Single Price/Case Price Purchasing in orthopaedic surgery: experience at the Lahey Clinic

How to Run a Cost-Effective Operating Room: Opportunities for Efficiency and Cost-Savings

US health care spending is growing at an unsustainable rate. Since physicians control or influence the majority of spending, it is our responsibility to try and control costs. As surgeons we need to learn and consider the cost of implants and supplies and factor them into our treatment decisions to ensure we are providing value for our patients. Although the burden is on us to become more cost conscious, we should never do it at the expense of quality of patient care.

A Preferred Vendor Model Reduces the Costs of Sports Medicine Surgery

PURPOSE

To report on our institution's first year of experience with a preferred vendor program for implants and disposables for sports medicine surgery.

METHODS

Cost and utilization data for implants and disposables were analyzed for knee and shoulder sports medicine surgeries performed during the 2-year period including the 12 months preceding the start of the contract (contract year 0 [CY0] and the first 12 months of the contract period (CY1). The costs of grafts and biological therapies were excluded. Utilization of the preferred vendor's products, operative time, and per-case costs were compared between the 2 time periods and adjusted for patient factors and case mix.

RESULTS

Utilization of the preferred vendor's shavers (0% to 94%, P < .001) and radiofrequency ablation wands (0% to 91%, P < .001) increased significantly in CY1 (n = 5,068 cases) compared with CY0 (n = 5,409 cases), with a small but significant increase in use of the preferred vendor's implants (64% to 67%, P = .023). There was no significant difference in mean operative time between CY0 and CY1 (P = .485). Mean total per-case implant and disposable costs decreased by 12% (P < .001) in CY1 versus CY0.

CONCLUSION

Our institution was able to reduce the costs of sports medicine surgery with the implementation of a preferred single-vendor program for implants and disposables. This program had widespread surgeon adoption and did not have any detrimental effect on operating room efficiency.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Barriers to Revision Total Hip Service Lines: A Surgeon's Perspective Through a Deterministic Financial Model

BACKGROUND

Revision THA represents approximately 5% to 10% of all THAs. Despite the complexity of these procedures, revision arthroplasty service lines are generally absent even at high-volume orthopaedic centers. We wanted to evaluate whether financial compensation is a barrier for the development of revision THA service lines as assessed by RVUs.

QUESTIONS/PURPOSES

Therefore, we asked: (1) Are physicians fairly compensated for revision THA on a per-minute basis compared with primary THA? (2) Are physicians fairly compensated for revision THA on a per-day basis compared with primary THA?

METHODS

Our deterministic financial model was derived from retrospective data of all patients undergoing primary or revision THA between January 2016 and June 2018 at an academic healthcare organization. Patients were divided into five cohorts based on their surgical procedure: primary THA, head and liner exchange, acetabular component revision THA, femoral component revision THA, and combined femoral and acetabular component revision THA. Mean surgical times were calculated for each cohort, and each cohort was assigned a relative value unit (RVU) derived from the 2018 Center for Medicaid and Medicare assigned RVU fee schedule. Using a combination of mean surgical time and RVUs rewarded for each procedure, three models were developed to assess the financial incentive to perform THA services for each cohort. These models included: (1) RVUs earned per the mean surgical time, (2) RVUs earned for a single operating room for a full day of THAs, and (3) RVUs earned for two operating rooms for a full day of primary THAs versus a single rooms for a full day of revision THAs. A sixth cohort was added in the latter two models to more accurately reflect the variety in a typical surgical day. This consisted of a blend of revision THAs: one acetabular, one femoral, and one full revision. The RVUs generated in each model were compared across the cohorts.

RESULTS

Compared with primary THA by RVU per minute, in revision THA, head and liner exchange demonstrated a 4% per minute deficit, acetabular component revision demonstrated a 29% deficit, femoral component revision demonstrated a 32% deficit, and full revision demonstrated a 27% deficit. Compared with primary service lines with one room, revision surgeons with a variety of revision THA surgeries lost 26% potential relative value units per day. Compared with a two-room primary THA service, revision surgeons lost 55% potential relative value units per day.

CONCLUSIONS

In a comparison of relative value units of a typical two-room primary THA service line versus those of a dedicated revision THA service line, we found that revision specialists may lose between 28% and 55% of their RVU earnings. The current Centers for Medicare and Medicaid Services reimbursement model is not viable for the arthroplasty surgeon and limits patient access to revision THA specialists.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

Association of Cost Savings and Surgical Quality With Single-Vendor Procurement for Spinal Implants

IMPORTANCE

Significant cost savings can be achieved from consolidating purchases of spinal implants with a single vendor. However, it is currently unknown whether sole-source contracting or vendor rationalization more broadly affects patient care.

OBJECTIVES

To describe the single-vendor procurement of spinal implants, characterize the economic benefits of sole-source contracting, and gauge whether vendor rationalization is associated with a diminished quality of care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed adult patients receiving single-level lumbar interbody fusions at a single institution from January 1, 2009, to July 31, 2017. Exclusion criteria included multilevel fusions and prior spinal fusions.

EXPOSURES

Patients were analyzed based on the number of vendors available to surgeons at the time of the patient's surgery. January 1, 2009, to December 31, 2010, was defined as the multivendor period (10 vendors); January 1, 2011, to December 31, 2014, was defined as the dual-vendor period; and January 1, 2015, to July 31, 2017, was defined as the single-vendor period.

MAIN OUTCOMES AND MEASURES

Rates of 12-month revision surgery, complications, 30-day readmissions, and postoperative patient-reported outcomes, as measured by 5-dimension European Quality of Life (EQ-5D) and Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) utilities. Propensity score weighting was performed to control for confounding. The Holm method was used to correct for multiple testing. Annual cost savings associated with the dual-vendor and single-vendor periods were also reported.

RESULTS

A total of 1373 patients (mean [SD] age, 59.2 [12.6] years; 763 [55.6%] female; 1161 [84.6%] white) were analyzed. Rates of revisions after adjusting for confounding were 3.2% (95% CI, 1.5%-6.7%) for the multivendor period, 4.5% (95% CI, 3.1%-6.5%) for the dual-vendor period, and 3.0% (95% CI, 1.7%-5.0%) for the single-vendor period. Complication rates were 5.3% (95% CI, 2.7%-10.1%) for the multivendor period, 7.2% (95% CI, 5.4%-9.6%) for the dual-vendor period, and 6.4% (95% CI, 4.6%-8.8%) for the single-vendor period. Readmission rates were 14.2% (95% CI, 9.7%-20.2%) for the multivendor period, 12.6% (95% CI, 10.1%-15.5%) for the dual-vendor period, and 9.7% (95% CI, 7.4%-12.7%) for the single-vendor period. Revisions, complications, and patient-reported outcomes were statistically equivalent across all periods. Readmissions were not statistically equivalent but not statistically different. The savings attributable to vendor rationalization were 24% for the dual-vendor and 21% for the single-vendor periods.

CONCLUSIONS AND RELEVANCE

The single-vendor procurement of spinal implants was associated with significant cost savings without evidence of an associated decline in the quality of care. Large hospital systems may consider sole-source purchasing as a viable cost reduction strategy.

Preferred Single-Vendor Program for Total Joint Arthroplasty Implants: Surgeon Adoption, Outcomes, and Cost Savings

BACKGROUND

In total joint arthroplasty, variation in implant use can be driven by vendor relationships, surgeon preference, and technological advancements. Our institution developed a preferred single-vendor program for primary hip and knee arthroplasty. We hypothesized that this initiative would decrease implant costs without compromising performance on quality metrics.

METHODS

The utilization of implants from the preferred vendor was evaluated for the first 12 months of the contract (September 1, 2017, to August 31, 2018; n = 4,246 cases) compared with the prior year (September 1, 2016, to August 31, 2017; n = 3,586 cases). Per-case implant costs were compared using means and independent-samples t tests. Performance on quality metrics, including 30-day readmission, 30-day surgical site infection (SSI), and length of stay (LOS), was compared using multivariable-adjusted regression models.

RESULTS

The utilization of implants from the preferred vendor increased from 50% to 69% (p < 0.001), with greater use of knee implants than hip implants from the preferred vendor, although significant growth was seen for both (from 62% to 81% for knee, p < 0.001; and from 38% to 58% for hip, p < 0.001). Adoption of the preferred-vendor initiative was greatest among low-volume surgeons (from 22% to 87%; p < 0.001) and lowest among very high-volume surgeons (from 61% to 62%; p = 0.573). For cases in which implants from the preferred vendor were utilized, the mean cost per case decreased by 23% in the program's first year (p < 0.001), with an associated 11% decrease in the standard deviation. Among all cases, there were no significant changes with respect to 30-day readmission (p = 0.449) or SSI (p = 0.059), while mean LOS decreased in the program's first year (p < 0.001).

CONCLUSIONS

The creation of a preferred single-vendor model for hip and knee arthroplasty implants led to significant cost savings and decreased cost variability within the program's first year. Higher-volume surgeons were less likely to modify their implant choice than were lower-volume surgeons. Despite the potential learning curve associated with changes in surgical implants, there was no difference in short-term quality metrics.

LEVEL OF EVIDENCE

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

A dedicated revision total knee service: a surgeon’s perspective

AIMS

Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity.

MATERIALS AND METHODS

All patients that underwent primary or revision TKA from January 2016 to June 2018 were included as the primary source of data. All rTKA patients were categorized by the number of components revised (e.g. liner exchange, two or more components). Three models were used to assess the potential surgical productivity of a dedicated rTKA service : 1) work relative value unit (RVU) versus mean surgical time; 2) primary TKA with a single operating theatre (OT) versus rTKA with a single OT; and 3) primary TKA with two OTs versus rTKA with a single OT.

RESULTS

In total, 4570 procedures were performed: 4128 primary TKAs, 51 TKA liner exchanges, and 391 full rTKAs. Surgical time was significantly different between the primary TKA, liner exchange, and rTKA cohorts (100.6, 97.1, and 141.7 minutes, respectively; p < 0.001). Primary TKA yielded a mean of 7.1% more RVU/min per procedure than rTKA. Our one-OT model demonstrated that primary TKA (n = 4) had a 1.9% RVU/day advantage over rTKA (n = 3). If two OTs are used for primary TKA (n = 6), the outcome strongly favours primary TKA by an added 34.6% RVUs/day.

CONCLUSION

Our results suggest that a dedicated rTKA service would lead to lower surgeon remuneration based on the current RVU paradigm. Revision arthroplasty specialists may need additional or alternative incentives to promote the development of a dedicated revision service. Through such an approach, healthcare organizations could enhance the quality of care provided, but surgeon productivity measures would need to be adjusted to reflect the burden of these cases. Cite this article: Bone Joint J 2019;101-B:675-681.

Cost-Effectiveness of Dual Mobility and a Value-Based Algorithm of Utilization

Hip dislocation remains a major concern following total hip arthroplasty due to its high frequency and economic burden. This article evaluates the cost-effectiveness regarding dual mobility as an alternative to standard implant designs. A review of literature analyzing the PubMed Central database was undertaken using the following terms in the primary query: dual mobility, cost-effectiveness, cost-analysis, or economic analysis. Dual mobility systems may be a cost-effective alternative when the price of the implant does not exceed the traditional system by $1023. Dual mobility cups may be an essential component for the future success of value-based total hip arthroplasty.

The Historical Development of Value-Based Care: How We Got Here

The original architects of Medicare modeled the payment system on the existing fee-for-service (FFS) structure that historically dominated the health-insurance market. Under the FFS paradigm, health-care expenditures experienced an exponential rise. In response, the managed care and capitation models of health-care delivery were developed. However, changes in Medicare reimbursement, along with an increasing volume of orthopaedic procedures and escalating implant costs, call into question the cost-effectiveness of this service line. The success of the Medicare Acute Care Episode (ACE) Demonstration Project proved the feasibility of value-based care and ushered in a new era of bundled payment initiatives.

Comparison of Direct Perioperative Costs in Treatment of Unstable Distal Radial Fractures: Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Pinning

BACKGROUND

As the United States transitions to value-based insurance, bundled payments, and capitated models, it is paramount to understand health-care costs and resource utilization. The financial implications of open reduction and internal fixation (ORIF) with a volar locking plate for management of unstable distal radial fractures have not been established. We aimed to elucidate cost differences between ORIF and closed reduction and percutaneous pinning (CRPP). Our hypothesis was that ORIF has greater direct perioperative costs than CRPP but that the costs equilibrate over time.

METHODS

We reviewed financial data for 40 patients prospectively enrolled and randomized to undergo CRPP or ORIF for treatment of a closed, displaced, unstable distal radial fracture. Clinical and functional outcomes, hospital-associated direct perioperative costs, postoperative care and therapy costs, and costs for additional procedures were compared. Cost data were stratified into perioperative, 90-day, and 1-year periods, and were reported utilizing cost ratios (CRs) relative to the CRPP cohort. Statistical analysis was performed with chi-square and independent-samples t tests with an alpha level of <0.05.

RESULTS

Seventeen patients underwent CRPP and 23 underwent ORIF with a volar plate. Patients who underwent ORIF incurred greater 90-day (CR = 2.03/1.0, p < 0.001) and 1-year (CR = 1.60/1.0, p < 0.001) direct costs than those who underwent CRPP. The differential was greatest in the immediate perioperative period and gradually decreased over time. Operating room fees (CR = 1.7/1.0, p < 0.001), operating room implants, anesthesia (CR = 1.8/1.0, p < 0.001), and total perioperative costs (CR = 2.7/1.0, p < 0.001) were significantly greater in the ORIF cohort. Rehabilitation and cast technician costs were comparable (CR = 0.9/1.0 [ORIF/CRPP], p = 0.69). At 1 year, the CR for all costs of decreased to 1.6/1.0 (ORIF/CRPP, p < 0.001). Compared with the CRPP cohort, the ORIF cohort demonstrated significantly better functional outcomes at 6, 9, and 12 weeks and similar outcomes at 1 year.

CONCLUSIONS

ORIF for a displaced, unstable distal radial fracture incurred greater direct costs than CRPP. Although implant costs for ORIF provided the greatest cost differential, additional procedures and higher clinic costs in the CRPP cohort narrowed the 90-day and 1-year cost gaps.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Bundle Payment for Musculoskeletal Care: Current Evidence (Part 1)

In the face of escalating costs and variations in quality of care, bundled payment models for total joint arthroplasty procedures are becoming increasingly common, both through the Centers for Medicare & Medicaid Services and private payer organizations. The effective implementation of these payment models requires cooperation between multiple service providers to ensure economic viability without deterioration in care quality. This article introduces a stepwise model for the financial analysis of bundled contracts for use in negotiations between hospitals and private payer organizations.

Acetabular components with or without screws in total hip arthroplasty

AIM

To compare the operation time, blood loss, and early outcomes of acetabular components with and without the screw.

METHODS

Thirty patients who underwent cementless acetabular component with or without screw and whose follow-up exceeded one year period in total hip arthroplasty were evaluated. A posterior approach was used in all surgical procedures by one experienced surgeon. Demographic data, operation time, intra- and postoperative blood loss volume, follow-up clinical score, cup migration, and osteolysis were recorded. The Kolmogorov-Smirnov test was performed for testing the normality of study data. Mann-Whitney U test was used to analyze the inter-group differences. A P-value of ≤ 0.05 was considered statistically significant.

RESULTS

Acetabular components were used in 16 (53.3%) patients with screw and 14 (46.7%) without screw. After one year of follow-up, an osteolytic lesion of 3 mm was found in only one patient in the screw group. No cup migration was encountered. Intra-group mean Harris hip score significantly increased, but there was no significant inter-group difference. While the mean operation time of the screw group was 121.8 min (range; 95-140), it was 102.7 min (range; 80-120) in the no-screw group, and this difference was statistically significant (P = 0.002). The mean intraoperative/postoperative, and total blood loss were 556.6 mL (range: 350-800)/423.3 mL (range: 250-600), and 983.3 mL (range: 600-1350), respectively in the screw group; and 527 mL (range: 400-700)/456 mL (range: 230-600), and 983 mL (range: 630-1250), respectively in the no-screw group. The blood loss difference between the two groups was not significant. In the screw group, the operation time was 19.1 min longer than the no-screw group, and this difference was statistically significant.

CONCLUSION

Acetabular components with or without screw have similar results, but the use of screw increases the operation time significantly, while not changing the blood loss volume.

Financial Impact of Dual Vendor, Matrix Pricing, and Sole-Source Contracting on Implant Costs

Implant costs comprise the largest proportion of operating room supply costs for orthopedic trauma care. Over the years, hospitals have devised several methods of controlling these costs with the help of physicians. With increasing economic pressure, these negotiations have a tremendous ability to decrease the cost of trauma care. In the past, physicians have taken no responsibility for implant pricing which has made cost control difficult. The reasons have been multifactorial. However, industry surgeon consulting fees, research support, and surgeon comfort with certain implant systems have played a large role in slowing adoption of cost-control measures. With the advent of physician gainsharing and comanagement agreements, physicians now have impetus to change. At our facility, we have used 3 methods for cost containment since 2009: dual vendor, matrix pricing, and sole-source contracting. Each has been increasingly successful, resulting in massive savings for the institution. This article describes the process and benefits of each model.

Affordable Care Organizations and Bundled Pricing: A New Philosophy of Care

Under the Patient Protection and Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services' Innovation was chartered to develop new models of health care delivery. The changes meant a drastic need to restructure the health care system. To minimize costs and optimize quality, new laws encourage continuity in health care delivery within an integrated system. Affordable care organizations provided a model of high-quality care while reducing costs. Bundled payments can have a substantial effect on the national expenditures. This article examines new developments in bundle payments, affordable care organizations, and gainsharing agreements as they pertain to arthroplasty.

Prevalence of knee arthroplasty in the state of São Paulo between 2003 and 2010

CONTEXT AND OBJECTIVE:

The volume of knee arthroplasty procedures has increased over the last decade. The aim of this study was to estimate the frequency of these procedures performed within the public healthcare system of the state of São Paulo between 2003 and 2010.

DESIGN AND SETTING:

Cross-sectional study conducted in the state of São Paulo by researchers at Hospital do Servidor Público do Estado de São Paulo.

METHODS:

A sample of 10,952 patients (7,891 females and 3,061 males) who underwent primary total knee arthroplasty (TKA) and revision of total knee arthroplasty (RTKA) in the state of São Paulo between 2003 and 2010 was evaluated. The patients were cataloged using the public healthcare service's TABNET software. All of the patients presented primary osteoarthritis of the knee. The variables of gender, number of primary TKA procedures and number of RTKA procedures were evaluated.

RESULTS:

A total of 10,952 TKA procedures were performed (annual average of 1369), of which 9,271 (85%) were TKA and 1,681 (15%), RTKA. Of the TKA procedures, 72% were carried out on females (P < 0.0001), while 70% of the RTKA procedures were on females (P < 0.0001). The average ratio of TKA to RTKA was 5.5:1 (P < 0.0001); the ratios in 2003 and 2010 were 9.0:1 and 4.4:1 (P < 0.0001), respectively.

CONCLUSION:

The number and frequency of TKA and RTKA procedures increased in the state of São Paulo between 2003 and 2010. This increase was relatively greater in RTKA than in TKA and was predominantly in female patients.

Cost-effective trauma implant selection: AAOS exhibit selection

Today's increasingly complex health-care landscape requires that physicians take an active role in minimizing health-care costs and expenditures. Judicious choice of implants, a fracture-driven treatment algorithm, capitation models, use of generic fracture implants, and reuse of external fixation constructs all represent mechanisms that can result in substantial savings. In some health-care environments, these cost savings programs may be directly linked to physician reimbursement in the form of gainsharing plans. Evidence-based critical evaluations of implant usage patterns are necessary to help control implant-related health-care spending but are lacking in the current literature. Physicians need to acknowledge their influence and responsibility in this realm and assume an active role to help reduce costs.

Effect of price capitation on implant selection for primary total hip and knee arthroplasty

While price capitation strategies may help to control total hip (THA) and knee arthroplasty (TKA) implant costs, its effect on premium implant selection is unclear. Primary THA and TKA cases 6 months before and after capitated pricing implementation were retrospectively identified. After exclusions, 716 THA and 981 TKA from a large academic hospital and 2 midsize private practice community hospitals were reviewed. Academic hospital surgeons increased premium THA implant usage (66.5% to 70.6%; P = 0.28), while community surgeons selected fewer premium implants (36.4%) compared to academic surgeons, with no practice change (P = 0.95). Conversely, premium TKA implant usage significantly increased (73.4% to 89.4%; P < 0.001) for academic surgeons. Community surgeons used premium TKA implants at greater rates in both periods, with all cases having ≥1 premium criterion.

Implant standardization for hemiarthroplasty: implementation of a pricing matrix system at a level II community based trauma system

Our purpose was to perform a clinical and financial analysis of a pricing matrix system on operative hip fracture care concerning hemiarthroplasty for displaced femoral neck fractures in elderly low demand patients. Data analysis on 81 pre-matrix and 88 post-matrix patients demonstrated no significant differences in age, sex, ASA or fracture pattern between the two groups. No difference in surgical approach, cement use, prosthesis choice, operative time, estimated blood loss, or intra-operative complication rate was observed. No radiographic difference in subsidence or loosening was demonstrated. Readmission form cardiac, UTI, PE or DVT rates were similar between groups and no increase in revision surgery or mortality was observed. Overall, our hospital realized a 37% reduction in implant costs, resulting in $165,500 savings for the calendar year.

Cumulative revision rate is higher in metal-on-metal THA than metal-on-polyethylene THA: analysis of survival in a community registry

BACKGROUND

Metal-on-metal (MOM) THA bearing technology has focused on improving the arc of motion and stability and minimizing wear compared with traditional metal-on-polyethylene (MOP) bearing couples. It is unclear whether this more costly technology adds value in terms of improved implant survival.

QUESTIONS/PURPOSES

This study evaluated Kaplan-Meier survival, revisions for dislocation, and cost of MOM THA compared with metal-on-cross-linked polyethylene (MOXP) THA in a community joint registry, with subset analysis of the recalled Depuy ASR™ implant.

METHODS

All MOM THAs (resurfacings excluded) performed between January 2002 and December 2009 were included (n = 1118) and compared with a control group of MOXP THAs (n = 1286) done during the same time. Analysis was performed to compare age, gender, cost of implant, length of stay, year of index procedure, diagnosis, head size (< 32 mm versus ≥ 32 mm), revision and revision reason for both groups. Analysis at a mean of 3.6 years was done using Wilcoxon rank sum tests, Pearson's chi-square tests, Kaplan Meier methods, and Cox regression.

RESULTS

The cumulative revision rate (CRR) was higher in MOM implants than in MOXP implants (MOM CRR = 13%; MOXP CRR = 3%). MOM implants were three times as likely to be revised as MOXP implants after adjustment for age, head size, and year of procedure. The recalled DePuy ASR™ implant was six times as likely to be revised as other MOM THAs. After removing the ASR™ implants from analysis, survivorship of MOM implants was not better than that of the MOXP hips.

CONCLUSIONS

During the study time, MOM THAs showed inferior survival to MOXP THAs after adjusting for age, head size, and year of procedure. Longer followup is necessary to see whether MOM THAs add value in younger patient groups.

All-polyethylene and metal-backed tibial components are equivalent with BMI of less than 37.5

BACKGROUND

Modular, metal-backed tibial (MBT) components are associated with locking mechanism dysfunction, breakage, backside wear, and osteolysis, which compromise survivorship. All-polyethylene tibial (APT) components eliminate problems associated with MBTs, but, historically, APT utilization has generally been limited to older, less active patients. However, it is unclear whether APT utilization can be expanded to a nonselected patient population.

QUESTIONS/PURPOSES

We therefore determined the survivorship of APT components compared with MBT components in a non-age- or activity-selected population who underwent TKA.

METHODS

Using a longitudinal database, we identified 775 patients with primary TKAs utilizing a single implant design between 1999 and 2007. Of these, 558 (72%) patients had APT components (APT2), while 217 (28%) patients with tibial bone loss or defects, contralateral MBT components, or a BMI of greater than 37.5 received MBT components. We determined the survivorship in the two groups. The minimum followup was 2 years for both groups (mean ± SD: MBT, 80 ± 29 months; APT, 63 ± 27 months). The APT group was older (average age: APT2, 70 years; MBT, 64.7 years) and had a lower BMI than the MBT group (APT2, 30.8; MBT, 33.8).

RESULTS

Survivorship, as defined by revision for any reason, was 99% for the APT group and 97% for the MBT group. There were four (2%) tibial failures in the MBT group in patients with a BMI of greater than 40. There were no revisions for loosening or osteolysis in the APT group.

CONCLUSION

APT implants perform as well as MBT implants in a non-age- or activity-selected TKA population with a BMI of less than 37.5.

Migration pattern of cementless press fit cups in the presence of stabilizing screws in total hip arthroplasty

The aim of this study was to evaluate the initial acetabular implant stability and late acetabular implant migration in press fit cups combined with screw fixation of the acetabular component in order to answer the question whether screws are necessary for the fixation of the acetabular component in cementless primary total hip arthroplasty. One hundred and seven hips were available for follow-up after primary THA using a cementless, porous-coated acetabular component. A total of 631 standardized radiographs were analyzed digitally by the "single-film-x-ray-analysis" method (EBRA). One hundred and one (94.4 %) acetabular components did not show significant migration of more than 1 mm. Six (5.6%) implants showed migration of more than 1 mm. Statistical analysis did not reveal preoperative patterns that would identify predictors for future migration. Our findings suggest that the use of screw fixation for cementless porous-coated acetabular components for primary THA does not prevent cup migration.

Hospital economics of primary THA decreasing reimbursement and increasing cost, 1990 to 2008

BACKGROUND

The introduction of new technology has increased the hospital cost of THA. Considering the impending epidemic of hip osteoarthritis in the United States, the projections of THA prevalence, and national cost-containment initiatives, we are concerned about the decreasing economic feasibility of hospitals providing THA.

QUESTIONS/PURPOSES

We compared the hospital cost, reimbursement, and profit/loss of THA over the 1990 to 2008 time period.

METHODS

We reviewed the hospital accounting records of 104 patients in 1990 and 269 patients in 2008 who underwent a unilateral primary THA. Hospital revenue, hospital expenses, and hospital profit (loss) for THA were evaluated and compared in 1990, 1995, and 2008.

RESULTS

From 1990 to 2008, hospital payment for primary THA increased 29% in actual dollars, whereas inflation increased 58%. Lahey Clinic converted a $3848 loss per case on Medicare fee for service, primary THA in 1990 to a $2486 profit per case in 1995 to a $2359 profit per case in 2008. This improvement was associated with a decrease in inflation-adjusted revenue from 1995 to 2008 and implementation of cost control programs that reduced hospital expenses. Reduction of length of stay and implant costs were the most important drivers of expense reduction. In addition, the managed Medicare patient subgroup reported a per case profit of only $650 in 2008.

CONCLUSIONS

If hospital revenue for THA decreases to managed Medicare levels, it will be difficult to make a profit on THA. The use of technologic enhancements for THA add to the cost problem in this era of healthcare reform. Hospitals and surgeons should collaborate to deliver THA at a profit so it will be available to all patients. Government healthcare administrators and health insurance payers should provide adequate reimbursement for hospitals and surgeons to continue delivery of high-quality THAs.

LEVEL OF EVIDENCE

Level III, economic and decision analysis. See Guidelines for Authors for a complete description of levels of evidence.

Do "premium" joint implants add value?: analysis of high cost joint implants in a community registry

BACKGROUND

Numerous joint implant options of varying cost are available to the surgeon, but it is unclear whether more costly implants add value in terms of function or longevity.

QUESTIONS/PURPOSES

We evaluated registry survival of higher-cost "premium" knee and hip components compared to lower-priced standard components.

METHODS

Premium TKA components were defined as mobile-bearing designs, high-flexion designs, oxidized-zirconium designs, those including moderately crosslinked polyethylene inserts, or some combination. Premium THAs included ceramic-on-ceramic, metal-on-metal, and ceramic-on-highly crosslinked polyethylene designs. We compared 3462 standard TKAs to 2806 premium TKAs and 868 standard THAs to 1311 premium THAs using standard statistical methods.

RESULTS

The cost of the premium implants was on average approximately $1000 higher than the standard implants. There was no difference in the cumulative revision rate at 7-8 years between premium and standard TKAs or THAs.

CONCLUSIONS

In this time frame, premium implants did not demonstrate better survival than standard implants. Revision indications for TKA did not differ, and infection and instability remained contributors. Longer followup is necessary to demonstrate whether premium implants add value in younger patient groups.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hospital economics of primary total knee arthroplasty at a teaching hospital

BACKGROUND

The hospital cost of total knee arthroplasty (TKA) in the United States is a major growing expense for the Centers for Medicare & Medicaid Services (CMS). Many hospitals are unable to deliver TKA with profitable or breakeven economics under the current Diagnosis-Related Group (DRG) hospital reimbursement system.

QUESTIONS/PURPOSES

The purposes of the current study were to (1) determine revenue, expenses, and profitability (loss) for TKA for all patients and for different payors; (2) define changes in utilization and unit costs associated with this operation; and (3) describe TKA cost control strategies to provide insight for hospitals to improve their economic results for TKA.

RESULTS

From 1991 to 2009, Lahey Clinic converted a $2172 loss per case on primary TKA in 1991 to a $2986 profit per case in 2008. The improved economics was associated with decreasing revenue in inflation-adjusted dollars and implementation of hospital cost control programs that reduced hospital expenses for TKA. Reduction of hospital length of stay and reduction of knee implant costs were the major drivers of hospital expense reduction.

CONCLUSIONS

During the last 25 years, our economic experience with TKA is concerning. Hospital revenues have lagged behind inflation, hospital expenses have been reduced, and our institution is earning a profit. However, the margin for TKA is decreasing and Managed Medicare patients do not generate a profit. The erosion of hospital revenue for TKA will become a critical issue if it leads to economic losses for hospitals or reduced access to TKA.

LEVEL OF EVIDENCE

Level III, Economic and Decision Analyses. See Guidelines for Authors for a complete description of levels of evidence.

Incidence and cost of intraoperative waste of hip and knee arthroplasty implants

Many strategies have been reported for decreasing the cost of orthopedic procedures, but prosthetic waste has not been investigated. The purpose of this study was to characterize the cost of intraoperative waste of hip and knee implants. A regional prospective assessment was performed, evaluating the reasons for component waste, the cost of the wasted implants, and where the cost was absorbed (hospital or manufacturer). Implant waste occurred in 79 (2%) of 3443 procedures, with the surgeon and operating room staff bearing primary responsibility in 73% of occurrences. The annualized cost was $109 295.35, with 67% absorbed by hospitals. When extrapolated to the whole of the United States, the annual cost to hospitals would be $36,019,000 and is estimated to rise to $112,033,000 by 2030, representing a potential target for educational programs and other cost containment measures.

Cementless acetabular fixation with and without screws: analysis of stability and migration

The purpose of this study was to compare initial stability and late migration of 775 cementless acetabular components with and without screw fixation. Screw fixation was used in 509 cups and no screws in 266 cups. Average follow-up in the screw fixation group was 6.32 years (range, 2-10 years) and 6.9 years (range, 2-10 years) in the no-screw group. One component (0.2%, osteolysis) in the screw group and one (0.4%, loss of fixation) in the no-screw group required revision. Osteolytic lesions more than 4 cm(2) were noted in 8 (1.6%) screw fixation cups and 2 (0.75%) no-screw fixation cups. No cups in either cohort had radiographic evidence of migration. Screw fixation did not have a favorable or adverse effect on the outcome of acetabular reconstruction.

Intraoperative waste of trauma implants: a cost burden to hospitals worth addressing?

OBJECTIVES

The purposes of this study were to assess the incidence of intraoperative trauma implant waste in a regional territory of the United States and to assess its impact on costs.

METHODS

The total number of procedures using a single device manufacturer's orthopaedic trauma implants in one geographic region and number of occurrences of intraoperative orthopaedic trauma implant waste were recorded prospectively from 74 contiguous hospitals over a period of 18 months along with the individual responsible for the waste (surgeon, vendor representative, or operating room staff), the cost of the wasted implant, and whether the hospital paid for the implant. Hospitals were stratified into teaching or community institutions. The collected data were then aggregated and analyzed for overall incidence and cost as well as cost per trauma procedure.

RESULTS

Implant waste occurred in 37 of 6531 procedures (0.6%) with 16 of the centers (21.6%) reporting at least one occurrence and 95% attributed to the surgeon or operating room staff. Community hospitals were found to have a significantly higher incidence of implant waste as compared with teaching hospitals. Hospitals absorbed 74% of the wasted implant costs ($20,357 over the study period). This expense represented a mean additional cost of $3.12 per orthopaedic trauma procedure performed.

CONCLUSIONS

There is a small but notable annual incidence and cost of orthopaedic trauma implant waste in the study region with the majority of this cost borne by the hospitals. However, implant waste occurs infrequently and represents a very small cost to hospitals per procedure. Educational programs and other strategies to reduce its incidence are unlikely to yield any substantial cost savings.

The effects of a prospective case payment system on hospital charges for total hip arthroplasty in Taiwan

We evaluate the effects of instituting prospective case payment system (PPS) system on total hip arthroplasty (THA) charges and compare our university hospital THA cost structure with comparable health care institutions in the United States. The study consisted of 5009 patients who received a primary THA in 24 hospitals between 1995 and 2001. After adjusting for inflation, the average total charge of THA for pre-PPS was 4762 US dollars and 4054 US dollars for post-PPS. The average cost for prostheses accounted for 61% of total costs at our hospital, as compared with the US studies ranging from 27% to 34%. As United States, PPS achieved the purpose of cost containment and changed practice patterns of orthopedic surgeons and hospital resource use in Taiwan.

Cost effectiveness of revision total knee arthroplasty

Total knee arthroplasty now exceeds total hip arthroplasty as the most commonly performed joint replacement. Projections suggest the need for revision knee arthroplasty in the future will produce an immense economic burden. The excellent cost effectiveness of primary knee arthroplasty has been well established. This article explores the cost effectiveness of revision knee arthroplasty, and makes a comparison of costs between different international health care systems. While revision knee arthroplasty is more costly, technically difficult, and complicated than primary knee arthroplasty, it is still a cost effective means of improving function, pain relief, and quality of life. The role of national arthroplasty registries will be important in guiding decision making toward reducing the requirements for revision surgery.

LEVEL OF EVIDENCE

Prognostic study, level II-1 (prospective study). See Guidelines for Authors for complete description of levels of evidence.

Improving anesthesiologist performance through profiling and incentives

STUDY OBJECTIVE

To determine the influence of profiling and incentives on anesthesiologist behavior in relation to several key indicators of performance.

DESIGN

Prospective collection and analysis of operational data before and after implementation of a physician profiling, reporting, and incentive program.

SETTING

University hospital.

MEASUREMENTS

An intervention consisting of two components was studied with the intent of stimulating a high level of performance in relation to a peer group. The first component, a monthly report of physician performance via an individualized performance report, was provided to each physician for each of 6 months. The second component consisted of a financial incentive. For each month in the study, physicians were eligible to receive a variable financial incentive of between $0 and $500 per month depending on individual performance based scoring in relation to each other. Physician performance was tracked in five areas: 1) percentage of first cases of the day in the room at or before the scheduled in-room time, 2) percentage of cases with an anesthesia prep time less than a target, 3) percentage of cases delayed due to waiting for an anesthesiology patient evaluation, 4) percentage of cases delayed during the anesthesiology controlled time, and, 5) percentage of cases delayed due to waiting for the anesthesiology attending. Results were reported to each physician on a monthly basis, by e-mail distribution, of an individualized perioperative efficiency summary report. A monthly financial incentive was awarded to the top performing physicians in the form of a credit to the physician's personal CME/expense account. Also, all physicians received a rank order list of their performance on each indicator at the end of each month.

MAIN RESULTS

31 anesthesiologists, comprising the multispecialty division, and covering all services with the exception of obstetrics, pediatrics, and cardiothoracic anesthesia were tracked for 6 months. Compared to the first month, the percent of first cases of the day in the room at or before the scheduled start time and the percent of cases with an anesthesiology prep time less than target increased significantly (19 +/- 4.6%, vs. 61 +/- 6.5%, 95% CI, p <0.001; and 57 +/- 5.3%, vs. 73 +/- 5.1%, 95% CI, p <0 .001) during the sixth month. The mean number of cases per physician with a delay during anesthesiology controlled time decreased (14.9 +/- 2.9 vs. 3.3 +/- 1, p <0.001), no change occurred in the number of cases with a delay due to waiting for an anesthesiology patient evaluation or number of cases delayed due to waiting for the anesthesiology attending in the sixth month compared with the first month.

CONCLUSION

Tracking and rewarding physician performance with monthly profiling and a financial incentive given to the best in a peer group improves anesthesiologist performance in several key areas.

Economic evaluation in total hip arthroplasty: analysis and review of the literature

We performed a bibliographic search of MEDLINE databases from January 1966 to July 2002 to identify English language articles that contained either "cost" or "economic" in combination with "total hip arthroplasty" (THA) in the abstract or title. Each study was then critically reviewed for content, technique, and adherence to established healthcare economic principles. Only 81 of the 153 studies retrieved contained actual economic data. Only 6% of studies adhered to established criteria for a comprehensive health care economic analysis. Although the number of publications regarding economic evaluation of THA is on the rise, the methodologic quality of many of these studies remains inadequate. Future studies should employ sound healthcare economic techniques to properly evaluate and assess the true social and economic value of THA.

Hip implant selection for total hip arthroplasty in elderly patients

Total hip arthroplasty in patients 75 years and older should relieve pain, improve function, and last for the rest of the patient's life. The achievement of this goal depends on health status, response to anesthesia, surgical technique, hip implant selection, and recovery from surgery. Considerations regarding hip implant selection in the elderly include bone quality, morphologic features of bone, implant fixation, design of the joint articulation, wear of the joint bearing surface, and implant cost. Implant cost should be negotiated and controlled in the business office and the boardroom rather than the operating room. Two hundred twenty-eight primary hip replacements done in 204 patients 75 years or older were evaluated. Complete clinical and radiographic evaluations were available for 190 hips in 152 patients at a mean 4 years followup (range, 1-11 years). Significant improvement in pain scores and clinical hip scores was observed. Patient outcome criteria were improved consistently. One acetabulum was loose in one patient (acetabular loosening, 0.5%), and five femoral stems were loose in five patients (femoral loosening, 2.6%). Four patients (four hips; 2.1%) required revision operations. One cemented cup (0.5%) in one patient and no cementless cups were revised. Four cemented stems (2.1%) in four patients and no cementless stems were revised. Cemented and cementless hip implants provided reliable results in these patients. In 2002, the author prefers cementless hip implant fixation.

Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty

BACKGROUND

During the 1990s, cost reduction programs were developed to decrease the hospital cost of total knee arthroplasty. The purpose of this study was to evaluate the impact of hospital cost reduction programs for total knee arthroplasty on patient outcome at our hospital.

METHODS

We evaluated 159 patients who had undergone unilateral primary total knee arthroplasty for the treatment of osteoarthritis at the Lahey Clinic. The results of fifty-six knee replacements performed in 1992 without a clinical pathway or a knee-implant standardization program (the control group) were compared with the results of 103 knee replacements performed in 1995 with a clinical pathway and a knee-implant standardization program (the study group). Before the operation, the two patient populations were similar in terms of age, pain score on a visual analog scale, and clinical knee scores; the groups were also similar with regard to the surgical approach and the time in the operating room. The minimum duration of follow-up was eight years for the control group and five years for the study group.

RESULTS

All patients in both groups had excellent relief of pain and improvement in function. There were no differences in clinical outcome between the patient groups. The rate of patient satisfaction was 98% in the control group and 99% in the study group. Implementation of the clinical pathway was associated with a reduction in the average length of the stay in the hospital from 6.79 days in 1992 to 4.16 days in 1995. Implementation of the knee-implant standardization program was associated with increased use of all-polyethylene tibial components in 1995. Hospital cost adjusted for medical inflation was reduced 19% with the implementation of the clinical pathway and the knee-implant standardization program.

CONCLUSIONS

The clinical pathway and the knee-implant standardization program reduced resource utilization and hospital cost for total knee arthroplasty without affecting short-term patient outcome in our hospital. Orthopaedic surgeons should carefully evaluate cost reduction programs, which may affect their patients, in order to maintain high-quality orthopaedic care and consistently successful patient outcomes.