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Connolly P, Thomas J, Bieganowski T, Schwarzkopf R, Lajam CM, Davidovitch RI, Rozell JC. Outpatient vs. inpatient designation in total hip arthroplasty: can we predict who will require hospitalization? Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05502-3. [PMID: 39172260 DOI: 10.1007/s00402-024-05502-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/14/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Following removal of total hip arthroplasty (THA) from the inpatient only (IPO) list by the Center for Medicare Services (CMS), arthroplasty surgeons face increased pressure to perform procedures on an outpatient (OP) basis. The purposes of the present study were to compare patients booked for THA as OP who required conversion to IP status postoperatively, to patients who were booked as, and remained OP, and to identify factors predictive of conversion from OP to IP status. METHODS We retrospectively reviewed all patients who underwent a primary THA at our institution between January 1, 2020 and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions were used to determine factors predictive of status conversion. RESULTS Of 1,937 patients, 372 (19.2%) designated as OP preoperatively required conversion to IP status postoperatively. These patients had significantly higher facility discharge rates (P < 0.001) and 90-day readmission rates (P = 0.024). Patients aged 65 and older (P < 0.001), females (P < 0.001), patients with Black/African American race (P = 0.027), with a recovery room arrival time after 12 pm (P < 0.001), with a BMI > 30 kg/m2 (P = 0.001), and with a Charlson Comorbidity Index (CCI) ≥ 4 (P = 0.013) were Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation more likely to require conversion to IP designation. Marital status and time of procedure were also significant factors, as patients who were married (P < 0.001) and who were the first case of the day (P < 0.001) were less likely to be converted to IP. CONCLUSION Several factors were identified which could help determine appropriate hospital designation status at the time of surgical booking to ultimately avoid insurance claim denials. These included BMI, certain demographic factors, CCI ≥ 4, and patients 65 or older. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Patrick Connolly
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Jeremiah Thomas
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Thomas Bieganowski
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Claudette M Lajam
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Roy I Davidovitch
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, 301 East 17th Street, New York, NY, 10003, USA.
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Acuña AJ, Forlenza EM, Serino JM, Lavu MS, Della Valle CJ. Is Hospital-Based Outpatient Revision Total Knee Arthroplasty Safe? An Analysis of 2,171 Outpatient Aseptic Revision Procedures. J Arthroplasty 2024:S0883-5403(24)00619-3. [PMID: 38897263 DOI: 10.1016/j.arth.2024.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Outpatient primary total knee arthroplasty (TKA) has been well-established as a safe and effective procedure; however, the safety of outpatient revision TKA remains unclear. Therefore, this study utilized a large database to compare outcomes between outpatient and inpatient revision TKA. METHODS An all-payor database was queried to identify patients undergoing revision TKA from 2010 to 2022. Patients who had diagnosis codes related to periprosthetic joint infection (PJI) were excluded. Outpatient surgery was defined as a length of stay < 24 hours. Cohorts were matched by age, sex, Elixhauser Comorbidity Index, comorbidities (diabetes, obesity, tobacco use), components revised (1-versus 2-component), and revision etiology. Medical complications at 90 days and surgical complications at 1 and 2 years postoperatively were evaluated through multivariate logistic regression. A total of 4,342 aseptic revision TKAs were included. RESULTS No differences in patient characteristics, procedure type, or revision etiologies were seen between groups. The outpatient cohort had a lower risk of PJI (odds ratio (OR): 0.547, 95% confidence interval (CI): 0.337 to 0.869; P = .012), wound dehiscence (OR: 0.393, 95% CI: 0.225 to 0.658; P < .001), transfusion (OR: 0.241, 95% CI: 0.055 to 0.750; P = .027), reoperation (OR: 0.508, 95% CI: 0.305 to 0.822; P = .007), and any complication (OR: 0.696, 95% CI: 0.584 to 0.829; P < .001) at 90 days postoperatively. At 1 year and 2 years postoperatively, outpatient revision TKA patients had a lower incidence of revision for PJI (OR: 0.332, 95% CI: 0.131 to 0.743; P = .011 and OR: 0.446, 95% CI; 0.217 to 0.859; P = .020, respectively) and all-cause revision (OR: 0.518, 95% CI: 0.377 to 0.706; P < .001 and OR: 0.548, 95% CI: 0.422 to 0.712; P < .001, respectively). CONCLUSIONS Our findings suggest that revision TKA can be safely performed on an outpatient basis in appropriately selected patients who do not have an increased risk of adverse events relative to inpatient revision TKA. However, we could not ascertain case complexity in either cohort, and despite controlling for several potential confounders, other less tangible differences could exist between groups.
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Affiliation(s)
- Alexander J Acuña
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois
| | - Enrico M Forlenza
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois
| | - Joseph M Serino
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois
| | - Monish S Lavu
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Craig J Della Valle
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois
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Dove JH, Laperche JM, Kutschke MJ, Painter DF, Antoci V, Cohen EM. The Effect of Surgical Approach on the Outcomes of Same-Day Discharge Outpatient Total Hip Arthroplasty at a Single Ambulatory Surgery Center. J Arthroplasty 2024; 39:398-401. [PMID: 37595765 DOI: 10.1016/j.arth.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Primary total hip arthroplasty (THA) is increasingly being performed in the outpatient setting. However, there is little known regarding the differences in same-day discharge (SDD) rates and complications of operative approach in same-day total hip arthroplasty in the ambulatory surgery center (ASC) setting. METHODS A retrospective chart review was performed between July 2019 and October 2021 for all patients who underwent primary THA in a single freestanding ASC. Successful SDDs, surgical approaches, lengths of surgery, estimated blood losses (EBL), complications, and readmission events were recorded for each patient. Complications were compared using Pearson Chi-Squares, while EBL and surgery lengths were compared with 1-way analysis of variances (ANOVA) (alpha = 0.5). There were 17 total complications in 326 total hip arthroplasties (5.2%), including direct admissions to the emergency department, 30-day and 90-day readmissions, wound complications, instability, infection, and revision surgery. Among all complications, there were 5 direct admissions, making the successful SDD rate 98.5%. RESULTS Complications and direct admissions were not associated with approach. The 30-day readmission rates were associated with approach, with no readmissions in the direct anterior approach (DAA) or the antero-lateral approach (AL) cohorts and 3 (4.3%) in the posterior approach (PA) cohort. CONCLUSIONS In the ASC setting, patients undergoing THA regardless of approach showed no difference in successful SDDs or complications aside from 30-day readmissions. Same-day THA can be safely performed in the DAA, AL, and PA to the hip.
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Affiliation(s)
- James H Dove
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jacob M Laperche
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut; University Orthopedics Inc, East Providence, Rhode Island
| | - Michael J Kutschke
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David F Painter
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Valentin Antoci
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island; University Orthopedics Inc, East Providence, Rhode Island; Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Eric M Cohen
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island; University Orthopedics Inc, East Providence, Rhode Island; Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Mosher ZA, Calkins TE, Cope SR, Pharr ZK, Ford MC. Safety of Outpatient Total Hip Arthroplasty Performed in Patients 65 Years of Age and Older in an Ambulatory Surgery Center. Orthop Clin North Am 2024; 55:1-7. [PMID: 37980094 DOI: 10.1016/j.ocl.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Studies regarding the safety of same day discharge (SDD) in patients ≥65 years of age undergoing total hip arthroplasty (THA) are lacking. A retrospective review of 69 patients undergoing SDD following primary THA in 2 free-standing ambulatory surgical centers (ASCs) was performed to evaluate for safety and complications. Sixty-six patients met SDD goals, while 1 patient required transport to a hospital for transfusion, and 2 patients underwent overnight observation in the ASC. This study reveals that with appropriate preoperative evaluation, patient selection, and education, THA in a free-standing ASC can be safely performed in patients ≥65 years of age.
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Affiliation(s)
- Zachary A Mosher
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA; Department of Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA
| | - Tyler E Calkins
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA; Department of Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA
| | - Seth R Cope
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA; Department of Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA
| | - Zachary K Pharr
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA; Department of Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA
| | - Marcus C Ford
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA; Department of Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38014, USA.
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McCoy M, Touchet N, Chapple AG, Cohen-Rosenblum A. Total Joint Arthroplasty Patient Demographics Before and After Coronavirus Disease 2019 Elective Surgery Restrictions. Arthroplast Today 2023; 20:101081. [PMID: 36619704 PMCID: PMC9805899 DOI: 10.1016/j.artd.2022.101081] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/06/2022] [Indexed: 01/03/2023] Open
Abstract
Background In 2020, the coronavirus disease 2019 (COVID-19) pandemic caused the cessation of nonemergent total joint arthroplasty (TJA, referring to total hip and total knee arthroplasty) operations between mid-March and April 2020. The purpose of this study is to analyze the effects and potential disparities in access to care due to the COVID-19 restrictions. Methods A database was used to examine the demographics of patients undergoing TJA from May to December 2019 (pre-COVID-19) and from May to December 2020 (post-COVID-19 restrictions). Categorical covariates were summarized by reporting counts and percentages and compared using Fisher exact tests. Continuous covariates were summarized by reporting means and standard deviations. Two-sample t-tests were used for continuous covariates. The equality of TJA counts by year was tested using a test of proportions. Results There were more TJA procedures performed during the post-COVID-19 period in 2020 than in the pre-COVID-19 period (1151 vs 882, P < .001). There was an increase in the relative percentage of THAs vs TKAs performed in 2020 vs 2019 (26.9% vs 18.8%, P < .001) and an increase in patients with Medicaid with a decrease in private insurance (P = .043). The average length of stay was shorter in 2020 with a greater percentage of TJAs performed outpatient (P < .001). There were no differences in patient sex, race, body mass index, smoking status, or age between the 2 periods. Conclusions A relative increase in THA procedures, an increase in patients with Medicaid and decrease in private insurance, and a a decreased length of stay were seen after COVID-19 restrictions. These trends may reflect pandemic-related changes in insurance status as well as the growing shift to same-day discharge.
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Affiliation(s)
| | | | | | - Anna Cohen-Rosenblum
- Corresponding author. LSUHSC Department of Orthopaedic Surgery, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA. Tel.: +1 504 903 9420
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Christensen TH, Bieganowski T, Malarchuk AW, Davidovitch RI, Bosco JA, Schwarzkopf R, Macaulay WB, Slover JD, Lajam CM. Hospital Revenue, Cost, and Contribution Margin in Inpatient Versus Outpatient Primary Total Joint Arthroplasty. J Arthroplasty 2023; 38:203-208. [PMID: 35987495 DOI: 10.1016/j.arth.2022.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty. METHODS We reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-squared tests. RESULTS Among Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (P < .001), although there was no statistical significance difference between cohorts for TKA (P = .501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (P < .001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (P < .001). CONCLUSION Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
| | - Thomas Bieganowski
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Alex W Malarchuk
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Roy I Davidovitch
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - William B Macaulay
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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7
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Gordon AM, Magruder ML, Ng MK, Sheth BK, Conway CA, Hang Jason Wong C. The combined effect of policy changes and the covid-19 pandemic on the same day discharge and complications following total hip arthroplasty: a nationwide analysis. ARTHROPLASTY 2022; 4:28. [PMID: 35909141 PMCID: PMC9340697 DOI: 10.1186/s42836-022-00131-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/31/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction As a result of the SARS-CoV-2 (COVID-19) pandemic in 2020, elective surgeries, including total joint arthroplasty (TJA), were suspended nationwide. Concurrent removal of total hip arthroplasty (THA) from the Medicare inpatient-only list posed challenges to the delivery of quality patient care with low payor cost. Therefore, the objective of this study was to compare temporal trends in patient demographics, case volumes, length of stay, and complications following elective THA in the years 2019 to 2020 in the United States. Methods The 2019 to 2020 ACS-NSQIP database was queried for elective THA patients. Patients Pre-COVID (2019 and 2020Q1) were compared with post-COVID (2020Q2-Q4). THA utilization, demographics, 30-day complications, and length of stay (LOS) were compared between years. Linear regression evaluated changes in case volumes over time with significance threshold of P < 0.05. Results A total of 77,797 patients underwent elective THA in 2019 (n = 43,667) and 2020 (n = 34,130), resulting in a 24.5% decline. Outpatient THA increased in 2020 (35.6%) vs. 2019 (5.7%) (P < 0.001). There was no significant difference in the volume of cases in 2019Q1 through 2019Q4 (P = 0.984). Elective THA volumes declined by 68.8% in 2020Q2, returned to pre-pandemic baseline in 2020Q3, before leveling off at 81.5% of baseline in Q4. Average LOS was significantly shorter in 2020 (1.55 days) vs. 2019 (1.78 days) (P < 0.001) and the proportion of same day discharge (SDD) increased quarterly from 2019 to 2020. There was no significant difference in the total complication rates in 2019 (6.6%) vs. 2020 (6.6%) (P = 0.831). Discussion Elective THA precipitously declined during the second quarter of 2020. The combined effect of policy changes and the COVID-19 pandemic resulted in a seven-fold increase in the number of surgeries performed in the outpatient setting in 2020. Rates of SDD doubled over the study period, despite no change in complication rates.
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8
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Pagani NR, Puzzitiello RN, Stambough JB, Saxena A. Online Crowdsourcing Survey of United States Population Preferences and Perceptions Regarding Outpatient Hip and Knee Arthroplasty. J Arthroplasty 2022; 37:2323-2332. [PMID: 35738362 DOI: 10.1016/j.arth.2022.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/11/2022] [Accepted: 06/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Outpatient total joint arthroplasty (TJA) has been shown to be both safe and cost-effective in appropriately selected patients and continues to expand substantially across the United States. Using online crowdsourcing, we aimed to assess population perceptions regarding outpatient TJA and to determine factors associated with preference for outpatient versus inpatient arthroplasty. METHODS A closed-ended survey consisting of 39 questions was administered to members of a public platform. Study participants responded to questions regarding demographic factors and outpatient TJA. Validated assessments to capture health literacy and engagement were also used. To determine factors associated with preference for outpatient TJA, multivariable logistic regression analyses were performed. RESULTS In total, 900 participants completed the survey. After exclusion of surveys with incomplete data, 725 responses remained for analysis (80.6%). Over half (59.9%) of the survey participants would feel comfortable going home the same day of surgery following TJA. However, two-thirds (64.6%) would prefer to stay in the hospital following TJA. The majority (68.0%) of respondents perceive a hospital setting as the safest location for TJA. The 3 major concerns regarding outpatient TJA were cost, post-operative pain control, and post-operative complication. Among the 111 respondents (15.3%) who would prefer outpatient TJA, 45% would pay more out-of-pocket, 63.1% travel further, and 55.9% would be willing to wait longer to have their surgery performed as an outpatient. On multivariable regressions, those living in a suburban setting (adjusted odds ratios, 95% confidence intervals: 4.2 [1.3-2.7], P = .02) and >60 year old adjusted odds ratios (95% confidence intervals: 8 [2-33.1], P = .004) were more likely to prefer outpatient TJA. CONCLUSION Despite the rise in outpatient TJA, the majority of the public appears to prefer inpatient TJA and the minority would expect to be discharged home the same day. Our data can be used to address specific patient concerns regarding outpatient TJA and set realistic expectations for hospital systems and ambulatory facilities.
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Affiliation(s)
- Nicholas R Pagani
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Richard N Puzzitiello
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Arjun Saxena
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Sutton R, Chisari E, Scaramella A, Krueger CA, Courtney PM. Total Hip and Knee Revisions are Really Outpatient Procedures? Implications of the Removal From the Inpatient Only List. J Arthroplasty 2022; 37:S732-S737. [PMID: 34902514 DOI: 10.1016/j.arth.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/17/2021] [Accepted: 12/06/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In 2021, the Centers for Medicare and Medicaid Services (CMS) removed over 200 procedures from the Inpatient Only (IPO) list including revision total hip (THA) and total knee arthroplasties (TKA). The purpose of this study is to determine if some revision TKA and THA procedures may be appropriate for outpatient status. METHODS We reviewed a consecutive series of 1026 revision THA and TKA patients at our tertiary academic institution from 2015 to 2020. An outpatient procedure was defined as a length of stay of <2 midnights. We queried our prospectively collected arthroplasty database and compared demographics, comorbidities, surgical indication, type of procedure, discharge disposition, readmissions, and complications between the outpatient and inpatient groups. RESULTS There were only 166 revision patients (16%) who met outpatient criteria. Revision THA outpatients were more likely to have a head and liner exchange (49% vs 25%, P < .001) and an indication of instability (93% vs 44%, P < .001). Revision TKA outpatients were more likely to have an isolated liner exchange (34% vs 14%, P < .001) and have an indication of instability (67% vs 25%, P < .001). Patients undergoing a revision for infection and aseptic loosening were more likely to require an inpatient stay than other revision indication (P < .05). CONCLUSION The vast majority of revision TKA and THA patients met CMS inpatient criteria. In addition to a projected decrease in facility reimbursement, concerns exist for the safety of early discharge and access to care for these complex patients if CMS removes all revisions from the Inpatient Only list.
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Affiliation(s)
- Ryan Sutton
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Emanuele Chisari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Amira Scaramella
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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10
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Gold PA, Krueger CA, Barnes CL. Identifying and Creating Value for Employed Arthroplasty Surgeons in an Era of Decreasing Reimbursement. J Arthroplasty 2022; 37:1452-1454. [PMID: 35189291 DOI: 10.1016/j.arth.2022.02.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/02/2022] [Accepted: 02/13/2022] [Indexed: 02/02/2023] Open
Abstract
Recent regulatory changes made by the Center for Medicare and Medicaid Services (CMS) will result in a 9% decrease in reimbursement for hip and knee replacements by the end of 2022. Combining this with CMS's recent removal of total knee and total hip arthroplasty from the inpatient-only list has begun to take effect on the bottom line for hospital systems, which now employ around 50% of the arthroplasty community. Employed joint replacement surgeons should continue to innovate and be leaders within their hospital systems in the outpatient and ambulatory surgery space to recoup lost value, increase autonomy, and should be compensated for this work. Employed arthroplasty surgeon leaders can better align goals with and control the narrative in the C-suite to redefine their value as the most consistent, dependable, and transparent department within a larger health system or corporate medical group.
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Affiliation(s)
- Peter A Gold
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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11
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Arshi A, Wellens B, Krueger CA. How the Shift in Arthroplasty Surgery Location Impacts the Relationship of Private Surgeons, Hospitals, and Ambulatory Surgery Centers. J Arthroplasty 2022; 37:1455-1458. [PMID: 34942346 DOI: 10.1016/j.arth.2021.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/06/2021] [Accepted: 12/12/2021] [Indexed: 02/02/2023] Open
Abstract
The recent removal of total hip and knee arthroplasty from the Medicare inpatient-only list, COVID-19 pandemic, decreasing reimbursements, and bundled payment programs have all had tremendous impact on the practice of arthroplasty. Surgeons and practices must adapt to these challenges to achieve the ideal triad of quality patient care, low cost to payors, and sustainable financial margins for stakeholders. Here, we review institutional data and present our experience with the changing arthroplasty practice landscape. With the principle of demand matching, arthroplasty surgeons and practices can risk-stratify and shuttle patients in the appropriate operative and rehabilitation setting to optimize quality and efficiency.
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Affiliation(s)
- Armin Arshi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
| | - Bryan Wellens
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
| | - Chad A Krueger
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
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Bernstein JA, Rana A, Iorio R, Huddleston JI, Courtney PM. The Value-Based Total Joint Arthroplasty Paradox: Improved Outcomes, Decreasing Cost, and Decreased Surgeon Reimbursement, Are Access and Quality at Risk? J Arthroplasty 2022; 37:1216-1222. [PMID: 35158003 DOI: 10.1016/j.arth.2022.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
| | - Adam Rana
- Department of Orthopedics and Sports Medicine, Maine Medical Center, Portland, ME
| | - Richard Iorio
- Brigham and Women's Hospital, Harvard Medical School, Department of Orthopaedic Surgery, Boston, MA
| | | | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Ambulatory shoulder arthroplasty provides a mild reduction in overall cost compared with inpatient shoulder arthroplasty cost of ambulatory shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:S90-S93. [PMID: 34864155 DOI: 10.1016/j.jse.2021.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/10/2021] [Accepted: 10/23/2021] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The purpose of this study was to determine the relative cost difference of inpatient vs. ambulatory total shoulder arthroplasty (TSA) procedures. METHODS A retrospective case series was performed to identify a consecutive series of patients who underwent primary anatomic or reverse TSA at 2 orthopedic specialty hospitals between September 2015 and August 2020. Those undergoing surgery for fracture or revision were excluded. Itemized facility costs were analyzed with a time-driven activity-based costing model and compared between ambulatory and non-ambulatory procedures. Ambulatory patients were defined as those admitted and discharged on the same calendar day. All other patients were considered non-ambulatory. RESULTS A total of 1027 patients were analyzed, comprising 38 ambulatory patients (3.7%) and 989 non-ambulatory patients (96.3%). There was a higher proportion of anatomic TSA than reverse shoulder arthroplasty in the ambulatory group (81.6% vs. 51.7%, P < .0001). Overall, there was no difference in cost between the 2 groups ($8832 vs. $8841, P = .97). However, personnel costs were greater in the non-same-day group ($1895 vs. $2743, P < .0001) whereas supply costs were less ($6937 vs. $6097, P < .0003). When implant costs were excluded, outpatient shoulder arthroplasty provided a cost savings of $745. CONCLUSION Ambulatory shoulder arthroplasty provides a mild cost savings of $745 after controlling for fixed costs. This is much less dramatic than previously reported and should raise concern as shoulder arthroplasty continues to be targeted by payers as a potential for cost savings through decreased reimbursement.
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Barra MF, Kaplan NB, Balkissoon R, Drinkwater CJ, Ginnetti JG, Ricciardi BF. Same-Day Outpatient Lower-Extremity Joint Replacement: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202206000-00003. [PMID: 35727992 DOI: 10.2106/jbjs.rvw.22.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
➢ The economics of transitioning total joint arthroplasty (TJA) to standalone ambulatory surgery centers (ASCs) should not be capitalized on at the expense of patient safety in the absence of established superior patient outcomes. ➢ Proper patient selection is essential to maximizing safety and avoiding complications resulting in readmission. ➢ Ambulatory TJA programs should focus on reducing complications frequently associated with delays in discharge. ➢ The transition from hospital-based TJA to ASC-based TJA has substantial financial implications for the hospital, payer, patient, and surgeon.
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Affiliation(s)
- Matthew F Barra
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York
| | - Nathan B Kaplan
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York
| | - Rishi Balkissoon
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York
| | - Christopher J Drinkwater
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York
| | - John G Ginnetti
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York
| | - Benjamin F Ricciardi
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York.,Center for Musculoskeletal Research, Department of Orthopaedic Surgery, University of Rochester School of Medicine, Rochester, New York
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Xu RF, Varady NH, Chen AF. Disparities Among Leading Publishers of Arthroplasty Research. J Arthroplasty 2021; 36:1804-1809. [PMID: 33281019 DOI: 10.1016/j.arth.2020.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite the importance of diversity in advancing scientific progress, diversity among leading authors in arthroplasty has not been examined. This study aimed to identify, characterize, and assess disparities among leading authors in arthroplasty literature from 2002 to 2019. METHODS Articles published between 2002 and 2019 from 12 academic journals that publish orthopedic and arthroplasty research were extracted from PubMed. Original articles containing keywords related to arthroplasty were analyzed. Author gender was assigned using the Genderize algorithm. Gender and characterization of the top 100 male and female authors utilized available information on academic profiles. RESULTS From the 14,692 articles that met inclusion criteria, the genders of 23,626 unique authors were identified. Women were less likely than men to publish 5 years after beginning their publishing careers (adjusted odds ratio 0.51, 95% confidence interval 0.45-0.57, P < .001). Of the top 100 authors, 96 were men, while only 4 were women. Orthopedic surgeons made up 93 of 100 top authors, of which 92 were men and 1 was a woman. Among the top 10 publishing female and male authors, 10 of 10 men were orthopedic surgeons, only 2 of 10 women were physicians, and only one was an attending orthopedic surgeon. CONCLUSION While the majority of authors with high arthroplasty publication volume were orthopedic surgeons, there were significant gender disparities among the leading researchers. We should continue working to increase gender representation and supporting the research careers of women in arthroplasty.
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Affiliation(s)
- Raylin F Xu
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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