilized to determine the association of independent factors with LOS and 90-day readmission rates.

RESULTS

Our sample included 1896 patients; 265 (14%) had LOS ≥2 days, and 121 (6.4%) had a readmission within 90 days of surgery. Patient and surgical factors associated with LOS included patient age ≥65 years (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.15-2.56), marriage (OR 0.57, 95% CI 0.43-0.79), private health insurance (OR 0.28, 95% CI 0.15-0.50), American Society of Anesthesiologists (ASA) score (OR 1.52, 95% CI 1.12-1.86), African American race (OR 1.95, 95% CI 1.38-2.72), and harvesting iliac crest autograft (OR 4.94, 95% CI 2.31-10.8). Patient and surgical factors associated with 90-day hospital readmission included ASA score (OR 1.81, 95% CI 1.32-2.49), length of surgery (OR 1.002, 95% CI 1.001-1.004), and radiculopathy as indication for surgery (OR 0.60, 95% CI 0.39-0.96).

CONCLUSIONS

Extended LOS and 90-day hospital readmissions may lead to poorer patient outcomes and increased episode of care costs. Our study identified patient and surgical factors associated with extended LOS and 90-day readmission rates. In general, preoperative patient factors affected these outcomes more than surgical factors.

Drivers of Variability in 90-Day Cost for Elective Laminectomy and Fusion for Lumbar Degenerative Disease

BACKGROUND

Considerable variability exists in the cost of surgery following spine surgery for common degenerative spine diseases. This variation in the cost of surgery can affect the payment bundling during the postoperative 90 d.

OBJECTIVE

To determine the drivers of variability in total 90-d cost for laminectomy and fusion surgery.

METHODS

A total of 752 patients who underwent elective laminectomy and fusion for degenerative lumbar conditions and were enrolled into a prospective longitudinal registry were included in the study. Total cost during the 90-d global period was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multivariable regression models were built for total 90-d cost.

RESULTS

The mean 90-d direct cost was $29 295 (range, $28 612-$29 973). Based on our regression tree analysis, the following variables were found to drive the 90-d cost: age, BMI, gender, diagnosis, postop imaging, number of operated levels, ASA grade, hypertension, arthritis, preop and postop opioid use, length of hospital stay, duration of surgery, 90-d readmission, outpatient physical/occupational therapy, inpatient rehab, postop healthcare visits, postop nonopioid pain medication use nonsteroidal antiinflammatory drug (NSAIDs), and muscle relaxant use. The R2 for tree model was 0.64.

CONCLUSION

Utilizing prospectively collected data, we demonstrate that considerable variation exists in total 90-d cost, nearly 70% of which can be explained by those factors included in our modeling. Risk-adjusted payment schemes can be crafted utilizing the significant drivers presented here. Focused interventions to target some of the modifiable factors have potential to reduce cost and increase the value of care.

The Value of Home Health Physical Therapy

The purpose of the Triple Aim is to improve population health, reduce healthcare costs, and improve the patient experience. These goals-to reduce cost while improving health outcomes and patient experiences have shifted utilization of services from other postacute care settings to the home. The purpose of this perspective article is to discuss how home healthcare services, and home physical therapy (PT) specifically, provide value to patients, caregivers, and payers to meet the goals of the Triple Aim. This article will substantiate the value of home PT and provide healthcare professionals with evidence-based information on the value of home PT.

Successful Implementation of an Accelerated Recovery and Outpatient Total Joint Arthroplasty Program at a County Hospital

Outpatient and accelerated recovery total joint arthroplasty (TJA) programs have become standard for private and academic practices. County hospitals traditionally serve patients with limited access to TJA and psychosocial factors which create challenges for accelerated recovery. The effectiveness of such programs at a county hospital has not been reported.

Methods

In 2017, our county hospital implemented an accelerated recovery protocol for all TJA patients. This protocol consisted of standardized, preoperative medical and psychosocial optimization, perioperative spinal anesthesia, tranexamic acid and local infiltration analgesia use, postoperative emphasis on non-narcotic analgesia, and early mobilization. LOS, complications, disposition, and cost were compared between patients treated before and after protocol implementation.

Results

In 15 months, 108 primary TJA patients were treated. Compared with the previous 108 TJA patients, LOS dropped from 3.4 to 1.6 days (P < 0.001), more patients discharged home (92% versus 72%, P < 0.001), average hospitalization and procedure-specific costs decreased 24.7% and 22.1%, respectively, and were significantly fewer complications (7% versus 21%, P = 0.007).

Conclusions

Implementation of an accelerated recovery TJA program at a County Hospital is novel. This implementation requires careful patient selection and a coordinated multidisciplinary approach and is a safe and cost-effective method of delivering high-quality care to an underserved cohort.

Evidence of the Linkage Between Hospital-based Care Coordination Strategies and Hospital Overall (Star) Ratings

BACKGROUND

In the new era of value-based payment models and pay for performance, hospitals are in search of the silver bullet strategy or bundle of strategies capable of improving their performance on quality measures.

OBJECTIVES

To determine whether there is an association between adoption of hospital-based care coordination strategies and Centers for Medicare and Medicaid Services overall hospital quality (star) ratings and readmission rates.

RESEARCH DESIGN

We used survey data from the American Hospital Association (AHA) and categorized respondents by the number of care coordination strategies that they reported having widely implemented. We used multiple logistic regression models to examine the association between the number of strategies and hospital overall rating performance and disease-specific 30-day excess readmission ratios, while controlling for hospital and county characteristics and state-fixed effects.

SUBJECTS

A total of 710 general acute care noncritical access hospitals that received star ratings and responded to the 2015 AHA Care Systems and Payment Survey.

MEASURES

Centers for Medicare and Medicaid Services overall hospital ratings, 30-day excess readmission ratios.

RESULTS

As compared with hospitals with 0-2 strategies, hospitals with 3 to 4 strategies (P=0.007), 5-7 strategies (P=0.002), or 8-12 strategies (P=0.002) had approximately 2.5× the odds of receiving a top rating (4 or 5 stars). Care coordination strategies were positively associated with lower 30-day readmission ratios for patients with chronic medical conditions, but not for surgical patients. Medication reconciliation, visit summaries, outreach after discharge, discharge care plans, and disease management programs were each individually associated with top ratings.

CONCLUSIONS

Care coordination strategies are associated with high overall hospital ratings.

Association of Intraoperative Findings With Outcomes and Resource Use in Children With Complicated Appendicitis

Importance

The influence of disease severity on outcomes and use of health care resources in children with complicated appendicitis is poorly characterized. Adjustment for variation in disease severity may have implications for ensuring fair reimbursement and comparative performance reporting among hospitals.

Objective

To examine the association of intraoperative findings as a measure of disease severity with complication rates and resource use in children with complicated appendicitis.

Design

This retrospective cohort study used clinical data from the American College of Surgeons National Surgical Quality Improvement Program pediatric appendectomy pilot database (NSQIP-P database) and cost data from the Pediatric Health Information System database. Twenty-two children's hospitals participated in the NSQIP Pediatric Appendectomy Collaborative Pilot Project. Patients aged 3 to 18 years with complicated appendicitis who underwent an appendectomy from January 1, 2013, through December 31, 2014, were included in the study. Appendicitis was categorized in the NSQIP-P database as complicated if any of the following 4 intraoperative findings occurred in the operative report: visible hole, fibropurulent exudate in more than 2 quadrants, abscess, or extraluminal fecalith. Data were analyzed from January 1, 2013, through December 31, 2014.

Main Outcomes and Measures

Thirty-day postoperative adverse event rate, revisit rate, hospital cost, and length of stay. Multivariable regression was used to estimate event rates and outcomes for all observed combinations of intraoperative findings, with adjusting for patient characteristics and clustering within hospitals.

Results

A total of 1333 patients (58.7% boys; median age, 10 years; interquartile range, 7-12 years) were included; multiple intraoperative findings of complicated appendicitis were reported in 589 (44.2%). Compared with single findings, the presence of multiple findings was associated with higher rates of surgical site infection (odds ratio, 1.40; 95% CI, 0.95-2.06; P = .09), higher revisit rates (odds ratio, 1.60; 95% CI, 1.15-2.21; P = .005), longer length of stay (rate ratio, 1.45; 95% CI, 1.36-1.55; P < .001), and higher hospital cost (rate ratio, 1.35; 95% CI, 1.19-1.53; P < .001). Significant differences were found among different combinations of intraoperative findings for all outcomes, including a 3.6-fold difference in rates of surgical site infection (range, 7.5% for fecalith alone to 27.2% for all 4 findings; P = .002), a 2.6-fold difference in revisit rates (range, 8.9% for exudate alone to 22.9% for all 4 findings; P = .001), a 2.2-fold difference in length of stay (range, 4.0 days for exudate alone to 8.9 days for all 4 findings; P < .001), and a 2.4-fold difference in mean cumulative cost (range, $13 296 for exudate alone to $32 282 for all 4 findings; P < .001).

Conclusions and Relevance

More severe presentations of complicated appendicitis are associated with worse outcomes and greater resource use. Severity adjustment may be needed to ensure fair reimbursement and comparative performance reporting, particularly at hospitals treating underserved populations where more severe presentations are common.

Patterns and Costs of 90-Day Readmission for Surgical and Medical Complications Following Total Hip and Knee Arthroplasty

BACKGROUND

Unplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications.

METHODS

We performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories.

RESULTS

Among THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all).

CONCLUSION

Readmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.

Self-Directed Home Exercises vs Outpatient Physical Therapy After Total Knee Arthroplasty: Value and Outcomes Following a Protocol Change

BACKGROUND

The need for outpatient physical therapy (OPPT) has been questioned following primary total knee arthroplasty (TKA). Recent studies have suggested that similar outcomes may be possible with self-directed home exercise programs (HEP) compared to OPPT, which can be costly to both the patient and healthcare system. The aim of the present study is to compare the safety, efficacy, and health economics of formal OPPT with self-directed home exercises after TKA following a protocol change.

METHODS

A single-surgeon, retrospective study of 520 consecutive patients undergoing primary unilateral TKA from 2016 to 2018 was performed. All 251 TKAs performed in 2016 were routinely prescribed OPPT, while all 269 TKAs in 2017 completed a self-directed HEP alone for 2 weeks. At their 2-week visit, OPPT was prescribed if patients had less than 90° range of motion or per patient request. Financial data of postdischarge costs were collected for all patients. Multivariate logistic regression evaluated for variables associated with failure of the HEP program.

RESULTS

Overall, 65.8% (177/269) of patients in the HEP group did not require OPPT. There was no significant difference in percentage of patients whose range of motion was less than 90° at 2-week follow-up between OPPT and HEP (14% vs 11.9%, P = .467). Between OPPT and HEP, there were no differences in manipulation under anesthesia (3.2% vs 3%, P = .883). On average, patients who received OPPT incurred an increase in average cost of $1340.87 and $1893.42 for Medicare and private insurer patients, respectively. We did not identify any significant risk factors for failing HEP.

CONCLUSION

Comparable outcomes were demonstrated between patients receiving HEP compared to OPPT with a substantial cost saving. While a portion of patients still require formal OPPT, the majority do not. Surgeons should consider an initial trial of HEP with close follow-up in order to limit unnecessary costs associated with OPPT.

Drivers of Variability in 90-Day Cost for Elective Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disease

BACKGROUND

Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period.

OBJECTIVE

To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease.

METHODS

Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost.

RESULTS

The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616.

CONCLUSION

There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons' and institution-specific differences.

Spinal Cord Stimulation vs Conventional Therapies for the Treatment of Chronic Low Back and Leg Pain: A Systematic Review of Health Care Resource Utilization and Outcomes in the Last Decade

Objective

The purpose of this review is to critically appraise the literature for evidence supporting the health care resource utilization and cost-effectiveness of spinal cord stimulation (SCS) compared with conventional therapies (CTs) for chronic low back and leg pain.

Methods

The PubMed, MEDLINE, Embase, CINAHL, and Rehabilitation & Sports Medicine databases were searched for studies published from January 2008 through October 2018, using the following MeSH terms: “spinal cord stimulation,” “chronic pain,” “back pain,” “patient readmission,” “economics,” and “costs and cost analysis.” Additional sources were added based on bibliographies and consultation with experts. The following data were extracted and analyzed: demographic information, study design, objectives, sample sizes, outcome measures, SCS indications, complications, costs, readmissions, and resource utilization data.

Results

Of 204 studies screened, 11 studies met inclusion criteria, representing 31,439 SCS patients and 299,182 CT patients. The mean age was 53.5 years for SCS and 55.6 years for CT. In eight of 11 studies, SCS was associated with favorable outcomes and found to be more cost-effective than CT for chronic low back pain. Compared with CT, SCS resulted in shorter hospital stays and lower complication rates and health care costs at 90 days. SCS was associated with significant improvement in health-related quality of life, health status, and quality-adjusted life-years.

Conclusions

For the treatment of chronic low back and leg pain, the majority of studies are of fair quality, with level 3 or 4 evidence in support of SCS as potentially more cost-effective than CT, with less resource expenditure but higher complication rates. SCS therapy may yet play a role in mitigating the financial burden associated with chronic low back and leg pain.

Are Patients Who Undergo THA for Infection at Higher Risk for 30-day Complications?

BACKGROUND

Value-based payment models, such as bundled payments, continue to become more widely adopted for total joint arthroplasty. However, concerns exist regarding the lack of risk adjustment in these payment and quality reporting models for THA. Providers who care for patients with more complicated problems may be financially incentivized to screen out such patients if reimbursement models fail to account for increased time and resources needed to care for these more complex patients.

QUESTIONS/PURPOSES

(1) Are patients who undergo revision THA for infectious causes at greater adjusted risk of 30-day short-term major complications, return to the operating room, readmission, and mortality compared with patients undergoing aseptic revision? (2) What are other independent factors associated with the risk of 30-day major complications, readmission, and mortality in this patient population?

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database for all patients undergoing revision THA from 2012 to 2015. The NSQIP database allows for the analysis of 30-day surgical outcomes, including postoperative complications, return to the operating room, readmission, and mortality of patients from approximately 400 participating institutions. The NSQIP was selected over other larger databases, such as the National Impatient Sample (NIS), because the NSQIP includes readmission data and 30-day complications rates that were relevant to our study. Patients undergoing aseptic revision THA and those undergoing revision THA with a diagnosis of periprosthetic joint infection were identified. We identified 8973 patients who underwent revision THA and excluded six patients due to a diagnosis of malignancy leaving 8967 patients; 726 (8%) of these were due to infection. Demographic variables, medical comorbidities, and 30-day major complications, hospital readmissions, reoperations, and mortality were compared among patients undergoing aseptic and infected revision THA. A major complication was defined as myocardial infarction, postoperative mortality, sepsis, septic shock, and stroke. A multivariate logistic regression analysis was then performed to identify factors independently associated with the primary outcome of 30-day hospital readmission, and secondary endpoints of 30-day major complications, return to operating room, and mortality.

RESULTS

Controlling for medical comorbidities and demographic factors, the patients who underwent THA for infection were more likely to experience a major complication (odds ratio [OR], 4.637; 95% confidence interval [CI], 2.850-7.544; p < 0.001) within 30 days of surgery and more likely to return to the operating room (OR = 1.548; 95% CI, 1.062-2.255; p = 0.023). However, there were no greater odds of 30-day readmission (OR, 1.354; 95% CI, 0.975-1.880; p = 0.070) or 30-day mortality (OR, 0.661; 95% CI, 0.218-2.003; p = 0.465). Preoperative malnutrition was associated with an increased risk of return to the operating room (OR, 1.561; 95% CI, 1.152-2.115; p = 0.004), 30-day readmission (OR, 1.695; 95% CI, 1.314-2.186; p < 0.001), and 30-day mortality (OR, 7.240; 95% CI, 2.936-17.851; p < 0.001).

CONCLUSIONS

Patients undergoing revision THA for infection undergo reoperation and experience major complications more frequently in a 30-day episode of care than patients undergoing aseptic revision THA. Without risk adjustment to existing alternative payment and quality reporting models, providers may experience a disincentive to care for patients with infected THAs, who may face difficulties with access to care.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Bundled Payments Are Effective in Reducing Costs Following Bilateral Total Joint Arthroplasty

BACKGROUND

Alternative payment models such the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative have been effective in reducing costs following unilateral total hip (THA) and knee arthroplasty (TKA), but few studies exist on bilateral arthroplasty. This study aimed to determine whether the BPCI program for bilateral THA and TKA reduced episode-of-care costs.

METHODS

We retrospectively reviewed a consecutive series of patients who underwent simultaneous bilateral primary THA and TKA between 2015 and 2016. We recorded demographic variables, comorbidities, readmissions, and calculated 90-day episode-of-care costs based on Centers for Medicare and Medicaid Services claims data. We compared data from patients before and after the start of our BPCI program, and performed a multivariate analysis to identify independent risk factors for increased costs.

RESULTS

Of 319 patients, 38 underwent bilateral THA (12%) while 287 underwent bilateral TKA (88%). There were 239 patients (74%) in the bundled payment group. Although there was no change in readmission rate (9% vs 8%), the post-BPCI group demonstrated reduced hospital costs ($21,251 vs $18,783), post-acute care costs ($15,488 vs $12,439), and overall 90-day episode-of-care costs ($39,733 vs $34,305). When controlling for demographics, procedure, and comorbidities, our BPCI model demonstrated a per-patient reduction of $5811 in overall claims costs. Additional risk factors for increased episode-of-care costs included age ($516/y increase) and cardiac disease ($5916).

CONCLUSION

Our bundled payment program for bilateral THA and TKA was successful with reduction in 90-day episode-of-care costs without placing the patient at higher risk of readmission. Older Medicare beneficiaries and those with cardiac disease should likely not undergo a simultaneous bilateral procedure due to concerns about increased costs.

Are Ceramic Bearings Becoming Cost-Effective for All Patients Within a 90-Day Bundled Payment Period?

BACKGROUND

We analyzed whether the total hospital cost in a 90-day bundled payment period for ceramic-on-polyethylene (C-PE) and ceramic-on-ceramic (COC) total hip arthroplasty (THA) bearings was changing over time, and whether the cost differential between ceramic bearings and metal-on-polyethylene (M-PE) bearings was approaching the previously published tipping point for cost-effectiveness of US$325.

METHODS

A total of 245,077 elderly Medicare patients (65+) who underwent primary THA between 2010 and 2015 were identified from the United States Medicare 100% national administrative hospital claims database. The total inpatient cost, calculated up to 90 days after index discharge, was computed using cost-to-charge ratios, and hospital payment was analyzed. The differential total inpatient cost of C-PE and COC bearings, compared to metal-on-polyethylene (M-PE), was evaluated using parametric and nonparametric models.

RESULTS

After adjustment for patient and clinical factors, and the year of surgery, the mean hospital cost up to 90 days for primary THA with C-PE or COC was within ±1% of the cost for primary THA with M-PE bearings (P < .001). From the nonparametric analysis, the median total hospital cost was US$296-US$353 more for C-PE and COC than M-PE. Cost differentials were found to decrease significantly over time (P < .001).

CONCLUSION

Patient and clinical factors had a far greater impact on the total cost of inpatient THA surgery than bearing selection, even when including readmission costs up to 90 days after discharge. Our findings indicate that the cost-effectiveness thresholds for ceramic bearings relative to M-PE are changing over time and increasingly achievable for the Medicare population.

Quality Measures in Foot and Ankle Care

BACKGROUND

Quality measures may be operationalized in payment models or quality reporting programs to assess foot and ankle surgeons, but if existing measures allow accurate representation of a foot and ankle surgeon's practice is unclear.

METHODS

National quality measures databases, clinical guidelines, and MEDLINE/PubMed were systematically reviewed for quality measures relevant to foot and ankle care. Measures meeting internal criteria were categorized by clinical diagnosis, National Quality Strategy priority, and Donabedian domain.

RESULTS

Of 12 quality measures and 16 candidate measures, National Quality Strategy priorities most commonly addressed "Effective Clinical Care" (n = 19) and "Communication and Coordination of Care" (n = 6). Donabedian classifications addressed were process (n = 25) and outcome (n = 3). Diabetic foot care was most commonly addressed (n = 18).

CONCLUSIONS

Available foot and ankle quality measures are limited in number and scope, which may hinder appropriate assessment of care, analysis of trends, and quality improvement. Additional measures are needed to support the transition to a value-based system.

LEVEL OF EVIDENCE

Level I.

Saving the split: the benefits of VATS thymectomy

Background

With the advent of minimally invasive techniques, the standard approaches to many surgeries have changed. We compared the financial costs and health care outcomes between standard thymectomy via sternotomy and video assisted thoracoscopic surgery (VATS).

Methods

A 3-year review [2010-2012] of the National Inpatient Sample (NIS) was performed. All patients undergoing thymectomy were included. Patients undergoing VATS thymectomy were identified. Outcomes measured were hospital length of stay (LOS), hospital charges, and mortality. Univariate and multivariate analyses were performed to control for demographics and comorbidities.

Results

The results of 2,065 patients who underwent thymectomy were analyzed, of which 373 (18.1%) had VATS thymectomy and 1,692 (81.9%) had standard thymectomy. Mean age was 52.8±16, 42.5% were male, and 65.5% were Caucasian. There was a significant interval increase in number of patients undergoing VATS thymectomy (10% in 2010 vs. 19.2% in 2012, P<0.001). Patients undergoing standard thymectomy had longer hospital LOS (6.8±6.6 vs. 3.3d±3.4 d, P<0.001), hospital charges $88,838±$120,892 vs. $57,251±$54,929) and hospital mortality (0.9% vs. 0%, P=0.01). In multivariate analysis, thymectomy via sternotomy was independently associated with increased hospital LOS B =1.6 d, P<0.001) and charges (B = $13,041, P=0.041).

Conclusions

Our study demonstrates decreased hospital length of stay and reduced hospital charges in patients undergoing VATS thymectomy compared to standard thymectomy. Our data demonstrates that the prevalence of VATS thymectomies is increasing, likely related to improved healthcare and financial outcomes.

Costs and complications of increased length of stay following adolescent idiopathic scoliosis surgery

Accelerated discharge protocols for scoliosis surgery have recently been described in the literature. There are limited data describing the association of length of stay (LOS) during the index admission with postoperative outcomes. We sought to define the economic and clinical implications of an additional 1 day in the hospital for scoliosis surgery. The Statewide Planning and Research Cooperative System database was used to identify patients with adolescent idiopathic scoliosis who underwent spinal fusion from 1 October 2007 to 30 September 2012 at high-volume institutions (>20 cases/year) in the state of New York. Regression models were adjusted for age, sex, race, insurance, comorbidity score, and perioperative complications during the index admission. Among the 1286 patients with AIS who underwent spinal fusion, the mean LOS was 4.90 days [95% confidence interval (CI)=4.84-4.97; SD=1.19]. In the perioperative period, 605 (47.05%) underwent transfusion and 202 (15.71%) had problems with pain control. An additional 1 day in the hospital was associated with $11 033 (95% CI=7162-14 904; P<0.001) in insurance charges, $5198 (95% CI=4144-6252; P<0.001) in hospital costs, 28% increased risk (odds ratio=1.28; 95% CI=1.01-1.63; P=0.041) of all-cause 90-day readmission, and a 57% increased risk (odds ratio=1.57; 95% CI=1.13-2.17; P=0.007) of returning to the operating room within 90 days. Increased LOS during the index admission scoliosis surgery is associated with higher costs and an increased risk of 90-day postoperative complications. Protocols to decrease LOS for this surgery have potential benefits to patients, hospitals, and insurers. Level of Evidence: Level III, retrospective comparative study.

Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature

BACKGROUND

Strategic purchasing of health care services has become a key policy measure on the path to achieving universal health coverage. National provider payment systems for health services are typically characterized by mixes of provider payment methods with each method associated with distinct incentives for provider behaviours. Reaching incentive alignment across methods is critical to enhancing the effectiveness of strategic purchasing.

METHODS

A structured literature review was conducted to synthesize the evidence on how purposively aligned mixed provider payment systems affect health expenditure growth management, efficiency, and equity in access to services with a particular focus on coordinated and/or integrated care management.

RESULTS

The majority of the 37 reviewed articles focused on high-income countries with 74% from the US. Four categories of payment mixes were examined in this review: blended payment, bundled payment, cost-containment reward models, and aligned cost sharing mechanisms. Blended payment models generally reported moderate to no substantive reductions in expenditure growth, but increases in health system efficiency. Bundled payment schemes consistently report increases in efficiency and corresponding cost savings. Cost-containment rewards generated cost savings that can contribute to effective management of health expenditure growth. Evidence on aligned cost-sharing is scarce.

CONCLUSION

There is lacking evidence on when and how mixed provider payment systems and cost sharing practices align towards achieving goals. A guiding framework for how to study and evaluate mixed provider payment systems across contexts is warranted. Future research should consider a conceptual framework explicitly acknowledging the complex nature of mixed provider payment systems.

Medicaid Payer Status Is Associated with Increased 90-Day Morbidity and Resource Utilization Following Primary Total Hip Arthroplasty: A Propensity-Score-Matched Analysis

BACKGROUND

Medicaid payer status has been shown to affect risk-adjusted outcomes and resource utilization across multiple medical specialties. The purpose of this study was to examine resource utilization via readmission rates, length of stay, and total cost specific to Medicaid payer status following primary total hip arthroplasty.

METHODS

The Nationwide Readmissions Database (NRD) was utilized to identify patients who underwent total hip arthroplasty in 2013 as well as corresponding "Medicaid" or "non-Medicaid" payer status. Demographic data, 14 individual comorbidities, readmission rates, length of stay, and direct cost were evaluated. A propensity-score-based matching model was utilized to control for baseline confounding variables between payer groups. Following propensity-score matching, the chi-square test was used to compare readmission rates between the 2 payer groups. The relative risk (RR) with 95% confidence interval (CI) was estimated to quantify readmission risk. Length of stay and total cost comparisons were evaluated using the Wilcoxon signed-rank test.

RESULTS

A total of 5,311 Medicaid and 144,814 non-Medicaid patients managed with total hip arthroplasty were identified from the 2013 NRD. A propensity score was estimated for each patient on the basis of the available baseline demographics, and 5,311 non-Medicaid patients were matched by propensity score to the 5,311 Medicaid patients. Medicaid versus non-Medicaid payer status yielded significant differences in overall readmission rates of 28.8% versus 21.0% (p < 0.001; RR = 1.37 [95% CI, 1.28 to 1.46]) and 90-day hip-specific readmission rates of 2.5% versus 1.8% (p = 0.01; RR = 1.38 [95% CI, 1.07 to 1.78]). Mean length of stay was greater in the Medicaid group than in the non-Medicaid group at 4.5 versus 3.3 days (p < 0.0001), as was the mean total cost at $71,110 versus $65,309 (p < 0.0001).

CONCLUSIONS

This study demonstrates that Medicaid payer status is independently associated with increased resource utilization, including readmission rates, length of stay, and total cost following primary total hip arthroplasty. Providers may have a disincentive to treat patient populations who require increased resource utilization following surgery. Risk adjustment models accounting for Medicaid payer status are necessary to avoid decreased access to care for this patient population and to avoid financial penalty for physicians and hospitals alike.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Academic Geriatric Orthopaedics: A New paradigm for Inpatient Care

Purpose of review

Healthcare systems are embarking on innovative, technologically savvy approaches to caring for our most rapidly growing population worldwide- the elderly. As healthcare systems respond, adapt and strategically plan for this rapidly growing population, it is paramount that we develop new paradigms of care for older patients. This review highlights some of the approaches academic medical centers are taking to improve the musculoskeletal and orthopaedic health of older adults.

Recent Findings

Academic health centers are posed to set and lead the standard of care for the next generation of orthopaedic care for older adults by leveraging innovative informatics platforms, quality improvement methodologies, game-changing research initiatives, education to the next generation of providers and helping change policies to help patients receive the best quality of life possible across the aging spectrum.

Summary

Academic geriatric orthopaedics can help society embrace a new paradigm in care for older adults by leveraging rapidly developing technologically and innovative approaches to care, advanced research, and education.

Risk Adjustment Is Necessary in Value-based Outcomes Models for Infected TKA

BACKGROUND

The Medicare Access and CHIP Reauthorization Act of 2015 provides the framework to link reimbursement for providers based on outcome metrics. Concerns exist that the lack of risk adjustment for patients undergoing revision TKA for an infection may cause problems with access to care.

QUESTIONS/PURPOSES

(1) After controlling for confounding variables, do patients undergoing revision TKA for infection have higher 30-day readmission, reoperation, and mortality rates than those undergoing revision TKA for aseptic causes? (2) Compared with patients undergoing revision TKA who are believed not to have infections, are patients undergoing revision for infected TKAs at increased risk for complications?

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients undergoing revision TKA from 2012 to 2015 identified by Current Procedural Terminology (CPT) codes 27486, 27487, and 27488. Of the 10,848 patients identified, four were excluded with a diagnosis of malignancy (International Classification of Diseases, 9th Revision code 170.7, 170.9, 171.8, or 198.5). This validated, national database records short-term outcome data for inpatient procedures and does not rely on administrative coding data. Demographic variables, comorbidities, and outcomes were compared between patients believed to have infected TKAs and those undergoing revision for aseptic causes. A multivariate logistic regression analysis was performed to identify independent factors associated with complications, readmissions, reoperations, and mortality.

RESULTS

After controlling for demographic factors and medical comorbidities, TKA revision for infection was independently associated with complications (odds ratio [OR], 3.736; 95% confidence interval [CI], 3.198-4.365; p < 0.001), 30-day readmission (OR, 1.455; 95% CI, 1.207-1.755; p < 0.001), 30-day reoperation (OR, 1.614; 95% CI, 1.278-2.037; p < 0.001), and 30-day mortality (OR, 3.337; 95% CI, 1.213-9.180; p = 0.020). Patients with infected TKA had higher rates of postoperative infection (OR, 3.818; 95% CI, 3.082-4.728; p < 0.001), renal failure (OR, 36.709; 95% CI, 8.255-163.231; p < 0.001), sepsis (OR, 7.582; 95% CI, 5.529-10.397; p < 0.001), and septic shock (OR, 3.031; 95% CI, 1.376-6.675; p = 0.006).

CONCLUSIONS

Policymakers should be aware of the higher rate of mortality, readmissions, reoperations, and complications in patients with infected TKA. Without appropriate risk adjustment or excluding these patients all together from alternative payment and quality reporting models, fewer providers will be incentivized to care for patients with infected TKA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Patient Perceptions of Home Health Care Services After Total Joint Replacement

Value-based payment programs have incentivized the reduction of many post-acute care services, including home health care. Patient perceptions of home health care services are currently unknown. The objectives of this study were to determine the value that patients place on home health care after joint replacement surgery and to assess their impression of Medicare reimbursement for these services. Patients with traditional Medicare insurance who underwent primary total hip or knee arthroplasty between January 2016 and July 2017 were given a questionnaire in which they were asked to quantify their satisfaction with home health care, estimate Medicare reimbursement for these services, and give their impression of actual reimbursement. One hundred sixtythree patients completed the questionnaire. Patients were generally satisfied with the services received, giving an overall mean ranking of 9.3 (range, 1-10). Respondent estimates of the cost of home health care services ranged from $0 to $300,000 (average, $8067). Ninety-three percent of patients would choose home health care again if they were to undergo another joint replacement. Patients in this study placed significant value on home health care services after total hip and knee replacement surgery. Further consideration of patient satisfaction may be warranted prior to eliminating home health care services following total joint arthroplasty. [Orthopedics. 2018; 41(5):e713-e717.].

Risk Adjustment Is Necessary in Medicare Bundled Payment Models for Total Hip and Knee Arthroplasty

BACKGROUND

Concerns exist that high-risk patients in alternative payment models may face difficulties with access to care without proper risk adjustment. The purpose of this study is to identify the effect of medical and orthopedic specific risk factors on the cost of a 90-day episode of care following total hip (THA) and knee arthroplasty (TKA).

METHODS

We queried the Medicare 5% Limited Data Set for all patients undergoing primary THA and TKA from 2010 to 2014. To evaluate the cost of an episode of care, we calculated all claims for 90 days following surgery. Multivariate analysis was performed to quantify the added episode-of-care costs for demographic variables, geography, medical comorbidities, and orthopedic specific risk factors.

RESULTS

Of the 58,809 TKA patients, the median 90-day Medicare costs was $23,800 (interquartile range, $18,900-$32,300), while the median of the 27,293 THA patients was $24,000 (interquartile range, $18,500-$33,900). Independent risk factors (all P < .05) resulting in at least a 10% increase in episode-of-care costs following TKA included malnutrition, age over 85, male gender, pulmonary disorder, failed internal fixation, Northeast region, lower socioeconomic status, neurologic disorder, and rheumatoid arthritis. Independent risk factors (all P < .05) resulting in at least a 10% increase in episode-of-care costs following THA included malnutrition, male gender, age over 85, failed internal fixation, hip dysplasia, Northeast region, neurologic disorder, lower socioeconomic status, conversion THA, avascular necrosis, and depression.

CONCLUSION

Certain comorbidities and orthopedic risk factors increase 90-day episode-of-care costs in the Medicare population. The current lack of proper risk stratification could be a powerful driver of decreased access to care for our most medically challenged members of society.

Cost of Surgical Treatment for Distal Radius Fractures and the Implications of Episode-Based Bundled Payments

PURPOSE

To examine the cost of care of surgical treatment for a distal radius fracture (DRF) and develop episodes that may be used to develop future bundled payment programs.

METHODS

Using 2009 to 2015 claims data from the Truven MarketScan Databases, we examined the cost of care for surgical treatment of DRFs among adult patients in the United States. We excluded patients with concurrent fractures, patients who required complex care, and patients in assisted living facilities. We extracted data on cost and type of services provided to eligible patients, tracking patients from 3 days prior to operation to 90 days after operation. From these data, we developed 4 episode-of-care scenarios to develop an estimated bundled payment. We computed the variation in cost between surgery types, time periods, and type of service provided.

RESULTS

Our final sample included 23,453 DRF operations, of which 15% were performed on patients 65 years of age or older. The majority (88%) underwent open fixation, the option associated with the highest cost. The average cost of care for a DRF patient ranged from $6,577 to $8,181 depending on the definition of an episode-of-care. Regardless of definition, the variation in cost was high. The cost of surgery itself composed 61% to 91% of the total cost of an episode. Of claims not directly related to the surgery, anesthesia and drugs, imaging, and therapy costs composed the next greatest proportions of the total cost of care.

CONCLUSIONS

Many DRF surgical episodes incur substantially higher costs than the average. To maximize cost reduction, bundled payments for DRFs are best designed with a clinically narrow definition that is limited to services related to the fracture and long enough to capture relevant postoperative therapy and imaging costs.

CLINICAL RELEVANCE

This study provides insight on spending to lay the foundation for shifting reimbursement strategies.

Bundled Payments for Care Improvement in the Private Sector: A Win for Everyone

BACKGROUND

To help slow the rising costs associated with total joint arthroplasty (TJA), the Centers for Medicare and Medicaid Services introduced the Bundled Payments for Care Improvement (BPCI) initiative. The purpose of this study is to report our 1-year experience with BPCI in our 2 arthroplasty surgeon private practice.

METHODS

In this series, a historical baseline group is compared with our first year under BPCI. We reviewed the cohorts with respect to hospital length of stay (LOS), readmission rates, discharge disposition, postacute care LOS, and overall savings on a per episode basis.

RESULTS

The baseline group included 582 episodes from July 2009 to June 2012. The BPCI study group included 332 episodes from July 2015 to September 2016. We witnessed a substantial learning curve over the course of our involvement in the initiative. The total reduction in cost per episode for TJA was 20.0% (P = .10). Hospital LOS decreased from 4.9 to 3.5 days (P = .02). All-cause 90-day readmission rates decreased from 14.5% to 8.2% (P = .0078). Overall, discharges to home increased from 11.6% to 49.8% (P = .005).

CONCLUSION

Our small, private, 2 arthroplasty surgeon orthopedic practice has shown improvement in postoperative management for TJA patients in 1 year under the BPCI initiative, with increased discharges to home, decreased skilled nursing admissions, days in skilled nursing, and overall readmissions. Because BPCI includes fracture care arthroplasty, the model could be made more equitable if these patients were reimbursed a rate commensurate with their increased costs and risks.

Alternative payment models: can (should) trauma care be bundled?

Background

Recent legislation repealing the Sustainable Growth Rate mandates gradual replacement of fee for service with alternative payment models (APMs), which will include service bundling. We analyzed the 2 years’ experience at our state-designated level I trauma center to determine the feasibility of such an approach for trauma care.

Methods

De-identified data from all injured patients treated by the trauma service during 2014 and 2015 were reviewed to determine individual patient injury profiles. Using these injury profiles we created the ‘trauma bundle’ by concatenating the highest Abbreviated Injury Scale score for each of the six body regions to produce a single ‘signature’ of injury by region for every patient. These trauma bundles were analyzed by frequency over 2 years and by each year. The impacts of physiology and resource consumption were evaluated by determination of the correlation of the mean and SD of calculated survival probability (Ps) and intensive care unit length of stay (ICU LOS) for each profile group occurring more than 12 times in 2 years.

Results

The 5813 patients treated over 2 years produced 858 distinct injury profiles, only 8% (71) of which occurred more than 12 times in 2 years. Comparison of 2014 and 2015 profiles demonstrated high frequency variation among profiles between the 2 years. Analysis of injury patterns occurring >12 times in 2 years demonstrated an inverse correlation between the mean and SD for Ps (R²=0.68) and a direct correlation for ICU LOS (R²=0.84).

Discussion

These data indicate that the disease of injury is too inconsistent a mix of injury pattern and physiologic response to be predictably bundled for an APM. The inverse correlation of increasing SD with increasing ICU LOS and decreasing Ps suggests an opportunity for measurable process improvement.

Level of evidence

Economic and value-based evaluations, level IV.

Study type

Economic/decision.

Medicaid is associated with increased readmission and resource utilization after primary total knee arthroplasty: a propensity score-matched analysis

Background

Medicaid payer status has been shown to affect resource utilization across multiple medical specialties. There is no large database assessment of Medicaid and resource utilization in primary total knee arthroplasty (TKA), which this study sets out to achieve.

Methods

The Nationwide Readmissions Database was used to identify patients who underwent TKA in 2013 and corresponding “Medicaid” or “non-Medicaid” payer statuses. Demographics, 15 individual comorbidities, readmission rates, length of stay, and direct cost were evaluated. A propensity score–based matching model was then used to control for baseline confounding variables between payer groups. A chi-square test for paired proportions was used to compare readmission rates between the 2 groups. Length of stay and direct cost comparisons were evaluated using the Wilcoxon signed-rank test.

Results

A total of 8372 Medicaid and 268,261 non-Medicaid TKA patients were identified from the 2013 Nationwide Readmissions Database. A propensity score was estimated for each patient based on the baseline demographics, and 8372 non-Medicaid patients were propensity score matched to the 8372 Medicaid patients. Medicaid payer status yielded a statistically significant increase in overall readmission rates of 18.4% vs 14.0% (P < .0001, relative risk = 1.31, 95% confidence interval [1.23-1.41]) with non-Medicaid status and 90-day readmission rates of 10.0% vs 7.4%, respectively (P < .001, relative risk = 1.35, 95% confidence interval [1.22-1.48]). The mean length of stay was longer in the Medicaid group compared with the non-Medicaid group at 4.0 days vs 3.3 days (P < .0001) as well as the mean total cost of $64,487 vs $61,021 (P < .0001).

Conclusions

This study demonstrates that Medicaid payer status is independently associated with increased resource utilization, including readmission rates, length of stay, and total cost after TKA.

Can Total Knee Arthroplasty Be Performed Safely as an Outpatient in the Medicare Population?

BACKGROUND

The Centers for Medicare and Medicaid Services has solicited public comments for the 2017 Proposed Rule to consider removing total knee arthroplasty (TKA) from the Inpatient Only List. The purpose of this study is to compare the complication rates between outpatient (same-day discharge), short-stay (discharge within 1 day), and inpatient TKA and to identify the ideal candidates for a short-stay or outpatient procedure.

METHODS

We queried the American College of Surgeons-National Surgical Quality Improvement Program database for patients over age 65 years who underwent TKA from 2014 to 2015. Demographics, comorbidities, 30-day complications, and readmission rates were compared between patients after outpatient, short-stay, and inpatient procedures. A multivariate regression analysis was then performed to identify at-risk patients who should not be candidates for outpatient or short-stay TKA.

RESULTS

Of the 49,136 Medicare-aged TKA patients, 365 (0.7%) were outpatient, 3033 (6%) were short-stay and 45,738 (93%) were inpatient. Short-stay patients had a lower complication rate than both the outpatient and inpatient groups (2% vs. 8% vs. 8%, P < .001). Independent risk factors (all P < .05) for experiencing a complication or requiring an inpatient stay include female gender (odds ratio [OR] 1.655), general anesthesia (OR 1.282), diabetes mellitus (OR 1.171), chronic obstructive pulmonary disease (OR 1.579, P < .001), hypertension (OR 1.144), kidney disease (OR 1.425), American Society of Anesthesiologists Score 4 (OR 1.748), body mass index >35 kg/m² (OR 1.265), and age >75 years (OR 1.429).

CONCLUSION

TKA can be performed safely as an outpatient in a subset of healthy Medicare patients with a complication rate similar to an inpatient stay. A 23-hour stay, however, may be the "sweet spot" that minimizes complications in this population.

Should Medicare Remove Total Knee Arthroplasty From Its Inpatient Only List? A Total Knee Arthroplasty Is Not a Partial Knee Arthroplasty

BACKGROUND

The Centers for Medicare and Medicaid Services have solicited comments to consider removing total knee arthroplasty (TKA) from the Inpatient Only list, as it has done for unicompartmental knee arthroplasty (UKA). The purpose of this study is to determine whether Medicare-aged patients undergoing TKA had comparable outcomes to those undergoing UKA.

METHODS

We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients aged 65 years or older who underwent elective TKA or UKA from 2014 and 2015. Demographic variables, comorbidities, length of stay (LOS), 30-day complication, and readmission rates were compared between UKA and TKA patients. A multivariate regression analysis was then performed to identify independent risk factors for complications and hospital LOS greater than 1 day.

RESULTS

Of the 50,487 patients in the study, there were 49,136 (97%) TKA patients and 1351 UKA patients (3%). Medicare-aged TKA patients had a longer mean LOS (2.97 vs 1.57 days, P < .001), had a higher complication rate (9% vs 3%, P < .001), and were more likely to be discharged to a rehabilitation facility (31% vs 9%, P < .001) than Medicare-aged UKA patients. When controlling for other variables, TKA patients were more likely to experience a complication (odds ratio, 2.562; P < .001) and require LOS >1 day (odds ratio, 14.679; P < .001) than UKA patients.

CONCLUSION

TKA procedure in the Medicare population is an independent risk factor for increased complications and LOS compared to UKA. Policymakers should use caution extrapolating UKA data to TKA patients and recognize the inherent disparities between the 2 procedures.

Payor Reform Opportunities for Spine Surgery: Part II: The Potential Emergence of Population Health

The pressures on spine surgery to adopt value-based reimbursement models are being seen in the increased implementation of bundled payment strategies. Given that bundled payment models typically link payments to the initiation of the surgical episode in question, despite their potential cost-saving attributes, financial incentives remain tied to the volume of services being provided. As payors and policy makers look to find savings by focusing on waste and variation of care, more comprehensive models such population health strategies are now being develop and deployed. The clinical delivery and cost variation currently seen in spine health management make spine surgery an acute target of such population health strategies. Spine surgeons should understand the forces driving such changes and the opportunities to optimize performance within them.

Adding Value to Total Joint Arthroplasty Care in an Academic Environment: The Utah Experience

BACKGROUND

Adding value in a university-based academic health care system provides unique challenges when compared to other health care delivery models. Herein, we describe our experience in adding value to joint arthroplasty care at the University of Utah, where the concept of value-based health care reform has become an embraced and driving force.

METHODS

To improve the value, new resources were needed for care redesign, physician leadership, and engagement in alternative payment models. The changes that occurred at our institution are described.

RESULTS

Real-time data and knowledgeable personnel working behind the scenes, while physicians provide clinical care, help move clinical pathway redesigns. Engaged physicians are essential to the successful implementation of value creation and care pathway redesign that can lead to improvements in value. An investment of money and resources toward added infrastructure and personnel is often needed to realize large-scale improvements. Alignment of providers, payers, and hospital administration, including by means of gainsharing programs, can lead to improvements.

CONCLUSION

Although significant care pathway redesign efforts may realize substantial initial cost savings, savings may be asymptotic in nature, which calls into question the likely sustainability of programs that incentivize or penalize payments based on historical targets.

Early Effects of Medicare's Bundled Payment for Care Improvement Program for Lumbar Fusion

STUDY DESIGN

Retrospective analysis of Medicare claims linked to hospital participation in the Center for Medicare and Medicaid Innovation's episode-based Bundled Payment for Care Improvement (BPCI) program for lumbar fusion.

OBJECTIVE

To describe the early effects of BPCI participation for lumbar fusion on 90-day reimbursement, procedure volume, reoperation, and readmission.

SUMMARY OF BACKGROUND DATA

Initiated on January 1, 2013, BPCI's voluntary bundle payment program provides a predetermined payment for services related to a Diagnosis-Related Group-defined "triggering event" over a defined time period. As an alternative to fee-for-service, these reforms shift the financial risk of care on to hospitals.

METHODS

We identified fee-for-service beneficiaries over age 65 undergoing a lumbar fusion in 2012 or 2013, corresponding to the years before and after BPCI initiation. Hospitals were grouped based on program participation status as nonparticipants, preparatory, or risk-bearing. Generalized estimating equation models adjusting for patient age, sex, race, comorbidity, and hospital size were used to compare changes in episode costs, procedure volume, and safety indicators based on hospital BPCI participation.

RESULTS

We included 89,605 beneficiaries undergoing lumbar fusion, including 36% seen by a preparatory hospital and 7% from a risk-bearing hospital. The mean age of the cohort was 73.4 years, with 59% women, 92% White, and 22% with a Charlson Comorbidity Index of 2 or more. Participant hospitals had greater procedure volume, bed size, and total discharges. Relative to nonparticipants, risk-bearing hospitals had a slightly increased fusion procedure volume from 2012 to 2013 (3.4% increase vs. 1.6% decrease, P = 0.119), did not reduce 90-day episode of care costs (0.4% decrease vs. 2.9% decrease, P = 0.044), increased 90-day readmission rate (+2.7% vs. -10.7%, P = 0.043), and increased repeat surgery rates (+30.6% vs. +7.1% points, P = 0.043).

CONCLUSION

These early, unintended trends suggest an imperative for continued monitoring of BPCI in lumbar fusion.

LEVEL OF EVIDENCE

3.