Bundle Payment for Musculoskeletal Care: Current Evidence (Part 2)

Time is money: An analysis of cost drivers in ambulatory sinus surgery

BACKGROUND

Functional endoscopic sinus surgery (FESS) is one of the most commonly performed otolaryngologic procedures and is associated with significant cost variability.

METHODS

We performed a retrospective analysis of all inflammatory sinus surgeries at a single tertiary care medical center from July 2021 to July 2023. The electronic medical record was reviewed for patient factors and cost variables for each procedure, and multivariable analysis was performed.

RESULTS

A total of 221 patients were included in analysis with a mean age of 48.2 years. There was a 44.8% incidence (n = 99) of nasal polyps and 31.2% (n = 69) of cases were revision surgeries. The average total cost for the surgical encounter was $8960.31 (standard deviation $1967.97). Operating room time represented $4912.46 (54.8% of all costs), while average operating room supply costs were $1296.06 (14.5%) and recovery room costs were $919.48 (10.3%). Total costs were significantly associated with length of surgery ($7.83/min, p = 0.04), in addition to presence of nasal polyps ($531.96, p = 0.04). There was no significant association between total costs and the remaining clinical and demographic factors.

CONCLUSIONS

Costs associated with ambulatory FESS for inflammatory sinus disease vary across patients and this cost variability is predominantly driven by time efficiency within the operating room, as well as supply utilization and nasal polyposis to a lesser degree. As a result, operating room efficiency represents a primary target for cost-related interventions. Additionally, our data provide a framework for surgeons and hospitals to make evidence-based decisions on intraoperative equipment in a tradeoff between efficiency and supply costs. Our findings indicate that an approach focused on streamlining efficiency across the entire ambulatory surgery encounter will have the greatest impact on reducing healthcare expenses for both the patient and the health system.

Trends in Physician Payments for Hand Surgery Consultations and Clinic Visits

PURPOSE

The primary objective of this study was to identify the trends in reimbursement for hand surgeons for new patient visits, outpatient consultations, and inpatient consultations from the years 2010-2018. In addition, we sought to investigate the influence of payer mix and coding level of service on physician reimbursement in these settings.

METHODS

The PearlDiver Patients Records Database was used to identify clinical encounters and their respective physician reimbursements for analysis within this study. This database was queried using Current Procedural Terminology codes to identify relevant clinical encounters for inclusion, filtered for the presence of valid demographic information and by physician specialty for the presence of a hand surgeon, and tracked by primary diagnoses. Cost data were then calculated and analyzed regarding the payer type and level of care.

RESULTS

In total, 156,863 patients were included in this study. The mean reimbursement for inpatient consultations, outpatient consultations, and new patient encounters increased by 92.75% ($134.85 to $259.93), 17.80% ($161.33 to $190.04), and 26.78% ($102.58 to $130.05), respectively. When normalized to 2018 dollars to adjust for inflation, the percent increases were 67.38%, 2.24%, and 10.09%, respectively. Commercial insurance reimbursed hand surgeons to a greater degree than any other payer type. Mean physician reimbursement differed depending on the level of service billed, with the level of service V reimbursing 4.41 times more than the level of service I visits for new outpatient visits, 3.66 times more for new outpatient consultations, and 3.04 times more for new inpatient consultations.

CONCLUSIONS

This study helps to provide physicians, hospitals, and policymakers with objective information regarding the trends in reimbursement to hand surgeons. Although this study indicates increasing reimbursements for consultations and new patient visits to hand surgeons, the margins shrink when adjusted for inflation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic Analysis IV.

Reversal of the Halo Effect: Prolonged Participation in Comprehensive Care for Joint Replacement Negatively Impacts Revision Metrics

Background

The downstream regional effect of the Comprehensive Care for Joint Replacement (CJR) program on care pathway-adjacent patients, including revision arthroplasty patients, is poorly understood. Prior studies have demonstrated that care pathways targeting primary total joint arthroplasty may produce a halo effect, impacting more complex patients with parallel care pathways. However, neither the effect of regional referral changes from CJR nor the durability of these positive changes with prolonged bundle participation has been assessed.

Methods

Blinded data were pulled from electronic medical records. Primary analyses focused on the effect of CJR participation from 2015 (baseline) to 2020 (final participation year) at a tertiary care safety-net hospital. Patient demographics were evaluated using multivariate analysis of variance and chi-square calculations between procedure types over time.

Results

Patients who underwent revision total knee arthroplasty (N = 376) and revision total hip arthroplasty (N = 482) were included. More patients moved through the revision-care pathway over the participation period, with volume increasing by 42% over time. Patients became more medically complex: the Charlson comorbidity index increased from 3.91 to 4.65 (P = .01). The mean length of stay decreased from 5.14 days to 4.50 days (P = .03), but the all-cause complication (8.3%-15.2%; P = .02) and readmission rates (13.6%-16.6%; P = .19) increased over time.

Conclusions

Despite care pathway improvements over 5 years of CJR participation, revision patients did not display clear benefits in quality metrics but demonstrated a considerable increase in volume and medical complexity over time. The care of these patients may supersede even thoughtfully implemented care pathways, especially when referral burden increases, as may be prone to happen in regional, financial risk-conferring value-based programs. Understanding the impact of mandatory bundled payment programs like CJR on the care of arthroplasty patients regionally will be essential as value-based programs evolve.

Risk stratification of patients undergoing outpatient lumbar decompression surgery

BACKGROUND CONTEXT

Reimbursement has slowly transitioned from a fee-for-service model to a bundled payment model after introduction of the United States Centers for Medicare and Medicaid Services bundled payment program. To minimize healthcare costs, some surgeons are trying to minimize healthcare expenditures by transitioning appropriately selected lumbar decompression patients to outpatient procedure centers.

PURPOSE

To prepare a risk stratification calculator based on machine learning algorithms to improve surgeon's preoperative predictive capability of determining whether a patient undergoing lumbar decompression will meet inpatient vs. outpatient criteria. Inpatient criteria was defined as any overnight hospital stay.

STUDY DESIGN/SETTING

Retrospective single-institution cohort.

PATIENT SAMPLE

A total of 1656 patients undergoing primary lumbar decompression.

OUTCOME MEASURES

Postoperative outcomes analyzed for inclusion into the risk calculator included length of stay.

METHODS

Patients were split 80-20 into a training model and a predictive model. This resulted in 1,325 patients in the training model and 331 into the predictive model. A logistic regression analysis ensured proper variable inclusion into the model. C-statistics were used to understand model effectiveness. An odds ratio and nomogram were created once the optimal model was identified.

RESULTS

A total of 1,656 patients were included in our cohort with 1,078 dischared on day of surgery and 578 patients spending ≥ 1 midnight in the hospital. Our model determined older patients (OR=1.06, p<.001) with a higher BMI (OR=1.04, p<0.001), higher back pain (OR=1.06, p=.019), increasing American Society of Anesthesiologists (ASA) score (OR=1.39, p=.012), and patients with more levels decompressed (OR=3.66, p<0.001) all had increased risks of staying overnight. Patients who were female (OR=0.59, p=.009) and those with private insurance (OR=0.64, p=.023) were less likely to be admitted overnight. Further, weighted scores based on training data were then created and patients with a cumulative score over 118 points had a 82.9% likelihood of overnight. Analysis of the 331 patients in the test data demonstrated using a cut-off of 118 points accurately predicted 64.8% of patients meeting inpatient criteria compared to 23.0% meeting outpatient criteria (p<0.001). Area under the curve analysis showed a score greater than 118 predicted admission 81.4% of the time. The algorithm was incorporated into an open access digital application available here: https://rothmanstatisticscalculators.shinyapps.io/Inpatient_Calculator/?_ga=2.171493472.1789252330.1671633274-469992803.1671633274 CONCLUSIONS: Utilizing machine-learning algorithms we created a highly reliable predictive calculator to determine if patients undergoing outpatient lumbar decompression would require admission. Patients who were younger, had lower BMI, lower preoperative back pain, lower ASA score, less levels decompressed, private insurance, lived with someone at home, and with minimal comorbidities were ideal candidates for outpatient surgery.

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program

BACKGROUND

Concerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution's exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A).

METHODS

We reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions. Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions.

RESULTS

Post-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224).

CONCLUSIONS

Since leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.

Value-based healthcare analysis of shoulder surgery for patients with symptomatic rotator cuff tears - Calculating the impact of arthroscopic cuff repair

BACKGROUND

Surgical repair of full-thickness rotator cuff tears in symptomatic patients is known to offer significant benefits. Despite this there remains a lack of universal appreciation that such surgery offers high clinical value, with some commissioners even limiting access to it. The value-based healthcare agenda provides a means to design, deliver and measure the impact of healthcare to a defined segment of patients. The aim of this study was to measure the value of surgically repairing primary symptomatic full-thickness rotator cuff tears when outcomes and costs were assessed over an entire care pathway.

METHODS

A prospective study of patients undergoing rotator cuff tears repair was undertaken. Patients were managed using a standardised integrated care pathway. Subsequent outcomes and costs were measured over the whole care pathway. Outcomes were assessed from both traditional and patient centric re-formatted prisms.

RESULTS

Significant improvement in clinical outcomes where recognised when assessed from either the traditional or re-formatted prisms. Economic review of this approach revealed the pathway generated a sustainable and notable positive margin.

DISCUSSION

This study evidences how a well-designed value-based healthcare shoulder approach can be delivered and measured. It demonstrates rotator cuff surgery to be a high value treatment for patients with symptomatic rotator cuff tears.

Predicting dissatisfaction following total hip arthroplasty using a Bayesian model averaging approach: Results from the Australian Arthroplasty Clinical Outcomes Registry National (ACORN)

BACKGROUND

Total hip arthroplasty (THA) provides excellent pain relief and improved function in patients with painful arthritis. The aim of this study was to identify rates and predictors of dissatisfaction following THA.

METHODS

Data were collected prospectively from the Australian Arthroplasty Clinical Outcomes Registry National (ACORN) database between 2014 and 2016 from 2096 patients who underwent THA. Data included baseline demographics, patient-reported outcome measures (PROMs) and postoperative clinical outcomes. Patients were dichotomized into two groups based on their 6-month response to the satisfaction question answered on a Likert scale. Eighteen predefined variables were analyzed. PROMs included full Oxford Hip Score, EQ-5D, and patient satisfaction. A Bayesian model averaging approach was used to build the best predictive model for dissatisfaction. Multiple logistic regression techniques were applied to quantify the effect size of the best model.

RESULTS

At 6 months following THA, 95.4% of patients (n = 2000) were satisfied with surgical outcome and 4.6% (n = 96) were dissatisfied. The only variable that was significantly associated with dissatisfaction after THA was "complications after discharge." This result was consistent for both the complete and imputed dataset (odds ratio 4.78, 95% confidence interval 2.60-8.80, P < 0.001 and odds ratio 3.8, 95% confidence interval 2.60-5.60, P < 0.001, respectively).

CONCLUSION

Our study confirms the high rates of patient satisfaction following THA, with postoperative complications being the only determinant of dissatisfaction. Optimization of patients prior to surgery, reducing postoperative complications, may further improve satisfaction rates after THA.

Medicare's Bundled Payment Initiatives for Hospital-Initiated Episodes: Evidence and Evolution

Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment.

CONTEXT

Bundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality.

METHODS

We examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs.

FINDINGS

Medicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change.

CONCLUSIONS

Bundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge.

Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare Beneficiaries

As the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005-2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post-acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patient-level (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 ± $1060. Individuals aged <65 or ≥70 years had significantly higher costs. Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577), trimalleolar fracture (+$1082), and syndesmotic fixation (+$2822). The top 5 comorbidities with the largest marginal cost increases were chronic kidney disease (+$8897), malnutrition (+$7908), obesity (+$5362), cerebrovascular disease/stroke (+$4159), and anemia (+$3087). Higher costs were seen in Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), and Maryland (+$3043) compared with Michigan. With the use of a national administrative claims database, the study identifies numerous patient-level, procedure-level, and state-level factors that significantly contribute to the cost variation seen in 90-day payments after ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in patients with fractures.

Re-evaluating the utility of routine postoperative laboratory tests after primary total knee arthroplasty

BACKGROUND

While advancements in surgery and reduced complication rates have made total knee arthroplasty (TKA) one of the most successful and cost-effective procedures in orthopaedic surgery, routine postoperative laboratory tests are still being ordered without evidence as to their necessity. With expansion of the bundled payment models, there may exist an opportunity to cut overall costs while maintaining quality of care by eliminating unnecessary interventions. The objective of this study was to examine the utility of routine postoperative laboratory tests in TKA.

METHODS

A retrospective review of 319 TKAs performed at a single institution over a 2-year period was performed. The primary outcomes were the rates of acute blood loss anemia requiring transfusion, acute kidney injury (AKI), electrolyte abnormalities, and 90-day emergency department visits and readmissions. Multivariate logistic regression analysis was also performed to identify the risk factors associated with abnormal laboratory values.

RESULTS

89 patients (27.9%) had abnormal postoperative laboratory results, of which 78% were exclusively due to electrolyte (sodium or potassium) abnormalities. The rates of AKI and blood transfusion were 3.8% and 1% respectively. Factors associated with electrolyte abnormalities were abnormal baseline electrolyte levels (p = 0.002 and = 0.006 for sodium and potassium respectively) and anemia (p = 0.049). Factors associated with blood transfusion were ASA score ≥3, preoperative anemia, and no tranexamic acid use. Factors associated with AKI were chronic kidney disease or having at least two of the following: age >65 years, BMI> 35, ASA score ≥3, diabetes, heart disease, and/or anemia. Laboratory results did not change the course of care in 305 of 319 patients (95.6%). There was no increased risk for 90-days ED visits or readmissions with abnormal laboratory values (p = 0.356).

CONCLUSION

With increasing pressure for cost containment in an era of bundled payment models, the very low rate of laboratory associated interventions suggest that routine postoperative laboratory tests is not justified. Obtaining laboratory after primary, unilateral TKA should be driven by patients' risk factors.

Predicting Opioid Use, Increased Health Care Utilization and High Costs for Musculoskeletal Pain: What Factors Mediate Pain Intensity and Disability?

This study determined the predictive capabilities of pain intensity and disability on health care utilization (number of condition-specific health care visits, incident, and chronic opioid use) and costs (total condition-specific and overall medical costs) in the year following an initial evaluation for musculoskeletal pain. We explored pain catastrophizing and spatial distribution of symptoms (ie, body diagram symptom score) as mediators of these relationships. Two hundred eighty-three military service members receiving initial care for a musculoskeletal injury completed a region-specific disability measure, numeric pain rating scale, Pain Catastrophizing Scale, and body pain diagram. Pain intensity predicted all outcomes, while disability predicted incident opioid use only. No mediation effects were observed for either opioid use outcome, while pain catastrophizing partially mediated the relationship between pain intensity and number of health care visits. Pain catastrophizing and spatial distribution of symptoms fully mediated the relationship between pain intensity and both cost outcomes. The mediation effects of pain catastrophizing and spatial distribution of symptoms are outcome specific, and more consistently observed for cost outcomes. Higher pain intensity may drive more condition-specific health care utilization and use of opioids, while higher catastrophizing and larger spatial distribution of symptoms may drive higher costs for services received. PERSPECTIVE: This article examines underlying characteristics that help explain relationships between pain intensity and disability, and the outcomes of health care utilization and costs. Health care systems can use these findings to refine value-based prediction models by considering factors that differentially influence outcomes for health care use and cost of services.

Factors Associated With the Cost of Care for the Most Common Atraumatic Painful Upper Extremity Conditions

PURPOSE

To help strategize efforts to optimize value (relative improvement in health for resources invested), we analyzed the factors associated with the cost of care and use of resources for painful, nontraumatic conditions of the upper extremity.

METHODS

The following were the most common upper extremity diagnoses in the Truven Health MarketScan database: shoulder pain and rotator cuff tendinopathy, shoulder stiffness, shoulder arthritis, lateral epicondylitis, hand arthritis, trigger finger, wrist pain, and hand pain. Multivariable generalized linear regression models were constructed accounting for sex, age, employment status, enrollment year, payer type, emergency room visit, joint injection, magnetic resonance imaging (MRI), physical or occupational therapy, outpatient and inpatient surgery, and insurance type. In addition, we assessed the use of the following 4 diagnostic and treatment interventions: joint injection, surgery, MRI, and physical or occupational therapy.

RESULTS

Inpatient and outpatient surgery are the largest contributors to the total amount paid for most diagnoses. Older patients had more injections for the majority of conditions.

CONCLUSIONS

Efforts to improve the value of care for nontraumatic upper extremity pain can focus on the relative benefits of surgery compared with other treatments and interventions to lower the costs of surgery (eg, office surgery and limited draping for minor hand surgery).

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic II.

Logistical and Economic Advantages of Sterile-Packed, Single-Use Instruments for Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is well established as a clinically successful and cost-effective procedure. The transition of the US healthcare system from a fee-for-service model to a value-based care model requires careful examination of patient care to ensure both quality and efficiency. Sterile-packed, single-use instruments have been introduced as a tool to help streamline the operating room (OR) logistics while reducing sterilization requirements. The aim of this study was to examine the potential logistic and economic benefits of single-use instruments compared to traditional, reusable instruments for TKA.

METHODS

Four variables related to TKA costs and logistics were modeled in this study: OR turnover time tray sterilization, tray management time, and 90-day infection rates. Model input data for traditional instruments and single-use instruments were based on peer-reviewed literature. A total of 200 sites and 500 cases per site were simulated using the Monte-Carlo-Technique.

RESULTS

The median total cost savings with single-use instruments was $994 per case. The largest driver for cost savings was tray sterilization. Sites with higher staff wages and sterilization costs had a larger probability of realizing greater cost savings with adoption of single-use instruments. In cases using single-use instruments, up to 51% of operating days could have accommodated an additional procedure due to the time savings in OR turnover.

CONCLUSION

This cost modeling study observed significant potential for logistical and economic improvements in TKA with single-use vs reusable instruments. Although few studies have been conducted to measure the impact of single-use instruments in practice, the results of these simulations motivate further investigation.

Analysis of 90-Day Readmissions After Total Shoulder Arthroplasty

BACKGROUND

The number of total shoulder arthroplasty (TSA) procedures performed annually is increasing as a result of an aging population and an increased access to subspecialty-trained upper extremity arthroplasty surgeons. An up-to-date analysis of the incidence of, risk factors for, and reasons for 90-day readmissions in primary anatomic TSA has yet to be performed.

PURPOSE

To characterize 90-day readmissions on a national level. An understanding of these data will help to predict resource utilization and expenses in shoulder arthroplasty.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

All adult patients undergoing elective primary TSA in 2014 who were included in the National Readmission Database were included in the analysis. Two cohorts were created according to 90-day readmission status. Multivariable analysis was then performed to determine predictors of 90-day readmissions. Reasons for 30-, 60-, and 90-day readmissions were identified, and total hospital resource utilization was calculated.

RESULTS

An estimated 26,023 patients were identified. The 30-, 60-, and 90-day rates of readmissions were 0.6%, 1.2%, and 1.7%, respectively. There was no difference in comorbidity burden between the cohorts. Medicare payer status (odds ratio [OR], 1.63; 95% CI, 1.00-2.65; P = .05), transfer to a skilled nurse facility (OR, 1.50; 95% CI, 1.05-2.14; P = .02), and chronic obstructive pulmonary disease (OR, 1.32; 95% CI, 1.04-1.66; P = .02) were identified as predictors of 90-day readmission. Female sex decreased odds of 90-day readmission (OR, 0.72; 95% CI, 0.59-0.87; P = .001). Ninety-day readmissions were associated with significant cost increases (P < .001). The most common identifiable reason for related readmissions was a hardware-related complication at all time points.

CONCLUSION

While uncommon, 90-day readmissions after primary TSA are associated with significant patient morbidity and ultimately substantial hospital costs. Truncating readmission analysis at a 30-day period will miss most arthroplasty-related hospital readmissions.

90-day Readmission in Elective Primary Lumbar Spine Surgery in the Inpatient Setting: A Nationwide Readmissions Database Sample Analysis

STUDY DESIGN

Secondary analysis of a large administrative database.

OBJECTIVE

The objectives of this study are to: 1) identify the incidence and cause of 90-day readmissions following primary elective lumbar spine surgery, 2) offer insight into potential risk factors that contribute to these readmissions, and 3) quantify the cost associated with these readmissions.

SUMMARY OF BACKGROUND DATA

As bundled-payment models for the reimbursement of surgical services become more popular in spine, the focus is shifting toward long-term patient outcomes in the context of 90-day episodes of care. With limited data available on national 90-day readmission statistics available, we hope to provide evidence that will aid in the development of more cost-effective perioperative care models.

METHODS

Using ICD-9 coding, we identified all patients 18 years of age and older in the 2014 Nationwide Readmissions Database (NRD) who underwent an elective, inpatient, primary lumbar spine surgery. Using multivariate logistic regression, we identified independent predictors of 90-day readmission while controlling for a multitude of confounding variables and completed a comparative cost analysis.

RESULTS

We identified 169,788 patients who underwent a primary lumbar spine procedure. In total 4268 (2.5%) were readmitted within 90 days. There was no difference in comorbidity burden between cohorts (readmitted vs. not readmitted) as quantified by the Elixhauser Comorbidity index. Independent predictors of increased odds of 90-day readmission were: anemia, uncomplicated diabetes and diabetes with chronic complications, surgical wound disruption and acute myocardial infarction at the time of the index admission, self-pay status, and an anterior surgical approach. Implant complications were identified as the primary related cause of readmission. These readmissions were associated with a significant cost increase.

CONCLUSION

There are clearly identifiable risk factors that increase the odds of hospital readmission within 90 days of primary lumbar spine surgery. An overall 90-day readmission rate of 2.5%, while relatively low, carries significantly increased cost to both the patient and hospital.

LEVEL OF EVIDENCE

3.

Value-based healthcare analysis of joint replacement surgery for patients with primary hip osteoarthritis

Background

A quarter of the population present at least once a year with a musculoskeletal disorder. Primary hip osteoarthritis is a high-volume condition with significant clinical need and population-level costs. There remains much variation in patient outcomes and care delivery costs for this condition.

Aims

The study aimed to gauge if pathway redesign based on the principles of value-based healthcare (VBHC) could increase value. The aim was to calculate the value of treatment for primary hip osteoarthritis through measuring outcomes that matter to patients, as well as the costs of delivering them. Additionally it aimed to compare two care pathways to identify which elements may better promote the delivery of high-value clinical care.

Methods

Two care models were evaluated: the first being a traditional model with multiple entry points and without pathway standardisation, and the second an intentionally designed standardised multidisciplinary pathway. Mandated National Health Service patient-reported outcomes were assessed but were restructured into a patient-centred format to assess the impact on pain, function and psychological outcomes. Patient-level pathway economic evaluation was performed. Using these data, outcomes were mapped against cost to calculate value.

Results

There were no significant differences in clinical outcomes between the two models. The intentionally designed model delivered better value care, having lower pathway costs. This model produced a small but inconsistent positive financial margin.

Conclusions

Intentionally designed, integrated elective services offer an opportunity to develop and evaluate VBHC models. Analysis of two care pathways from a VBHC perspective demonstrated that an intentionally designed pathway had higher value. The higher value pathway maximised the benefits of having physiotherapists and orthopaedic surgeons working side by side. Developing and measuring patient-orientated outcomes and performing accurate economic evaluation are the key to understanding and achieving better value care.

Changes in Discharge to Rehabilitation: Potential Unintended Consequences of Medicare Total Hip Arthroplasty/Total Knee Arthroplasty Bundled Payments, Should They Be Implemented on a Nationwide Scale?

BACKGROUND

As a part of the 2010 Affordable Care Act, Medicare was committed to changing 50% of its reimbursement to alternative payment models by 2018. One strategy included introduction of "bundled payments" or a fixed price for an episode of care. Early studies of the first operative bundles for elective total hip and knee arthroplasty (THA/TKA) suggest changes in discharge to rehabilitation. It remains unclear the extent to which such changes affect patient well-being. In order to address these concerns, the objective of this study is to estimate projected changes in discharge to various type of rehabilitation, 90-day outcomes, extent of therapy received, and patient health-related quality-of-life before and after introduction of bundled payments should they be implemented on a nationwide scale.

METHODS

A nationwide policy simulation was conducted using decision-tree methodology in order to estimate changes in overt and patient-centered outcomes. Model parameters were informed by published research on bundled payment effects and anticipated outcomes of patients discharged to various types of rehabilitation.

RESULTS

Following bundled payment introduction, discharge to inpatient rehabilitation facilities decreased by 16.9 percentage-points (95% confidence interval [CI] 16.5-17.3) among primary TKA patients (THA 16.8 percentage-points), a relative decline from baseline of 58.9%. Skilled nursing facility use fell by 24.0 percentage-points (95% CI 23.6-24.4). It was accompanied by a 36.7 percentage-point (95% CI 36.3-37.2) increase in home health agency use. Although simulation models predicted minimal changes in overt outcome measures such as unplanned readmission (TKA +0.8 percentage-points), changes in discharge disposition were accompanied by significant increases in the need for further assistive care (TKA +8.0 percentage-points) and decreases in patients' functional recovery and extent of therapy received. They collectively accounted for a 30% reduction in recovered motor gains.

CONCLUSION

The results demonstrate substantial changes in discharge to rehabilitation with accompanying declines in average functional outcomes, extent of therapy received, and health-related quality-of-life. Such findings challenge notions of reduced cost at no harm previously attributed to the bundled payment program and lend credence to concerns about reductions in access to facility-based rehabilitation.

Ninety-day readmissions following reverse total shoulder arthroplasty

Background

An adequate characterization of 90-day readmissions after primary reverse total shoulder arthroplasty (RTSA) on a national level remains to be undertaken. As bundled payment models become more prevalent, an improved understanding of readmission data will help to predict resource utilization and expenses.

Methods

All adult patients who underwent elective primary RTSA in 2014 in the National Readmission Database were included in the analysis. Two cohorts were created based on 90-day readmission status. Multivariate analysis was then performed to determine predictors of 90-day readmissions. Reasons for 30-, 60-, and 90-day readmissions were identified. Total hospital resource utilization was calculated.

Results

An estimated 25,196 patients were identified. The 30-, 60-, and 90-day rates of readmissions were 0.6%, 1.2%, and 1.7%, respectively. Diabetes (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.14-1.78), hypertension (OR, 1.63; 95% CI, 1.28-2.08), paralysis (OR, 3.61; 95% CI, 1.63-7.97), and solid tumor without metastasis (OR, 2.72; 95% CI, 1.21-6.12) were identified as independent predictors of 90-day readmission. Ninety-day readmissions were associated with a significant increase in cost (P = .02). The most common related reason for 90-day readmission was hardware-related complications at all time points.

Conclusion

Although uncommon, 90-day readmissions after primary RTSA are associated with significant patient morbidity and consequently substantial hospital costs.

Are HCAHPS Scores Higher for Private vs Double-Occupancy Inpatient Rooms in Total Joint Arthroplasty Patients?

BACKGROUND

Private hospital rooms have a number of potential advantages compared to shared rooms, including reduced noise and increased control over the hospital environment. However, the association of room type with patient experience metrics in total joint arthroplasty (TJA) patients is currently unclear.

METHODS

For private versus shared rooms, we compared our institutional Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in patients who underwent primary TJA over a 2-year period. Regression model odds ratios (ORs) were adjusted for surgeon, date of surgery, and length of stay.

RESULTS

Patients in private rooms were more likely to report a top-box score for overall hospital rating (85.6% vs 79.4%, OR = 1.53, P = .011), hospital recommendation (89.3% vs 83.0%, OR = 1.78, P = .002), call button help (76.0% vs 68.7%, OR = 1.40, P = .028), and quietness (70.4% vs 59.0%, OR = 1.78, P < .001). There were no significant differences on surgeon metrics including listening (P = .225), explanations (P = .066), or treatment with courtesy and respect (P = .396).

CONCLUSION

For patients undergoing TJA, private hospital rooms were associated with superior performance on patient experience metrics. This association appears specific for global and hospital-related metrics, with little impact on surgeon evaluations. With the utilization of HCAHPS data in value-based initiatives, placement of TJA patients in private rooms may lead to increased reimbursement and higher hospital rankings.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Machine Learning and Primary Total Knee Arthroplasty: Patient Forecasting for a Patient-Specific Payment Model

BACKGROUND

Value-based and patient-specific care represent 2 critical areas of focus that have yet to be fully reconciled by today's bundled care model. Using a predictive naïve Bayesian model, the objectives of this study were (1) to develop a machine-learning algorithm using preoperative big data to predict length of stay (LOS) and inpatient costs after primary total knee arthroplasty (TKA) and (2) to propose a tiered patient-specific payment model that reflects patient complexity for reimbursement.

METHODS

Using 141,446 patients undergoing primary TKA from an administrative database from 2009 to 2016, a Bayesian model was created and trained to forecast LOS and cost. Algorithm performance was determined using the area under the receiver operating characteristic curve and the percent accuracy. A proposed risk-based patient-specific payment model was derived based on outputs.

RESULTS

The machine-learning algorithm required age, race, gender, and comorbidity scores ("risk of illness" and "risk of morbidity") to demonstrate a high degree of validity with an area under the receiver operating characteristic curve of 0.7822 and 0.7382 for LOS and cost. As patient complexity increased, cost add-ons increased in tiers of 3%, 10%, and 15% for moderate, major, and extreme mortality risks, respectively.

CONCLUSION

Our machine-learning algorithm derived from an administrative database demonstrated excellent validity in predicting LOS and costs before primary TKA and has broad value-based applications, including a risk-based patient-specific payment model.