Financial analysis of revision knee surgery at a tertiary referral centre as classified according to the Revision Knee Complexity Classification (RKCC)

Revision total knee replacement finances: a detailed cost-analysis of operative practice at a regional tertiary referral centre

BACKGROUND

The revision knee complexity classification (RKCC) stratifies knee revision operations depending on their level of complexity from simple revisions (R1) to highly complex cases (R3). Current financial codes used for calculation of reimbursement for knee revision services provided at the Trust, rely on patients' comorbidities. However, previous research has demonstrated that this approach may not yield an accurate financial account of knee revision arthroplasty cost. This is a single centre study from a secondary and tertiary revision unit, with work previously presented by the authors demonstrating that the majority of complex revision knee replacement within the region, take place in this unit. The aims of this study were to illustrate the current cost profile and renumeration service currently in place for revision knee and show the differences in cost based on complexity of the operation.

METHODS

In this retrospective study, 90 cases who underwent revision knee operations in 2019 were analysed. Data was obtained from a tertiary referral centre where the episodes had occurred. Mean cost, tariff, and subsequent deficit were calculated for the R1, R2 and R3 episodes.

RESULTS

R2 and R3 episodes were significantly more expensive than R1 episodes. The increase in cost between R3 and R2 episodes was not significant. The total cost of the revision operations was £1,162,343. Tariffs received for R2 and R3 revision operations were significantly more expensive than R1 operations. However, the increase in tariffs received for R3 operations was not significant in relation to R2 operations. The total amount of tariffs received by the Trust was £ 770,996 generating a net deficit of - £ 391,347.

CONCLUSION

Current financial coding for revision knee does not accurately predict costs associated with revision knee surgery. Net deficit varies depending on the RKCC grade of the knee revision episode with more complex operations resulting in a higher mean net deficit. Implementation of the RKCC could prove to be a useful tool in generating an accurate prediction of the cost associated with knee revision surgery.

Revision total knee arthroplasty results in financial deficits within the Swiss healthcare system

PURPOSE

Revision total knee arthroplasty (RTKA) results in high costs with inadequately low reimbursement in different healthcare systems. Therefore, a financial analysis was performed comparing costs and reimbursements of primary total knee arthroplasty (PTKA) versus RTKA using financial and total knee arthroplasty-register data from a large tertiary hospital, the Cantonal Hospital of St. Gallen (KSSG), Switzerland.

METHODS

All PTKA and RTKA performed between January 2012 and September 2019 at the KSSG were included. Financial and TKA-register data for each case were collected, including detailed cost allocation, reimbursement, patients' insurance status, type and indication for surgery and length of hospital stay. RTKA was further subdivided in one-stage and two-stage RTKA. Direct hospital costs were analyzed and compared to reimbursement in both groups. Cost-coverage ratios were calculated.

RESULTS

730 PTKA and 106 RTKA were included. The RTKA group contained 66 one-stage and 40 two-stage RTKA. Cost-coverage ratio for PTKA and RTKA showed to be 110.9% and 81.3%, respectively. Cost-coverage ratio was lower for two-stage RTKA than for one-stage RTKA with 74.1% and 92.3%, respectively.

CONCLUSION

RTKA leads to financial deficits especially for tertiary hospitals within the Swiss healthcare system. Restructuring of the reimbursements for PTKA and RTKA should be considered in favor of RTKA. Otherwise, tertiary hospitals will face a growing financial burden with the constantly increasing annual number of RTKA procedures, predominantly performed in this type of hospitals.

LEVEL OF EVIDENCE

III.

Patient-Relevant Outcomes Following First Revision Total Knee Arthroplasty, by Diagnosis: An Analysis of Implant Survivorship, Mortality, Serious Medical Complications, and Patient-Reported Outcome Measures Utilizing the National Joint Registry Data Set

BACKGROUND

The purpose of this study was to investigate patient-relevant outcomes following first revision total knee arthroplasties (rTKAs) performed for different indications.

METHODS

This population-based cohort study utilized data from the United Kingdom National Joint Registry, Hospital Episode Statistics Admitted Patient Care, National Health Service Patient-Reported Outcome Measures, and the Civil Registrations of Death. Patients undergoing a first rTKA between January 1, 2009, and June 30, 2019, were included in our data set. Patient-relevant outcomes included implant survivorship (up to 11 years postoperatively), mortality and serious medical complications (up to 90 days postoperatively), and patient-reported outcome measures (at 6 months postoperatively).

RESULTS

A total of 24,540 first rTKAs were analyzed. The patient population was 54% female and 62% White, with a mean age at the first rTKA of 69 years. At 2 years postoperatively, the cumulative incidence of re-revision surgery ranged from 2.7% (95% confidence interval [CI], 1.9% to 3.4%) following rTKA for progressive arthritis to 16.3% (95% CI, 15.2% to 17.4%) following rTKA for infection. The mortality rate at 90 days was highest following rTKA for fracture (3.6% [95% CI, 2.5% to 5.1%]) and for infection (1.8% [95% CI, 1.5% to 2.2%]) but was <0.5% for other indications. The rate of serious medical complications requiring hospital admission within 90 days was highest for patients treated for fracture (21.8% [95% CI, 17.9% to 26.3%]) or infection (12.5% [95% CI, 11.2% to 13.9%]) and was lowest for those treated for progressive arthritis (4.3% [95% CI, 3.3% to 5.5%]). Patients who underwent rTKA for stiffness or unexplained pain had some of the poorest postoperative joint function (mean Oxford Knee Score, 24 and 25 points, respectively) and had the lowest proportion of responders (48% and 55%, respectively).

CONCLUSIONS

This study found large differences in patient-relevant outcomes among different indications for first rTKA. The rate of complications was highest following rTKA for fracture or infection. Although rTKA resulted in large improvements in joint function for most patients, those who underwent surgery for stiffness and unexplained pain had worse outcomes.

LEVEL OF EVIDENCE

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

Financial analysis of revision hip surgery at a tertiary referral centre as classified using the British Hip Society Revision Hip Complexity Classification

Aims

The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS.

Methods

A retrospective analysis of all revision hip procedures was performed at this centre over two consecutive financial years (2018 to 2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and whether they were infected or non-infected. Patients with an American Society of Anesthesiologists (ASA) grade ≥ III or BMI ≥ 40 kg/m² are considered "high risk" by the RHCC. Costs were calculated using the Patient Level Information and Costing System (PLICS), and remuneration based on Healthcare Resource Groups (HRG) data. The primary outcome was the financial difference between tariff and cost per patient episode.

Results

In all, 199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1); 110 (55%) complex revisions (H2); and 64 (32%) most complex revisions (H3). Of the 199, 76 cases (38%) were due to infection, and 78 patients (39%) were "high risk". Median length of stay increased significantly with case complexity from four days to six to eight days (p = 0.006) and for revisions performed for infection (9 days vs 5 days; p < 0.001). Cost per episode increased significantly between complexity groups (p < 0.001) and for infected revisions (p < 0.001). All groups demonstrated a mean deficit but this significantly increased with revision complexity (£97, £1,050, and £2,887 per case; p = 0.006) and for infected failure (£2,629 vs £635; p = 0.032). The total deficit to the NHS Trust over two years was £512,202.

Conclusion

Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHAs at major revision centres will likely place a greater financial burden on these units.

The impact of a revision arthroplasty network on patient outcomes

Aims

Revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) are complex procedures with higher rates of re-revision, complications, and mortality compared to primary TKA and THA. We report the effects of the establishment of a revision arthroplasty network (the East Midlands Specialist Orthopaedic Network; EMSON) on outcomes of rTKA and rTHA.

Methods

The revision arthroplasty network was established in January 2015 and covered five hospitals in the Nottinghamshire and Lincolnshire areas of the East Midlands of England. This comprises a collaborative weekly multidisciplinary meeting where upcoming rTKA and rTHA procedures are discussed, and a plan agreed. Using the Hospital Episode Statistics database, revision procedures carried out between April 2011 and March 2018 (allowing two-year follow-up) from the five network hospitals were compared to all other hospitals in England. Age, sex, and mean Hospital Frailty Risk scores were used as covariates. The primary outcome was re-revision surgery within one year of the index revision. Secondary outcomes were re-revision surgery within two years, any complication within one and two years, and median length of hospital stay.

Results

A total of 57,621 rTHA and 33,828 rTKA procedures were performed across England, of which 1,485 (2.6%) and 1,028 (3.0%), respectively, were conducted within the network. Re-revision rates within one year for rTHA were 7.3% and 6.0%, and for rTKA were 11.6% and 7.4% pre- and postintervention, respectively, within the network. This compares to a pre-to-post change from 7.4% to 6.8% for rTHA and from 11.7% to 9.7% for rTKA for the rest of England. In comparative interrupted time-series analysis for rTKA there was a significant immediate improvement in one-year re-revision rates for the revision network compared to the rest of England (p = 0.024), but no significant change for rTHA (p = 0.504). For the secondary outcomes studied, there was a significant improvement in trend for one- and two-year complication rates for rTHA for the revision network compared to the rest of England.

Conclusion

Re-revision rates for rTKA and complication rates for rTHA improved significantly at one and two years with the introduction of a revision arthroplasty network, when compared to the rest of England. Most of the outcomes studied improved to a greater extent in the network hospitals compared to the rest of England when comparing the pre- and postintervention periods.

Epidemiology of primary and revision total knee arthroplasty: analysis of demographics, comorbidities and outcomes from the national inpatient sample

INTRODUCTION

Primary total knee arthroplasty (TKA) is a preferred treatment for end-stage knee osteoarthritis. In the setting of a failed TKA, revision total knee arthroplasty (rTKA) acts as a salvage procedure and carries a higher risk compared to primary TKA. Given increased interest in postoperative outcomes from these procedures, a thorough understanding of the demographics, comorbidities, and inpatient outcomes is warranted. This study aimed to report the epidemiological data of demographics, comorbidity profiles and outcomes of patients undergoing TKA and rTKA.

METHODS

A retrospective review of NIS registry discharge data from 2006 to 2015 third quarter was performed. This study included adults aged 40 and older who underwent TKA or rTKA. A total of 5,901,057 TKA patients and 465,968 rTKA patients were included in this study. Simple descriptive statistics were used to present variables on demographics, medical comorbidities, and postoperative complications.

RESULTS

A total of 5,901,057 TKA and 465,968 rTKA discharges were included in this study, with an average age of 66.30 and 66.56 years, and the major payor being Medicare, accounting for 55.34% and 59.88% of TKA and rTKA cases, respectively. Infection (24.62%) was the most frequent reason for rTKA, and was followed by mechanical complications (18.62%) and dislocation (7.67%). The most common medical comorbidities for both groups were hypertension, obesity, and diabetes. All types of inpatient complications were reported in 22.21% TKA and 28.78% of rTKA cases. Postoperative anemia was the most common complication in both groups (20.34% vs. 25.05%).

CONCLUSIONS

Our data demonstrated a 41.9% increase in patients receiving TKA and 28.8% increase in rTKA from the years 2006 to 2014. The data showed a 22.21% and a 28.78% "complication" rate with TKA and rTKA, with postoperative anemia being the most common complication. The top 3 medical comorbidities were hypertension, obesity, and diabetes for both groups and with increased focus on perioperative optimization, future analyses into preoperative medical optimization, and improved primary arthroplasty protocol may result in improved postoperative outcomes.

Re-revision Knee Arthroplasty in a Tertiary Center: Infection and Multiple Previous Surgeries Were Associated With Poor Early Clinical and Functional Outcomes

BACKGROUND

The incidence of re-revision knee arthroplasty (re-revision KA) is increasing and associated with high complication and failure rates. The aim of this study was to investigate re-revision rates, complications, and patient-reported outcomes following re-revision KA and factors associated with poor outcome.

METHODS

This was a retrospective cohort study of 206 patients (250 knees) undergoing re-revision KA at a major revision center from 2015 to 2018. The mean follow-up was 26 months (range, 0 to 61) and mean age at re-revision KA was 69 years (range, 31 to 91 years). The main indications for surgery were prosthetic joint infection (PJI) (n = 171/250, 68.4%) and aseptic loosening (n = 25/250, 10.0%). We compared re-revision rates, joint function, and complications for aseptic and infective indications. Logistic regressions were performed to identify risk factors for further reoperation.

RESULTS

The estimated re-revision rates at 2 years were 28.7% (95% confidence interval [CI]: 22.7-35.9) and at 4 years were 42.0% (95% CI: 32.8-52.6). Mean Oxford Knee Score was 26 points (range, 1 to 48). Mean EuroQoL-5D-5L utility was 0.539 (range, -0.511 to 1.000). Multivariable analyses demonstrated that PJI (Odds Ratio [OR] 2.39, 95% CI 1.06-5.40, P = .036), greater number of previous surgeries (OR 1.18, 95% CI 1.04-1.33, P = .008), and higher Elixhauser score (OR 1.06, 95% CI 1.01-1.13, P = .045) were independently associated to further surgery.

CONCLUSION

Re-revision KA carried a high risk of early failure. Multiple revised joints and patients with more comorbidities had worse function. Patients undergoing re-revision KA for PJI should be counseled to expect higher failure rates and complications than patients who have aseptic indications.

Regional economic burden of revision total knee replacement: A cost-complexity analysis

BACKGROUND

GIRFT tasked regional networks with addressing case-load, complexity-spread and cost of revision knee replacement (KR), but the regional cost burden is not clear. The tariff for revision KR is currently not dependent on surgical complexity. 2 years of revision KR complexity data using the validated Revision Knee Complexity Classification (RKCC) checklist as a demonstration of complexity spread in the region has previously been published. The aims of this study were to estimate the annual regional cost of revision TKR using existing data, and estimate the cost/saving of complexity-clustering using existing data from 8 revision centres.

METHODS

Financial data from the regional high-volume centre for one year (2019) of RKCC data collection was obtained. Mean cost, tariff and balance was calculated for R1, R2 and R3 (RKCC), and applied to data from each revision centre to provide local estimates. Complexity clustering was considered using 3 hypothetical scenarios of high-volume centre absorbing R2s and/or R3s in place of R1s.

RESULTS

Mean net loss was £2,290.08 for R1s, £6,471.42 for R2s and £6,454.26 for R3s. The estimated total annual loss for the region was £1,005,025. Complexity-clustering was associated with greater losses; £162,918 for high-volume centre taking R2s and R3s, £37,477.60 for taking just R3s and £125,440 for taking just R2s.

CONCLUSION

Revision TKR surgery is expensive and insufficiently remunerated with current measures. Restructuring of regional workload would create additional financial burden on specialist centres with current tariff awards structure. Managing reimbursement at a regional or central level may help to incentivise compliance with GIRFT ideals.