Impact of Definition and Timeframe on Capturing Surgery-Related Readmissions After Primary Joint Arthroplasty

The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multicenter Randomized Clinical Trial

BACKGROUND

A periacetabular osteotomy (PAO) is often sufficient to treat the symptoms and improve quality of life for symptomatic hip dysplasia. However, acetabular cartilage and labral pathologies are very commonly present, and there is a lack of evidence examining the benefits of adjunct arthroscopy to treat these. The goal of this study was to compare the clinical outcome of patients undergoing PAO with and without arthroscopy, with the primary end point being the International Hip Outcome Tool-33 at 1 year.

METHODS

In a multicenter study, 203 patients who had symptomatic hip dysplasia were randomized: 97 patients undergoing an isolated PAO (mean age 27 years [range, 16 to 44]; mean body mass index of 25.1 [range, 18.3 to 37.2]; 86% women) and 91 patients undergoing PAO who had an arthroscopy (mean age 27 years [range, 16 to 49]; mean body mass index of 25.1 [17.5 to 25.1]; 90% women).

RESULTS

At a mean follow-up of 2.3 years (range, 1 to 5), all patients exhibited improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months postsurgery on all scores: preoperative International Hip Outcome Tool-33 score of 31.2 (standard deviation [SD] 16.0) versus 36.4 (SD 15.9), and 12 months postoperative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6). The preoperative Hip disability and Osteoarthritis Outcome pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0) and 12 months postoperative 88.2 (SD 15.8) versus 88.4 (SD 18.3). The mean preoperative physical health Patient-Reported Outcomes Measurement Information System score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months postoperative 48.7 (SD 8.5) versus 52.0 (SD 10.6). There were 4 patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and 1 patient from the PAO plus arthroscopy group required an additional arthroscopy.

CONCLUSIONS

This randomized controlled trial has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at 1-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

Trends in Venous Thromboembolism and Chemoprophylaxis Utilization in Elective Total Knee Arthroplasty From 2011 to 2020

BACKGROUND

Venous thromboembolism (VTE) is a feared complication of joint arthroplasty, leading to recent clinical practice guidelines aimed at VTE prevention and prophylaxis. However, limited studies have examined national changes in practice regarding chemoprophylaxis and the resultant changes in VTE rates. The purpose of this study was to identify: (1) the temporal trends in thrombotic complications; and (2) changes in chemoprophylaxis utilization in patients undergoing elective total knee arthroplasty (TKA).

METHODS

A retrospective study was conducted using a large all-payer claims dataset. Patients who underwent osteoarthritis-indicated TKA between 2011 and 2020 were identified. Annual rates of VTE, including deep vein thrombosis and pulmonary embolism, within 90 days of TKA were determined. Utilization patterns for postoperative aspirin and anticoagulant medications were observed. Temporal trends were analyzed with linear regression and the calculation of the cumulative annual growth rate. Multivariable logistic regression was conducted to account for the effects of age and comorbidities.

RESULTS

A total of 1,263,351 TKA patients were identified between 2011 and 2020. There were significant reductions in VTE rates (2.9% in 2011 to 1.8% in 2020), deep vein thrombosis rates (2.0% in 2011 to 1.3% in 2020), and pulmonary embolism rates (1.1% in 2011 to 0.6% in 2020). Postoperative utilization of aspirin increased from 5.9% in 2011 to 53.2% in 2020, whereas utilization of anticoagulants decreased from 94.1% in 2011 to 46.8% in 2020. Among anticoagulants, direct factor Xa inhibitors had the greatest increase in utilization (4.6 to 69.7%). The average reimbursement associated with VTE after TKA decreased from $18,061 in 2011 to $7,835 in 2020.

CONCLUSIONS

The incidence rate and economic burden of VTE after TKA have significantly declined since 2011. There has been a trend toward increased aspirin and direct oral anticoagulant utilization for postoperative chemoprophylaxis.

LEVEL OF EVIDENCE

Level III.

Prevalence of anemia and association with outcome in joint arthroplasty - is there a difference between primary and revision cases?

PURPOSE

Anemia has been shown to be a modifiable pre-operative, patient factor associated with outcome following arthroplasty. The aims of this retrospective study were to (1) ascertain the prevalence of preoperative anemia in patients undergoing primary and revision hip and knee arthroplasty at a tertiary referral center and (2) to test the association with outcome and whether it differs between primary and revision cases.

METHODS

All hip and knee primary and revision arthroplasties performed at a Canadian academic, tertiary-care, arthroplasty center between 2012 and 2017 were included in this study. The study group consisted of 5944 patients, of which 5251 were primary Total Hip and Knee Arthroplasties or Hip Resurfacings and 693 were revision arthroplasties (65% hip revisions/35% knee revisions). Anemia was classified as per WHO definition (hemoglobin < 130 g/L for men and < 120 g/L for women). All anemic patients were grouped into mild, moderate or severe anemia. Length-of-stay, perioperative transfusion-rate, 90-day readmission, overall complication rate and reoperation rates were recorded. The effect of preoperative anemia and the effect of severity of the anemia was evaluated through multivariable regression analysis controlling for relevant covariates.

RESULTS

Preoperatively, 15% (786/5251) of the primary patients and 47% (322/693) of the revision arthroplasty patients were anemic preoperatively. Anemic revision patients were 3.1 times more likely (95% CI: 1.47-6.33) to obtain blood transfusions during the hospital stay, compared to a 4.9 times higher risk in primary patients. The odds ratio to sustain any postoperative complication if anemic was 1.5 times higher (95% CI: 0.73-3.16) in revision patients and 1.7 in primary cases. In addition, the 90-day readmission rate among both groups was 1.6 times higher in anemic patients. Furthermore, anemic revision patients had a 5.3 days longer length of stay (95% CI: 2.63-7.91), compared to only 1 additional day in anemic primary patients (95% CI: 0.69-1.34).

CONCLUSION

In this study cohort, the prevalence of anemia in patients awaiting revision arthroplasty was 3 times higher (46.6%) than in primary arthroplasty patients (18.7%). Preoperative anemia was associated with similarly, inferior outcomes in both groups. To reduce postoperative complications and the "burden" associated with anemia, these findings strongly recommend optimizing the preoperative hemoglobin in all arthroplasty patients. However, revision patients are affected more frequently, and particular attention must therefore be taken to this growing group in the future.

LEVEL OF EVIDENCE

Level III.

Do preoperative PROMIS scores independently predict 90-day readmission following primary total knee arthroplasty?

INTRODUCTION

The rising demand for total knee arthroplasty (TKA) is expected to increase the total number of TKA-related readmissions, presenting significant public health and economic burden. With the increasing use of Patient-Reported Outcomes Measurement Information System (PROMIS) scores to inform clinical decision-making, this study aimed to investigate whether preoperative PROMIS scores are predictive of 90-day readmissions following primary TKA.

MATERIALS AND METHODS

We retrospectively reviewed a consecutive series of 10,196 patients with preoperative PROMIS scores who underwent primary TKA. Two comparison groups, readmissions (n = 79; 3.6%) and non-readmissions (n = 2091; 96.4%) were established. Univariate and multivariate logistic regression analyses were then performed with readmission as the outcome variable to determine whether preoperative PROMIS scores could predict 90-day readmission.

RESULTS

The study cohort consisted of 2170 patients overall. Non-white patients (OR = 3.53, 95% CI [1.16, 10.71], p = 0.026) and patients with cardiovascular or cerebrovascular disease (CVD) (OR = 1.66, 95% CI [1.01, 2.71], p = 0.042) were found to have significantly higher odds of 90-day readmission after TKA. Preoperative PROMIS-PF10a (p = 0.25), PROMIS-GPH (p = 0.38), and PROMIS-GMH (p = 0.07) scores were not significantly associated with 90-day readmission.

CONCLUSION

This study demonstrates that preoperative PROMIS scores may not be used to predict 90-day readmission following primary TKA. Non-white patients and patients with CVD are 3.53 and 1.66 times more likely to be readmitted, highlighting existing racial disparities and medical comorbidities contributing to readmission in patients undergoing TKA.

Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints

INTRODUCTION

As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty.

METHODS

A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room (OR) to physiotherapy (PT) assessment, and from OR to discharge were recorded. These were referred to as ambulation time and discharge time respectively.

RESULTS

The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), 227 minutes (range, 77 to 387) respectively-p<0.0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), 371 minutes (range, 217 to 570) respectively-(p<0.0001). No cases of transient neurologic symptoms were reported.

CONCLUSIONS

Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is quick and efficacious.

In meeting the increasing demands for total knee arthroplasty, can we achieve high levels of quality care in a small community hospital? A mixed-methods study

Purpose

Small community hospitals (SCHs) help meet the demand for total knee arthroplasty (TKA). This mixed-methods study compares outcomes and analyses of environmental differences following TKA at a SCH and a tertiary care hospital (TCH).

Methods

Quantitative: A retrospective review of 352 propensity-matched primary TKA procedures at both a SCH and a TCH, based on age, body mass index, and American Society of Anesthesiologists class, was completed. Groups were compared by length of stay (LOS), 90-day emergency department visits, 90-day readmissions, reoperations, and mortality. Qualitative: Based on the Theoretical Domains Framework, seven prospective semistructured interviews were performed. Interview transcripts were coded and belief statements were generated and summarized by two reviewers. Discrepancies were resolved by a third reviewer.

Results

Quantitative: The average LOS for the SCH was significantly shorter than that for the TCH (2.0 ± 0.2 vs. 3.6 ± 2.7 days; p < 0.001), a difference that persisted following a subgroup analysis of ASA I/II patients (2.0 ± 0.2 vs. 3.2 ± 2.2; p < 0.001). There were no significant differences in other outcomes. Qualitative: The main themes that revolved around a higher case load for physiotherapy at the TCH resulted in patients waiting longer to be mobilized after surgery. Patient disposition also affected their discharge rates.

Conclusion

Given the increasing demand for TKA, the SCH represents a viable option to increase capacity, while reducing LOS. Future directions to reduce LOS include addressing social barriers to discharge and patient prioritization for assessment by allied health services. When TKA is performed by the same set of surgeons, the SCH provides quality care with a shorter LOS and comparable with urban hospitals, and this can be attributed to the differences in resource utilization in the two hospital settings.

Preoperative Anemia in Primary Arthroplasty Patients-Prevalence, Influence on Outcome, and the Effect of Treatment

BACKGROUND

This study aims to: 1) Determine the prevalence of preoperative anemia in arthroplasty; 2) Assess whether preoperative anemia is associated with inferior outcomes; and 3) Ascertain whether optimization in a dedicated blood management program (BMP) is associated with improved outcomes.

METHODS

All primary arthroplasties performed at an academic, tertiary-care, arthroplasty center between 2012 and 2017 were reviewed. Hemoglobin level obtained in the preoperative assessment clinic was recorded. Patients with anemia were then considered for further review in BMP. Outcomes included improvement in hemoglobin level post-BMP; length of stay; perioperative transfusion; 90-day readmission, complication, and reoperation rates. The effect of preoperative anemia and the effect of treatment at the BMP on outcomes were evaluated through multivariable regression analysis controlling for relevant covariates.

RESULTS

17% of patients (932/5384) were found to have anemia; 115/357 patients who attended the BMP were no longer anemic. Thus, at time of operation, 15% of patients (817/5384) had anemia. Anemic patients were 4.09 times more likely (95% CI: 2.64-6.35) to require a transfusion; 1.42 times more likely (95% CI: 0.99-2.03) to sustain complications and had 19% longer (95% CI: 13%-26%) length of stay. Those who attended the BMP were less likely to receive a transfusion (OR = 0.32, 95% CI: 0.16-0.66), suffer from postoperative complications (OR = 0.30, 95% CI: 0.14-0.63), or require readmission compared with anemic patients not seen in the BMP (OR = 0.25, 95% CI: 0.09-0.71).

CONCLUSIONS

The prevalence of anemia in this arthroplasty cohort was 15%. Preoperative, timely, optimization of anemia should be strongly considered as it is likely to reduce "anemia-associated burden" after arthroplasty.

Safety of Single-Stage Bilateral Versus Unilateral Anterior Total Hip Arthroplasty: A Propensity-Matched Cohort Study

BACKGROUND

Limited data exist on patient safety after single-stage bilateral and unilateral total hip arthroplasty (THA) through the anterior approach (AA). Therefore, the aim of this study was to compare length of stay (LOS), operative time, 90-day adverse events, 90-day readmission rate, and 1-year revision rate after single-stage bilateral and unilateral THA in matched patients.

METHODS

This was a retrospective matched cohort study of prospectively collected data from 2008 to 2018 of a single-surgeon practice. We used the built-in propensity score matching formula in SPSS software and matched bilateral and unilateral patient groups on the relevant covariates of age, sex, and body mass index. This resulted in 60 patients undergoing bilateral THA and 60 patients undergoing unilateral THA.

RESULTS

The average LOS was 4.7 days (interquartile range [IQR], 3 to 5 days; range, 2 to 21 days) after bilateral THA and 3.0 days (IQR, 2 to 4 days; range, 1 to 13 days) after unilateral THA (p < 0.001). The mean operative time was 140 minutes for bilateral THA and 69 minutes for unilateral THA (p < 0.001). The adverse event rate was 6.7% after bilateral THA and 5.0% after unilateral THA (p = 0.660). The 90-day readmission rate was 3.3% after bilateral THA and 5.0% after unilateral THA (p = 0.321), which also accounted for all of the revisions within the first year.

CONCLUSIONS

When considering single-stage versus staged bilateral AA total hip replacement, patients can expect the same clinical outcome. Because the operative time is longer with bilateral THA, the main advantages are that the patient avoids a second anesthesia session and has an overall shorter recovery time.

LEVEL OF EVIDENCE

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

Periacetabular osteotomy with or without arthroscopic management in patients with hip dysplasia: study protocol for a multicenter randomized controlled trial

Background

Hip dysplasia is one of the most common causes of hip arthritis. Its incidence is estimated to be between 3.6 and 12.8% (Canadian Institute for Health Information, Hip and knee replacements in Canada, 2017–2018: Canadian joint replacement registry annual report, 2019; Jacobsen and Sonne-Holm, Rheumatology 44:211–8, 2004). The Periacetabular Osteotomy (PAO) has been used successfully for over 30 years (Gosvig et al., J Bone Joint Surg Am 92:1162–9, 2010), but some patients continue to exhibit symptoms post-surgery (Wyles et al., Clin Orthop Relat Res 475:336–50, 2017). A hip arthroscopy, performed using a small camera, allows surgeons to address torn cartilage inside the hip joint. Although both procedures are considered standard of care treatment options, it is unknown whether the addition of hip arthroscopy improves patient outcomes compared to a PAO alone. To delay or prevent future joint replacement surgeries, joint preservation surgery is recommended for eligible patients. While previous studies found an added cost to perform hip arthroscopies, the cost-effectiveness to Canadian Health care system is not known.

Methods

Patients randomized to the experimental group will undergo central compartment hip arthroscopy prior to completion of the PAO. Patients randomized to the control group will undergo isolated PAO. Patient-reported quality of life will be the primary outcome used for comparison between the two treatment groups as measured by The International Hip Outcome Tool (iHOT-33) (Saberi Hosnijeh et al., Arthritis Rheum 69:86–93, 2017). Secondary outcomes will include the four-square step test and sit-to-stand (validated in patients with pre-arthritic hip pain) and hip-specific symptoms and impairment using the HOOS; global health assessment will be compared using the PROMIS Global 10 Score; health status will be assessed using the EQ-5D-5L and EQ VAS questionnaires (Ganz et al., Clin Orthop Relat Res 466:264–72, 2008) pre- and post-operatively. In addition, operative time, hospital length of stay, adverse events, and health services utilization will be collected. A sub-group of patients (26 in each group) will receive a T1rho MRI before and after surgery to study changes in cartilage quality over time. A cost-utility analysis will be performed to compare costs and quality-adjusted life years (QALYs) associated with the intervention.

Discussion

We hypothesize that (1) concomitant hip arthroscopy at the time of PAO to address central compartment pathology will result in clinically important improvements in patient-reported outcome measures (PROMs) versus PAO alone, that (2) additional costs associated with hip arthroscopy will be offset by greater clinical improvements in this group, and that (3) combined hip arthroscopy and PAO will prove to be a cost-effective procedure.

Trial registration

ClinicalTrials.gov NCT03481010. Registered on 6 March 2020. Protocol version: version 3.

Unplanned Readmissions after Spine Surgery: A Single-Center Prospective Analysis of a 90-Day Model in 2,860 Cases

Study design

Prospective study.

Purpose

During the last decades, an emergence of unplanned readmissions has been shown to be a useful tool to gage the healthcare quality and hospital performance. Previous studies were limited by their retrospective designs based on database information and short-term 30-day follow-up intervals. We analyzed the incidence and causes for unplanned readmissions following spine surgery at a 90-day interval and the difference at 30-, 31–60-, and 61–90-day intervals after discharge. Additionally, we assessed total bed-days lost and the economic impact of readmissions and probable risk factors.

Overview of Literature

Recent reports on readmission rates suggested the contribution of this parameter for the assessment of healthcare quality.

Methods

A prospective analysis of 2,860 admissions was performed over 1 year in a tertiary care orthopedic hospital. All unscheduled readmissions following spine surgery within 90 days of discharge were included, irrespective of type or location of surgery. Polytrauma, primary osseous infections, and planned readmissions were excluded.

Results

Our readmission rate was 3.32% (95/2,860). Leading readmission causes were surgical site infections (SSIs) accounting for 44.21% (n=42; superficial, 23; deep, 11; organ and space, 8), followed by aseptic pain 31.58% (n=30) and medical causes 13.68% (n=13). Though 86.95% of superficial SSIs occurred within 30 days, 21.1% of deep SSIs occurred beyond 30 days. During the 30–90-day interval, 33.68% of readmissions occurred. The financial burden amounted to 41,93,660 Indian Rupees, and the mean bed-days lost was 7.33 per readmission. Hospital stay ≥10 days, health insurance, and comorbid illnesses (diabetes, hypertension, and liver disease) were associated with readmissions (p <0.05).

Conclusions

Our study showed that SSIs and aseptic pain were the leading causes of readmissions at 90 days after spine surgery. Limiting the analysis to 30-day readmissions as in previous studies would lead to failure in the identification of more severe complications like deep SSIs. Continued vigilance, particularly for patients with predisposing factors, could help alleviate the financial burden.

Readmission Rates for One Versus Two-Midnight Length of Stay for Primary Total Knee Arthroplasty: Analysis of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Database

BACKGROUND

The length of stay (LOS) in the hospital for total knee arthroplasty (TKA) has been declining over recent decades. The purpose of this study was to determine if patients with an LOS for TKA that includes only 1 midnight have an increased odds of 90-day readmission compared with those with a 2-midnight LOS. We also sought to identify any predictors of 90-day hospital readmission among those readmitted during our period of analysis.

METHODS

A retrospective review of the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was performed to identify patients with a 1-midnight or 2-midnight LOS for TKA during a 5-year period. The primary end point of this study was inpatient readmission within the 90-day postoperative period. A multiple logistic regression model and propensity score matching were used to compare the odds of 90-day readmission between 1-midnight and 2-midnight LOS. The secondary end points of this study were 90-day complications.

RESULTS

There were 96,250 TKA procedures identified in the database, and 46,709 met our inclusion criteria for LOS. No difference in 90-day-readmission odds between patients with a 1-midnight LOS and those with a 2-midnight LOS for primary TKA was identified. Male sex, single marital status, age of ≥80 years, type-I diabetes, previous smoking, narcotic use prior to surgery, and a higher American Society of Anesthesiologists (ASA) scores increased the odds of 90-day readmission. Patients in the age group of ≥50 to <65 years, those with a higher preoperative hemoglobin level, and those with a positive social history of alcohol use were found to have decreased odds of readmission.

CONCLUSIONS

We found no association between the LOS for primary TKA (1 midnight compared with 2 midnights) and the 90-day readmission risk.

LEVEL OF EVIDENCE

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

A Novel Risk Calculator Predicts 90-Day Readmission Following Total Joint Arthroplasty

BACKGROUND

A reliable prediction tool for 90-day adverse events not only would provide patients with valuable estimates of their individual risk perioperatively, but would also give health-care systems a method to enable them to anticipate and potentially mitigate postoperative complications. Predictive accuracy, however, has been challenging to achieve. We hypothesized that a broad range of patient and procedure characteristics could adequately predict 90-day readmission after total joint arthroplasty (TJA).

METHODS

The electronic medical records on 10,155 primary unilateral total hip (4,585, 45%) and knee (5,570, 55%) arthroplasties performed at a single institution from June 2013 to January 2018 were retrospectively reviewed. In addition to 90-day readmission status, >50 candidate predictor variables were extracted from these records with use of structured query language (SQL). These variables included a wide variety of preoperative demographic/social factors, intraoperative metrics, postoperative laboratory results, and the 30 standardized Elixhauser comorbidity variables. The patient cohort was randomly divided into derivation (80%) and validation (20%) cohorts, and backward stepwise elimination identified important factors for subsequent inclusion in a multivariable logistic regression model.

RESULTS

Overall, subsequent 90-day readmission was recorded for 503 cases (5.0%), and parameter selection identified 17 variables for inclusion in a multivariable logistic regression model on the basis of their predictive ability. These included 5 preoperative parameters (American Society of Anesthesiologists [ASA] score, age, operatively treated joint, insurance type, and smoking status), duration of surgery, 2 postoperative laboratory results (hemoglobin and blood-urea-nitrogen [BUN] level), and 9 Elixhauser comorbidities. The regression model demonstrated adequate predictive discrimination for 90-day readmission after TJA (area under the curve [AUC]: 0.7047) and was incorporated into static and dynamic nomograms for interactive visualization of patient risk in a clinical or administrative setting.

CONCLUSIONS

A novel risk calculator incorporating a broad range of patient factors adequately predicts the likelihood of 90-day readmission following TJA. Identifying at-risk patients will allow providers to anticipate adverse outcomes and modulate postoperative care accordingly prior to discharge.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

2018 John Charnley Award: Analysis of US Hip Replacement Bundled Payments: Physician-initiated Episodes Outperform Hospital-initiated Episodes

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) initiative in 2013 to create incentives to improve outcomes and reduce costs in various clinical settings, including total hip arthroplasty (THA). This study seeks to quantify BPCI initiative outcomes for THA and to determine the optimal party (for example, hospital versus physician group practice [PGP]) to manage the program.

QUESTIONS/PURPOSES

(1) Is BPCI associated with lower 90-day payments, readmissions, or mortality for elective THA? (2) Is there a difference in 90-day payments, readmissions, or mortality between episodes initiated by PGPs and episodes initiated by hospitals for elective THA? (3) Is BPCI associated with reduced total Elixhauser comorbidity index or age for elective THA?

METHODS

We performed a retrospective analysis on the CMS Limited Data Set on all Medicare primary elective THAs without a major comorbidity performed in the United States (except Maryland) between January 2013 and March 2016, totaling more than USD 7.1 billion in expenditures. Episodes were grouped into hospital-run BPCI (n = 42,922), PGP-run BPCI (n = 44,662), and THA performed outside of BPCI (n = 284,002). All Medicare Part A payments were calculated over a 90-day period after surgery and adjusted for inflation and regional variation. For each episode, age, sex, race, geographic location, background trend, and Elixhauser comorbidities were determined to control for major confounding variables. Total payments, readmissions, and mortality were compared among the groups with logistic regression.

RESULTS

When controlling for demographics, background trend, geographic variation, and total Elixhauser comorbidities in elective Diagnosis-Related Group 470 THA episodes, BPCI was associated with a 4.44% (95% confidence interval [CI], -4.58% to -4.30%; p < 0.001) payment decrease for all participants (USD 1244 decrease from a baseline of USD 18,802); additionally, odds ratios (ORs) for 90-day mortality and readmissions were unchanged. PGP groups showed a 4.81% decrease in payments (95% CI, -5.01% to -4.61%; p < 0.001) after enrolling in BPCI (USD 1335 decrease from a baseline of USD 17,841). Hospital groups showed a 4.04% decrease in payments (95% CI, -4.24% to 3.84%; p < 0.01) after enrolling in BPCI (USD 1138 decrease from a baseline of USD 19,799). The decrease in payments of PGP-run episodes was greater compared with hospital-run episodes. ORs for 90-day mortality and readmission remained unchanged after BPCI for PGP- and hospital-run BPCI programs. Patient age and mean Elixhauser comorbidity index did not change after BPCI for PGP-run, hospital-run, or overall BPCI episodes.

CONCLUSIONS

Even when controlling for decreasing costs in traditional fee-for-service care, BPCI is associated with payment reduction with no change in adverse events, and this is not because of the selection of younger patients or those with fewer comorbidities. Furthermore, physician group practices were associated with greater payment reduction than hospital programs with no difference in readmission or mortality from baseline for either. Physicians may be a more logical group than hospitals to manage payment reduction in future healthcare reform.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

An Evaluation of the Safety and Effectiveness of Total Hip Arthroplasty as an Outpatient Procedure: A Matched-Cohort Analysis

BACKGROUND

Outpatient hip arthroplasty is being performed more routinely; however, safety remains a concern. The purpose of this study was to compare the rate of adverse events of outpatient total hip arthroplasty (THA) and assess barriers to discharge.

METHODS

We examined 136 patients who underwent unilateral THA by one surgeon and were discharged on the same day of surgery. Using propensity matching, 136 inpatients who received the same procedure, and were discharged on postoperative day one or later, were identified. For each cohort, 90-day occurrence of adverse events, readmissions, and emergency visits were recorded and compared. Adverse events were graded using the OrthoSAVES tool. A secondary objective was to assess potential barriers to same-day discharge.

RESULTS

Within 90 days postoperatively, 12 outpatients (8.82%) and 14 inpatients (10.29%) developed an adverse event. There were no significant differences between the rate or severity of adverse events between the 2 groups and no serious adverse events in either group. In the outpatient group, there was a correlation between the dosage of spinal anesthetic (bupivacaine) given and time required to stay in postanesthetic care unit postoperatively.

CONCLUSION

When comparing the 2 groups, there were no differences in adverse events at 90 days. At our center, in the appropriate patient population, outpatient THA is a safe and cost-effective option. A potential barrier to mobility postoperatively and successful same-day discharge is the time required to stay in postanesthetic care unit postoperatively, which was significantly correlated with an increased dose of spinal anesthetic given in our outpatient cohort.

Characterization of Re-admission and Emergency Department Visits Within 90 Days Following Lower-Extremity Arthroplasty

BACKGROUND

Acute care events including emergency department (ED) visits and unscheduled inpatient re-admissions following lower-extremity arthroplasty are not fully understood.

QUESTION/PURPOSES

The purpose of this study was to characterize acute care events occurring after discharge in patients who received a lower-extremity arthroplasty: the incidence, timing, and risk factors of inpatient admission and ED visits within 90 days of discharge.

METHODS

The New York State Inpatient and Emergency Department Databases were used to identify patients who underwent elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) from 2009 to 2013 (124,234 and 76,411 patients, respectively). Multivariate logistic regression analysis was used to determine the predictors of and the most frequent reasons for unscheduled acute care within 90 days of discharge.

RESULTS

Unscheduled acute care was needed in 13.79% of patients (8.81% of inpatient re-admissions and 4.98% of ED visits), most often in the first week after discharge (61.05% of all inpatient re-admissions and 20.46% of all ED visits). Most of these visits were for musculoskeletal pain, peri-prosthetic joint or wound infection, cardiac complications, blood transfusion, psychiatric events, mechanical complications, and deep vein thrombosis. Predictors for the need for acute care after TKA included African American and Hispanic race or ethnicity, Medicaid coverage, and neuraxial anesthesia. Predictors for the need for acute care after THA included older age (over 85 years), African American race, and Medicaid coverage.

CONCLUSION

We identified demographic and procedure-related variables associated with an increased risk of ED visits and inpatient re-admissions after TKA or THA. Understanding these variables will contribute to improved care quality.