Recent Trends in Medicare Utilization and Reimbursement for Lumbar Fusion Procedures: 2000-2019

Correlations Between Psychiatric Disorders and Perioperative Outcomes After Lumbar Fusions: An Analysis of the National Inpatient Sample (2009-2020)

BACKGROUND

Preoperative diagnoses of psychiatric disorders have a demonstrated association with higher rates of perioperative complications. However, recent studies examining the influence of psychiatric disorders on lumbar fusion outcomes are scarce. Our objective was to determine the relationship between the most common psychiatric disorders and perioperative outcomes after lumbar fusion.

METHODS

Demographic and perioperative data for patients who underwent lumbar spine fusion between 2009 and 2020 were collected from the National Inpatient Sample database. These patients were divided into 2 groups: those who were previously diagnosed with depression, bipolar disorder, or anxiety, and those who were not. Univariable and multivariable linear and logistic regression models were utilized to analyze the data.

RESULTS

Of 2,877,241 patients identified in the National Inpatient Sample database as having undergone lumbar fusion, 647,951 had diagnosed psychiatric disorders, and the remaining 2,229,290 were the unaffected cohort. On multivariable analysis, patients diagnosed with psychiatric disorders had significantly increased odds of respiratory (odds ratio [OR]:1.09) and urinary (OR: 1.08) complications and experienced higher odds of mechanical injury (OR: 1.27), fusion disorders (OR: 1.62), dural tears (OR: 1.08), postprocedure anemia (OR: 1.29), longer hospital stays, and higher total costs (P < 0.001). Conversely, patients with psychiatric disorders had lower odds of neurologic injury (OR: 0.8) and wound complications (OR: 0.91) (P < 0.05).

CONCLUSIONS

Patients with depression, bipolar disorder, or anxiety exhibited higher rates of certain types of complications. However, they appeared to have fewer neurological injuries and wound complications than patients without these psychiatric disorders. These findings highlight the necessity for additional studies to elucidate underlying reasons for these disparities.

Prevalence of total joint arthroplasty in the adult spine deformity population

PURPOSE

The spine, hip, and knee are anatomically and biomechanically connected. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly employed to treat degenerative changes in the hip and knee, while fusion is used for spine degeneration. Spine deformity correction results in changes in sagittal alignment and pelvic parameters, and patients with stiff spines have higher rates of THA dislocation and revision due to instability. The goal of this study was to determine the prevalence of total joint arthroplasty (TJA) in adult spinal deformity (ASD) patients at our institution.

METHODS

Following Institutional Review Board approval, we retrospectively reviewed a list of cases performed by the senior author from 4/2017 to 5/2021. Patients > 18 years old undergoing preoperative evaluation for symptomatic lumbar degeneration or ASD were included. Patients < 18 years old, those diagnosed with adolescent idiopathic scoliosis, and non-fusion cases were excluded. Perioperative full-length standing EOS images were examined for the presence or absence of THA, TKA, or both. Demographic data was collected from patient electronic medical records, and statistical analyses were completed.

RESULTS

572 consecutive cases were reviewed, and 322 were excluded. 250 cases (97M:153F) were included in the final analysis, with a mean age of 61.8 ± 11.2 years. A total of 74 patients had a TJA (29.4%). THA was present in 41 patients (16.4%), and TKA was present in 49 patients (19.6%). Males had a higher prevalence of TJA, THA, and TKA (29.9%, 16.5%, and 21.6%) than females (29.4%, 16.3%, and 18.3%).

CONCLUSIONS

This study revealed a high prevalence TJA rate of 29.4% in ASD at our institution. This rate surpasses the prevalence rate reported among the general population in previous studies. High prevalence of patients with ASD and TJA may merit special surgical consideration.

Lumbar Fusions in Patients with Sickle Cell Disease: A Propensity-Matched Analysis of Postoperative Complications

OBJECTIVE

The present study compares postoperative outcomes between patients with and without sickle cell disease (SCD) undergoing 1-to 3-level lumbar spinal fusion for degenerative pathologies.

METHODS

Patients who underwent 1-to 3-level lumbar spinal fusion for degenerative pathologies from 2010 to 2021 were identified using the PearlDiver database. Patients were separated into 1) SCD and 2) non-SCD groups and were propensity-matched 1:1 for age, sex, Elixhauser Comorbidity Index, surgical approach, and various comorbidities. Complications were separately analyzed by single- and multilevel procedures using chi-squared and Mann-Whitney U testing.

RESULTS

Propensity-score matching identified 1934 SCD and non-SCD patients who underwent single-level fusion and 2094 SCD and non-SCD patients who underwent multilevel fusion. Across single-level fusions, those with SCD had a significantly higher risk of neurovascular compromise (P < 0.001), venous thromboembolism (P = 0.004), pneumonia (P = 0.032), urinary tract infections (P = 0.001), and greater postoperative opioid usage out to 12 months (P = 0.018). Across multilevel fusions, SCD carried higher risk for neurovascular compromise (P < 0.001), pneumonia (P = 0.010), and urinary tract infections (P < 0.001). All SCD patients had significantly higher opioid use at 1 month (P = 0.001) and at 6 months (P = 0.009) postoperatively.

CONCLUSIONS

Patients with SCD undergoing lumbar spinal fusion demonstrate higher risks for coagulopathic, ischemic, and infectious-related complications, as well as long-term postoperative opioid use. Awareness of the unique complication profile in SCD patients may help guide surgeons in refining perioperative management strategies to optimize outcomes in patients with SCD.

Prevalence, Characteristics, and Trends in Retracted Spine Literature: 2000-2023

BACKGROUND

Retraction of scientific publications is an important check on scientific misconduct and serves to maintain the integrity of the scientific literature. The present study aims to examine the prevalence, trends, and characteristics of retracted spine literature across basic science and clinical spine literature.

METHODS

Multiple databases were queried for retracted papers relating to spine or spine surgery, between January 2000 and May 2023. Of 112,668 publications initially identified, 125 were ultimately included in the present study following screening by 2 independent reviewers. Journal of origin, reasons for retraction, date of publication, date of retraction, impact factor of journal, countries of research origin, and study design were collected for each included publication.

RESULTS

Clinical studies were the most frequent type of retracted publication (n = 70). The most common reason for retraction was fraud (n = 58), followed by plagiarism (n = 22), and peer review process manipulation (n = 16). Impact factors ranged from 0.3 to 11.1 with a median of 3.75. Average months from publication to retraction across all studies was 37.5 months. The higher the journal impact factor, the longer the amount of time between publication and retraction (P = 0.01). China (n = 63) was the country of origin of more than half of all retracted spine publications.

CONCLUSIONS

The rate of retractions has been increasing over the past 23 years, and clinical studies have been the most frequently retracted publication type. Clinicians treating disorders of the spine should be aware of these trends when relying on the clinical literature to inform their practice.

Risk analysis index predicts mortality and non-home discharge following posterior lumbar interbody fusion: a nationwide inpatient sample analysis of 429,380 patients (2019-2020)

PURPOSE

Frailty is an independent risk factor for adverse postoperative outcomes following spine surgery. The ability of the Risk Analysis Index (RAI) to predict adverse outcomes following posterior lumbar interbody fusion (PLIF) has not been studied extensively and may improve preoperative risk stratification.

METHODS

Patients undergoing PLIF were queried from Nationwide Inpatient Sample (NIS) (2019-2020). The relationship between RAI-measured preoperative frailty and primary outcomes (mortality, non-home discharge (NHD)) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis.

RESULTS

A total of 429,380 PLIF patients (mean age = 61y) were identified, with frailty cohorts stratified by standard RAI convention: 0-20 "robust" (R)(38.3%), 21-30 "normal" (N)(54.3%), 31-40 "frail" (F)(6.1%) and 41+ "very frail" (VF)(1.3%). The incidence of primary and secondary outcomes increased as frailty thresholds increased: mortality (R 0.1%, N 0.1%, F 0.4%, VF 1.3%; p < 0.001), NHD (R 6.5%, N 18.1%, F 36.9%, VF 42.0%; p < 0.001), eLOS (R 18.0%, N 21.9%, F 31.6%, VF 43.8%; p < 0.001) and complication rates (R 6.6%, N 8.8%, F 11.1%, VF 12.2%; p < 0.001). The RAI demonstrated acceptable discrimination for NHD (C-statistic: 0.706) and mortality (C-statistic: 0.676) in AUROC curve analysis.

CONCLUSION

Increasing RAI-measured frailty is significantly associated with increased NHD, eLOS, complication rates, and mortality following PLIF. The RAI demonstrates acceptable discrimination for predicting NHD and mortality, and may be used to improve frailty-based risk assessment for spine surgeons.

Socioeconomic disparities in lumbar fusion rates were exacerbated during the COVID-19 pandemic

Background

The COVID-19 pandemic disrupted healthcare access and utilization throughout the US, with variable impact on patients of different socioeconomic status (SES) and race. We characterize pre-pandemic and pandemic demographic and SES trends of lumbar fusion patients in the US.

Methods

Adults undergoing first-time lumbar fusion 1/1/2004-3/31/2021 were assessed in Clinformatics® Data Mart for patient age, geographical location, gender, race, education level, net worth, and Charlson Comorbidity Index (CCI). Multivariable regression models were used to evaluate the significance of trends over time, with a focus on pandemic trends 2020-2021 versus previous trends 2004-2019.

Results

The total 217,204 patients underwent lumbar fusions, 1/1/2004-3/31/2021. The numbers and per capita rates of lumbar fusions increased 2004-2019 and decreased in 2020 (first year of COVID-19 pandemic), with large variation in geographic distribution. There was overall a significant decrease in proportion of White patients undergoing lumbar fusion over time (OR=0.997, p<.001), though they were more likely to undergo surgery during the pandemic (OR=1.016, p<.001). From 2004-2021, patients were more likely to be educated beyond high school. Additionally, patients in the highest (>$500k) and lowest (<$25k) net worth categories had significantly more fusions over time (p<.001). During the pandemic (2020-2021), patients in higher net worth groups were more likely to undergo lumbar fusions ($150k-249k & $250k-499k: p<.001) whereas patients in the lowest net worth group had decreased rate of surgeries (p<.001). Lastly, patients' CCI increased significantly from 2004 to 2021 (coefficient=0.124, p<.001), and this trend held true during the pandemic (coefficient=0.179, p<.001).

Conclusions

To the best of our knowledge, our work represents the most comprehensive and recent characterization of SES variables in lumbar fusion rates. Unsurprisingly, lumbar fusions decreased overall with the onset of the COVID-19 pandemic. Importantly, disparities in fusion patients across patient race and wealth widened during the pandemic, reversing years of progress, a lesson we can learn for future public health emergencies.

Projections of Single-level and Multilevel Spinal Instrumentation Procedure Volume and Associated Costs for Medicare Patients to 2050

BACKGROUND

Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States.

METHODS

Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index.

RESULTS

Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932).

CONCLUSIONS

The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution.

The efficacy of ultrasound-guided erector spinae plane block (ESPB) versus freehand ESPB in postoperative pain management after lumbar spinal fusion surgery: a randomized, non-inferiority trial

PURPOSE

Spine surgeries have experienced exponential growth over the past 2 decades. These surgeries are often accompanied by long and severe perioperative pain, presenting a significant management challenge. This study aims to assess and compare the efficacy of two techniques for postoperative pain (POP) management in lumbar spine surgeries: ultrasound-guided erector spinae plane block (ESPB) and intraoperative freehand ESPB.

METHODS

In this prospective randomized non-inferiority trial (Registration Number: IRCT20221107056427N1), adult patients who were candidates for lumbar spinal fusion surgery were randomly divided into two groups: ultrasound-guided ESPB (n = 29) and freehand ESPB (n = 29). The primary outcomes were the total amount of morphine consumed during the first 24 h following the surgery and the numerical rating scale (NRS) pain score at various time points within the first 24 h following the surgery. The secondary outcome was the fentanyl used during surgery.

RESULTS

Participants in the intraoperative freehand approach had considerably higher total morphine consumption in the first postoperative 24 h. The trend of NRS changes in both the ultrasound-guided ESPB group and the freehand ESPB group during the first 24 h after surgery showed a significant decrease. Still, there was no significant difference between the two groups. However, the first analgesic demand time was significantly shorter in the intraoperative freehand ESPB group compared to the ultrasound-guided approach.

CONCLUSION

According to our results, the ultrasound-guided approach of ESPB is more effective in POP management and opioid sparing in lumbar spinal fusion surgeries compared to the freehand approach. However, the data from this study are not sufficient to draw robust conclusions, and further randomized controlled trials with larger sample sizes are required to validate our results.

A matched-control study on the impact of depressive disorders following lumbar fusion for adult spinal deformity: an analysis of a nationwide administrative database

PURPOSE

In recent years, depression rates have been on the rise, resulting in soaring mental health issues globally. There is paucity of literature about the impact of depression on lumbar fusion for adult spine deformity. The purpose of this study is to investigate whether patients with depressive disorders undergoing lumbar deformity fusion have higher rates of (1) in-hospital length of stay; (2) ninety-day medical and surgical complications; and (3) medical reimbursement.

METHODS

A retrospective study was performed using a nationwide administrative claims database from January 2007 to December 2015 for patients undergoing lumbar fusion for spine deformity. Study participants with depressive disorders were selected and matched to controls by adjusting for sex, age, and comorbidities. In total, the query yielded 3706 patients, with 1286 who were experiencing symptoms of depressive disorders, and 2420 who served as the control cohort.

RESULTS

The study revealed that patients with depressive disorders had significantly higher in-hospital length of stay (6.0 days vs. 5.0 days, p < 0.0001) compared to controls. Study group patients also had higher incidence and odds of ninety-day medical and surgical complications (10.2% vs. 5.0%; OR, 2.50; 95% CI, 2.16-2.89; p < .0001). Moreover, patients with depressive disorders had significantly higher episode of care reimbursement ($54,539.2 vs. $51,645.2, p < 0.0001).

CONCLUSION

This study illustrated that even after controlling for factors such as sex, age, and comorbidities, patients with depressive disorders had higher rates of in-hospital length of stay, medical and surgical complications, and total reimbursement.

Understanding Geospatial Trends in Lumbar Fusion Incidence and Technique in Medicare Populations

STUDY DESIGN

Retrospective study with epidemiologic analysis of public Medicare data.

OBJECTIVE

This study seeks to utilize geospatial analysis to identify distinct trends in lumbar fusion incidence and techniques in Medicare populations.

SUMMARY OF BACKGROUND DATA

With an aging population and new technologies, lumbar fusion is an increasingly common procedure. There is controversy, however, regarding which indications and techniques achieve optimal outcomes, leading to significant intersurgeon variation and potential national disparities in care.

MATERIALS AND METHODS

Medicare billing datasets were supplemented with Census Bureau socioeconomic data from 2013 to 2020. These databases listed lumbar fusions billed to Medicare by location, specialty, and technique. Hotspots and coldspots of lumbar fusion incidence and technique choice were identified with county-level analysis and compared with Mann-Whitney U . A linear regression of fusion incidence and a logistic regression of lumbar fusion hotspots/coldspots were also calculated.

RESULTS

Between 2013 and 2020, 624,850 lumbar fusions were billed to Medicare. Lumbar fusion hotspots performed fusions at nearly five times the incidence of coldspots (101.6-21.1 fusions per 100,000 Medicare members) and were located in the Midwest, Colorado, and Virginia while coldspots were in California, Florida, Wisconsin, and the Northeast. Posterior and posterolateral fusion were the most favored techniques, with hotspots in the Northeast. Combined posterior and posterolateral fusion and posterior interbody fusion was the second most favored technique, predominantly in Illinois, Missouri, Arkansas, and Colorado.

CONCLUSIONS

The geographic distribution of lumbar fusions correlates with variations in residency training, fellowship, and specialty. The geospatial patterning in both utilization and technique reflects a lack of consensus in the application of lumbar fusion. The strong variance in utilization is a potentially worrying finding that could suggest that the nonstandardization of lumbar fusion indication has led to both overtreatment and undertreatment across the nation.

LEVEL OF EVIDENCE

Level 3-retrospective.

Minimally Invasive Revision of Luque Plate Instrumentation: A Case Report

Extension of existing spinal fusions may necessitate the removal of or linkage to prior constructs. Knowledge of previously placed instrumentation is critical to success in these revision scenarios. The Luque spinal instrumentation system, developed in the late 1980s, is a legacy pedicle screw and plate system that may be encountered during revision operations today. A 67-year-old male with a remote history of L4-S1 fusion with Luque instrumentation presented with bilateral lower extremity neurogenic claudication due to adjacent segment disease at L3-4. Decompression and extension of fusion to the L3-4 level were performed using minimally invasive techniques. Of note, posterior instrumentation was extended by removing prior L4 pedicle screws with a 7 mm female hexagonal driver through tubular retractors, leaving the Luque plates in place, placing modern pedicle screws at L4 (through the plates) and L3, and linking these with standard rods. The surgery and post-operative course were uncomplicated, and the patient experienced complete resolution of his pre-operative claudication symptoms. Extension of prior Luque plate instrumented fusion can be accomplished minimally invasively without removing the plates themselves, resulting in greater operative efficiency and less surgical morbidity.

Preoperative conservative treatment is insufficiently described in clinical trials of lumbar fusion: a scoping review

PURPOSE

To identify how pre-surgical conservative care is characterized and reported in randomized controlled trials of adults undergoing elective lumbar fusion, including duration and type of treatment.

METHODS

The study design is a scoping review. Data sources include PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL). All randomized controlled trials published in English between January 1, 2005, and February 15, 2022, assessing lumbar fusion as the intervention were included in this review.

RESULTS

Of 166 studies, 62.0% reported a failure in conservative care prior to lumbar fusion, but only 15.1% detailed the type of specific conservative care received. None of the trials provided sufficient details to understand the nature of the pre-surgical conservative treatment, such as frequency, recency/timing, or dosage of conservative interventions.

CONCLUSION

Although roughly two-thirds of trials reported that patients failed conservative care prior to receiving a lumbar fusion, few studies named the conservative intervention provided and no studies provided any details regarding dosing or recency of care. This lack of information creates ambiguity in the surgical decision-making process, setting the assumption that all patients received adequate conservative care prior to surgery. Details about pre-surgical conservative care should be disclosed to allow for appropriate clinical application, decision-making, and interpretation of treatment effects.

Preoperative Depression Screening in Primary Lumbar Fusion: An Evaluation of Its Modifiability on Outcomes in Patients with Diagnosed Depressive Disorder

OBJECTIVE

Studies have reported the detrimental effects of depression following spine surgery; however, none have evaluated whether preoperative depression screening in patients with a history of depression is protective from adverse outcomes and lowers health care costs. We studied whether depression screenings/psychotherapy visits within 3 months before 1- to 2-level lumbar fusion were associated with lower medical complications, emergency department utilization, readmissions, and health care costs.

METHODS

The PearlDiver database from 2010 to 2020 was queried for depressive disorder (DD) patients undergoing primary 1- to 2-level lumbar fusion. Two cohorts were 1:5 ratio matched and included DD patients with (n = 2,622) and DD patients without (n = 13,058) a preoperative depression screen/psychotherapy visit within 3 months of lumbar fusion. A 90-day surveillance period was used to compare outcomes. Logistic regression models computed odds ratio (OR) of complications and readmissions. P value < 0.003 was significant.

RESULTS

DD patients without depression screening had significantly greater incidence and odds of experiencing medical complications (40.57% vs. 16.00%; OR 2.71, P < 0.0001). Rates of emergency department utilization were increased in patients without screening versus screening (15.78% vs. 4.23%; OR 4.25, P < 0.0001), despite no difference in readmissions (9.31% vs. 9.53%; OR 0.97, P = 0.721). Finally, 90-day reimbursements ($51,160 vs. $54,731) were significantly lower in the screened cohort (all P < 0.0001).

CONCLUSIONS

Patients who underwent a preoperative depression screening within 3 months of lumbar fusion had decreased medical complications, emergency department utilization, and health care costs. Spine surgeons may use these data to counsel their patients with depression before surgical intervention.

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019

Importance

Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population.

Objective

To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019.

Design, Setting, and Participants

This retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023.

Main Outcome and Measure

The primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone.

Results

Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001).

Conclusions and Relevance

In this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.

Inflation-Adjusted Medicare Reimbursement for Hip Arthroscopy Fell by 21.1% on Average Between 2011 and 2022

Purpose

To examine Medicare reimbursement for hip arthroscopy from 2011 to 2022.

Methods

The seven most common procedures performed with hip arthroscopy by a single surgeon were gathered. The Physician Fee Schedule Look-Up Tool was utilized to access financial data of the associated Current Procedural Terminology (CPT) codes. The reimbursement data for each CPT were gathered from the Physician Fee Schedule Look-Up Tool. With the consumer price index database and inflation calculator, reimbursement values were adjusted for inflation to 2022 U.S. dollars.

Results

Following an adjustment for inflation, it was found that reimbursement rate for hip arthroscopy procedures on average was 21.1% lower between 2011 and 2022. The average reimbursement per CPT code for the included codes was $899.21 in 2022 compared to inflation adjusted $1,141.45 in 2011, a difference of $242.24.

Conclusions

From 2011 to 2022, the average inflation-adjusted Medicare reimbursement has steadily declined for the most common hip arthroscopy procedures. As Medicare is one of the largest insurance payers, these results have substantial financial and clinical implications for orthopaedic surgeons, policy makers, and patients.

Level of Evidence

Level IV, economic analysis.