Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.

Pre- and Postoperative Exercise Effectiveness in Mobility, Hemostatic Balance, and Prognostic Biomarkers in Hip Fracture Patients: A Study Protocol for a Randomized Controlled Trial

Hip fractures are a major health concern, particularly for older adults, as they can reduce life quality, mobility loss, and even death. Current evidence reveals that early intervention is recommended for endurance in patients with hip fractures. To our knowledge, preoperative exercise intervention in patients with hip fractures remains poorly researched, and no study has yet applied aerobic exercise preoperatively. This study aims to investigate the short-term benefits of a supervised preoperative aerobic moderate-intensity interval training (MIIT) program and the added effect of an 8-week postoperative MIIT aerobic exercise program with a portable upper extremity cycle ergometer. The work-to-recovery ratio will be 1-to-1, consisting of 120 s for each bout and four and eight rounds for the pre- and postoperative programs, respectively. The preoperative program will be delivered twice a day. A parallel group, single-blinded, randomized controlled trial (RCT) was planned to be conducted with 58 patients each in the intervention and control groups. This study has two primary purposes. First, to study the effect of a preoperative aerobic exercise program with a portable upper extremity cycle ergometer on immediate postoperative mobility. Second, to investigate the additional effect of an 8-week postoperative aerobic exercise program with a portable upper extremity cycle ergometer on the walking distance at eight weeks after surgery. This study also has several secondary objectives, such as ameliorating surgical and keeping hemostatic balance throughout exercise. This study may expand our knowledge of preoperative exercise effectiveness in hip fracture patients and enhance the current literature about early intervention benefits.

Cost-Effective Healthcare in Rehabilitation: Physiotherapy for Total Endoprosthesis Surgeries from Prehabilitation to Function Restoration

Knee and hip joint replacements for the elderly are increasingly placing a burden on healthcare. Our aim was to verify the efficiency of the prehabilitation program among patients with knee arthroplasty (TKA) and hip arthroplasty (THA), taking into account the length and cost of postoperative rehabilitation and the restoration of function. We introduced a two-week preoperative physiotherapy program for patients awaiting knee and hip replacement surgery. We measured the duration and costs of the hospital stays, the active and passive range of motion of the hip and knee joints, and the quality of life. In the study, 99 patients participated (31 male, 68 female), with a mean age of 69.44 ± 9.69 years. We showed that, as a result of the prehabilitation program, the length of postoperative hospital stay decreased (THA: median 31.5 (IQR 26.5-32.5) vs. median 28 (IQR 21-28.5), TKA: median 36.5 (IQR 28-42) vs. median 29 (IQR 26-32.5)), and the patients' quality of life showed a significant improvement (TKA: median 30.5 (IQR 30-35) vs. median 35 (IQR 33-35), THA: median 25 (IQR 25-30) vs. median 33 (IQR 31.5-35)). The flexion movements were significantly improved through prehabilitation in both groups. Based on our positive results, we recommend the introduction of prehabilitation into TKA- and THA-related care.

Clinical practice recommendations for prehabilitation and post-operative rehabilitation for arthroplasty: A scoping review

BACKGROUND

The rising need for arthroplasty (joint replacement) has resulted in a significant increase in wait-times. Longer surgical wait-times may further exacerbate functional decline in adults with osteoarthritis as well as delay postoperative functional recovery. This review aims to better inform rehabilitation care provision before (prehabilitation) and after (post-rehabilitation) hip or knee arthroplasty based on recommendations from clinical practice guidelines (CPGs).

METHODS

This scoping review used a three-stage process to screen and extract articles, which resulted in 123 articles reviewed for analysis. Included CPGs were in the English language and focussed on rehabilitation interventions or practices involving adult patients preparing for or recuperating from hip and knee arthroplasty (published 2009-2020).

RESULTS

Patient assessments, use of assistive devices, as well as self-management and education programs were recommended before and after arthroplasty. Physiotherapy was recommended to support post-operative rehabilitation. Conversely, there was limited evidence supporting recommendations for or against physiotherapy during the prehabilitation phase of the arthroplasty care journey.

CONCLUSIONS

The findings from this review highlight the current gap in high-quality evidence supporting hip and knee arthroplasty rehabilitation CPGs before and after surgery. Findings warrant additional research to ensure patients are best prepared for surgery and supported for optimal recovery.

Home Health Care in Medicare-Aged Patients is Associated With Increased Early Emergency Visits, Readmissions, and Costs Following Total Knee Arthroplasty

BACKGROUND

Home health services are utilized in order to provide at-home care following total knee arthroplasty (TKA). The purpose of this study is to determine whether patients receiving home health services post-operatively had lower rates of complications, emergency room visits, and readmissions as well as to determine if home health provided value by reducing total episode-of-care costs.

METHODS

The PearlDiver database was retrospectively reviewed to identify all primary TKA patients over 65 years old from 2010 to 2018. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home under self-care. We compared complication rates, emergency room visits, readmissions, and 90-day episode-of-care claims costs between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on emergency department (ED) visits and hospital readmissions.

RESULTS

Of the 185,444 TKA patients discharged home, 15,849 (8.5%) received home health services. Patients who received home health services had higher rates of ED visits at 2 weeks (3.3% vs 2.8%, P = .014) and 3 months (7.1% vs 6.5%, P = .038) as well as increased readmissions at 2 weeks (0.9% vs 0.7%, P = .028); complication rates were similar between groups (11.4% vs 10.9%, P = .159). Episode-of-care costs for home health patients were higher than those discharged under self-care ($24,266 vs $22,539, P < .001).

CONCLUSION

Home health services do not appear to provide value as they are associated with significantly increased costs and do not lower the rates of complications, ED visits, or readmissions following TKA.

Home Hospital for Orthopaedic Surgery: Opportunities and Challenges of a New Delivery Model

ABSTRACT

Home Hospital (HH) is a clinical service involving the delivery of acute inpatient care in the home setting. Acute care services provided via HH include continuous telemonitoring, intravenous fluids and medications, nursing care, point-of-care imaging and laboratory tests, and in-person and virtual clinician visits. Despite offering an inpatient level of care, HH has lower fixed costs and less overhead than conventional hospital settings and offers rapid scalability. Originally implemented for acute medical conditions, HH has proven to be a safe and value-based care-delivery model for a variety of medical conditions, ranging from heart failure to chronic obstructive pulmonary disease exacerbations. For surgical conditions, HH represents an opportunity to reduce adverse hospital-acquired conditions, improve patient and caregiver satisfaction, and decrease cost. The patient profile of orthopaedic surgery inpatients matches that of patients who are most likely to benefit from HH-namely, those who are prone to functional decline, delirium, and nosocomial infections. A focus on surgeon leadership, quality and safety, and digital health with collection of patient-reported outcome measures (PROMs) will ensure that the potential of HH is realized as implementation and widespread rollout proceed.

National Trends in Post-Acute Care Costs Following Total Hip Arthroplasty from 2010 through 2018

BACKGROUND

Post-acute care remains a target for episode-of-care cost reduction following total hip arthroplasty (THA). The introduction of bundled payment models in the United States in 2013 aligned incentives among providers to reduce post-acute care resource utilization. Institution-level studies have shown increased rates of home discharge with substantial cost savings after adoption of bundled payment models; however, national data have yet to be reported. The purpose of this study was to evaluate national trends in post-acute care utilization and costs following primary THA over the last decade.

METHODS

We reviewed the cases of 189,847 patients undergoing primary THA during 2010 through 2018 from the PearlDiver database. Annual trends in patient demographics, discharge disposition, and post-acute care resource utilization were evaluated. Post-acute care reimbursements were standardized to 2020 dollars and included outpatient visits, prescriptions, physical therapy, home health, inpatient rehabilitation, skilled nursing facilities, and any rehospitalizations or emergency department (ED) visits within 90 days of surgery.

RESULTS

From 2010 to 2018, the mean episode-of-care costs ($31,562 versus $24,188; p < 0.001) and overall post-acute care costs ($5,903 versus $3,485; p < 0.001) both declined. Post-acute care savings were primarily driven by reduced costs of skilled nursing facilities ($1,533 versus $627; p < 0.001), home health ($1,041 versus $763; p = 0.002), inpatient rehabilitation ($949 versus $552; p < 0.001), ED visits ($508 versus $102; p < 0.001), and rehospitalizations ($367 versus $179; p < 0.001). Post-acute care costs declined by $578 (p = 0.025) during 2010 to 2012, $768 (p = 0.038) during 2013 to 2015, and $884 (p = 0.020) during 2016 to 2018.

CONCLUSIONS

Over the last decade, the rate of home discharge after THA increased while rehospitalization and ED visit rates declined, resulting in a substantial decrease in total and post-acute care costs. Post-acute care costs declined most rapidly after the introduction of the new Medicare bundled payment programs in 2013 and 2016.

Nonoperative Care Including Rehabilitation Should Be Considered and Clearly Defined Prior to Elective Orthopaedic Surgery to Maximize Optimal Outcomes

Level of Evidence

Impact of Neuraxial Versus General Anesthesia on Discharge Destination in Patients Undergoing Primary Total Hip and Total Knee Replacement

BACKGROUND

Total knee replacement (TKR) and total hip replacement (THR) are 2 of the most common orthopedic surgical procedures in the United States. These procedures, with fairly low mortality rates, incur significant health care costs, with almost 40% of the costs associated with post acute care. We assessed the impact of general versus neuraxial anesthesia on discharge destination and 30-day readmissions in patients who underwent total knee and hip replacement in our health system.

METHODS

This was a retrospective cohort study of 24,684 patients undergoing total knee or hip replacement in 13 hospitals of a large health care network. Following propensity score matching, we studied the impact of type of anesthetic technique on discharge destination (primary outcome) and postoperative complications including readmissions in 8613 patients who underwent THR and 13,004 patients for TKR.

RESULTS

Our results showed that in patients undergoing THR and TKR, neuraxial anesthesia is associated with higher odds of being discharged from hospital to home versus other facilities compared to general anesthesia (odds ratio [OR] = 1.63, 95% confidence interval [CI], 1.52-1.76; P < .01) and (OR = 1.58, 95% CI, 1.49-1.67; P < .01), respectively.

CONCLUSIONS

Our results suggest an association between use of neuraxial anesthesia for total joint arthroplasty and a higher probability of discharge to home and a reduction in readmissions.

Association of Physical Therapy Interventions With Long-term Opioid Use After Total Knee Replacement

IMPORTANCE

Many individuals who undergo total knee replacement (TKR) become long-term opioid users after TKR. Associations of physical therapy (PT) interventions before or after TKR with long-term use of opioids are not known.

OBJECTIVES

To evaluate associations of PT interventions before and after TKR with long-term opioid use after TKR.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the OptumLabs Data Warehouse on 67 322 individuals aged 40 years or older who underwent TKR from January 1, 2001, to December 31, 2016, stratified by history of opioid use. The analyses for the study included data from January 1, 1999, to December 31, 2018.

EXPOSURES

Any PT interventions within 90 days before or after TKR, post-TKR PT dose as number of sessions (ie, 1-5, 6-12, and ≥13 sessions), post-TKR PT timing as number of days to initiation of care (ie, <30 days, 31-60 days, or 61-90 days after TKR), and post-TKR PT type (ie, active vs passive).

MAIN OUTCOMES AND MEASURES

The association of pre- and post-TKR PT with risk of long-term opioid use occurring more than 90 days after TKR was assessed using logistic regression while adjusting for confounders, including age, sex, race and ethnicity (Asian, Black, Hispanic, or White), obesity, type of insurance, geographical location, and physical and mental health comorbidities.

RESULTS

A total of 38 408 opioid-naive individuals (21 336 women [55.6%]; mean [SD] age, 66.2 [9.2] years) and 28 914 opioid-experienced individuals (18 426 women [63.7%]; mean [SD] age, 64.4 [9.3] years) were included. Receipt of any PT before TKR was associated with lower odds of long-term opioid use in the opioid-naive (adjusted odds ratio [aOR], 0.75 [95% CI, 0.60-0.95]) and opioid-experienced (aOR, 0.75 [95% CI, 0.70-0.80]) cohorts. Receipt of any post-TKR PT was associated with lower odds of long-term use of opioids in the opioid-experienced cohort (aOR, 0.75 [95% CI, 0.70-0.79]). Compared with 1 to 5 sessions of PT after TKR, 6 to 12 sessions (aOR, 0.82 [95% CI, 0.75-0.90]) and 13 or more sessions (aOR, 0.71 [95% CI, 0.65-0.77) were associated with lower odds in the opioid-experienced cohort. Compared with initiation of PT within 30 days after TKR, initiation 31 to 60 days or 61 to 90 days after TKR were associated with greater odds in the opioid-naive (31-60 days: aOR, 1.45 [95% CI, 1.19-1.77]; 61-90 days: aOR, 2.15 [95% CI, 1.43-3.22]) and opioid-experienced (31-60 days: aOR, 1.10 [95% CI, 1.02-1.18]; 61-90 days: aOR, 1.32 [95% CI, 1.12-1.55]) cohorts. Compared with passive PT, active PT was not associated with long-term opioid use in the opioid-naive (aOR, 1.00 [95% CI, 0.81-1.24]) or opioid-experienced (aOR, 0.99 [95% CI, 0.92-1.07]) cohorts.

CONCLUSIONS AND RELEVANCE

This cohort study suggests that receipt of PT intervention before and after TKR, receipt of 6 or more sessions of PT care after TKR, and initiation of PT care within 30 days after TKR were associated with lower odds of long-term opioid use. These findings suggest that PT may help reduce the risk of long-term opioid use after TKR.

Patient Satisfaction, Functional Outcomes, and Survivorship in Patients with a Customized Posterior-Stabilized Total Knee Replacement

BACKGROUND

In this study, we assessed implant survivorship, patient satisfaction, and patient-reported functional outcomes at approximately 2 years for patients who had received a customized posterior-stabilized (PS) knee replacement system. We hypothesized that the customized PS implant would have high overall patient-reported outcomes because of its patient-specific design.

METHODS

Ninety-three patients (100 knees) who had received the customized total knee replacement system were enrolled at 2 centers. The patients' length of hospitalization and preoperative pain intensity were assessed. At a single follow-up time-point, we assessed patient-reported outcomes utilizing the Knee injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), satisfaction rates, implant survivorship, and patients' perception of their knee.

RESULTS

At an average follow-up time of 1.9 years (range, 1.5 to 2.4 years), implant survivorship was found to be 100%. From an average preoperative baseline pain rating of 6.5 (range, 3 to 10) until the time of follow-up, we observed an average decrease of 5.2 on the numeric pain rating scale to an average of 1.3 (range, 0 to 8), indicating satisfactory pain relief after the procedure. The satisfaction rate was found to be high, with 90% of patients being satisfied or very satisfied and 88% of patients reporting a "natural" perception of their knee either some or all of the time. The evaluation of the patient-reported outcome measure showed satisfactory results with a high KOOS JR average score of 90 (range, 34 to 100) at the time of follow-up.

CONCLUSIONS

Based on our results, we believe that the customized PS implant provides patients with excellent postoperative outcomes.

LEVEL OF EVIDENCE

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

National Trends in Post-Acute Care Costs Following Total Knee Arthroplasty From 2007 to 2016

BACKGROUND

Post-acute care continues to represent a target for cost savings with increasing popularity of value-based payment models in total knee arthroplasty (TKA). Rapid recovery and accelerated rehabilitation protocols have been successful in reducing costs at the institutional level, but national trends are less clear. This study aimed to determine if advancements in perioperative care led to a reduction in post-acute care costs and resource utilization following TKA.

METHODS

We reviewed a consecutive series of 79,843 primary TKA patients from the Humana claims dataset from 2007 to 2016. Post-acute care costs included any claims within 90 days of surgery for subacute or inpatient rehabilitation, home health, outpatient or emergency visits, prescription medications, physical therapy, and readmissions. Demographics, episode-of-care and post-acute care costs, readmissions, and discharge disposition were compared. Controlling for demographics and comorbidities, multivariate regression analyses were performed to compare trends in discharge disposition and post-acute care costs.

RESULTS

From 2007 to 2016, the average episode-of-care costs ($46,754 vs $31,856) and post-acute care costs per patient decreased ($20,224 vs $13,498). Rates of discharge to skilled nursing facilities (25.0% vs 22.5%) and inpatient rehabilitation also declined (12.4% vs 2.1%). Readmissions also decreased (8.1% vs 7.1%) saving an average of $324 per patient. When compared to 2007-2012, total costs declined most rapidly after 2013 primarily due to a $3516 (21%) decrease in post-acute spending.

CONCLUSION

There has been a substantial decline in post-acute care costs and resource utilization following TKA, with the largest decrease occurring following the introduction of Medicare bundled payment models in 2013.

Relationships between physical therapy intervention and opioid use: A scoping review

OBJECTIVE

To synthesize available evidence that has examined the relationship between physical therapy (PT) and opioid use. TYPE: Scoping Review LITERATURE SURVEY: Data sources including Google Scholar, Embase, PubMed, Cochrane Library, and CINAHL were searched for English articles up to October 24, 2019 using terms ("physical therapy"[Title/Abstract] OR physiotherapy[Title/Abstract] OR rehabilitation[Title/Abstract]) AND (opiate*[Title/Abstract] OR opioid*[Title/Abstract]).

METHODOLOGY

Included studies evaluated a PT intervention and reported an opioid-use outcome. Data were extracted to describe the PT intervention, patient sample, opioid-use measurement, and results of any time or group comparisons. Study quality was evaluated with Joanna Briggs checklists based on study design.

SYNTHESIS

Thirty studies were included that evaluated PT in at least one of these seven categories: interdisciplinary program (n = 8), modalities (n = 3), treatment (n = 3), utilization (n = 2), content (n = 3), timing (n = 13), and location (n = 2). Mixed results were reported for reduced opioid-use after interdisciplinary care and after PT modalities. Utilizing PT was associated with lower odds (ranging from 0.2-0.8) of using opioid medication for persons with low back pain (LBP) and injured workers; however, guideline-adherent care did not further reduce opioid use for persons with LBP. Early PT utilization after index visit for spine or joint pain and after orthopedic surgery was also associated with lower odds of using opioid medications (ranging from 0.27-0.93). Emergency department PT care was not associated with fewer opioid prescriptions than standard emergency department care. PT in a rehabilitation center after total knee replacement was not associated with lower opioid use than inpatient PT.

CONCLUSIONS

The relationship between timing of PT and opioid use was evaluated in 13 of 30 studies for a variety of patient populations. Eight of these 13 studies reported a relationship between early PT and reduced subsequent opioid use, making the largest sample of studies in this scoping review with supporting evidence. There is limited and inconclusive evidence to establish whether the content and/or location of PT interventions improves outcomes because of heterogeneity between studies.

Variability in Discharge Disposition Across US Trauma Centers After Treatment for High-Energy Lower Extremity Injuries

OBJECTIVE

To evaluate the association between patient- and center-level characteristics and discharge to an inpatient facility versus home after treatment for lower extremity trauma, as well as examine the variability in discharge disposition across clinical centers after controlling for these factors.

DESIGN

This is an analysis of data collected prospectively across 5 multicenter studies of extremity trauma.

SETTING

US Trauma Centers.

PARTICIPANTS

Patients 18-80 years with lower extremity trauma treated at 1 of 55 participating centers.

MAIN OUTCOME MEASURE

Discharge disposition.

RESULTS

Among 2365 patients treated at 1 of 55 centers across 13 states, 673 (28.5%) were discharged to an inpatient facility, and 1692 (71.5%) were discharged home. Individuals who were older, female, unmarried, insured, higher body mass index, history of severe alcohol abuse, Gustilo type IIIB or IIIC open injuries, bilateral, spine and upper extremity injuries, higher injury severity score scores, or intensive care unit stay were more likely to be discharged to an inpatient facility. Even after accounting for patient- and center-level characteristics, there was substantial variation in discharge disposition across centers (likelihood ratio test: P < 0.001).

CONCLUSION

Variation in discharge disposition may represent a potential for improvement in resource utilization and cost savings. Further studies are needed to examine the relationship between utilization of postdischarge inpatient facility after trauma and outcomes.

LEVEL OF EVIDENCE

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

Association Between Outpatient Rehabilitation Therapy and Total Cost of Care for a Frail Elderly Population in a Medicare Accountable Care Organization

Frailty is a debilitating and increasingly costly condition in an elderly population equating to nearly $7.6 billion in Medicare spending in 2016. Understanding the burden of frailty and how to manage this population efficiently is of key importance in an accountable care organization. Using an operational, claims-derived definition of frailty, the authors set out to explore the association between therapy and total cost of care for the frail elderly population. Claims data were reviewed for nearly 94,000 beneficiaries to identify the burden of frailty in that population along with the association with therapy utilization. Nearly 10% of patients in the study populations were found to meet the operational definition of frailty. When the frail population is segmented into those who receive outpatient rehabilitation therapy and those who do not, outpatient rehabilitation therapy is associated with decreased cost at 13-32 therapy units delivered. Outside of this dose range, outpatient rehabilitation therapy was not associated with statistically significant improvements in total cost of care for this population. Results suggest that from the standpoint of population health management, utilization of outpatient rehabilitation services may be helpful to decrease costs in several domains. When that cost reduction is compared to therapy units delivered, it is demonstrated that outpatient rehabilitation therapy is associated with lower costs at a certain quantity of therapy. This study has implications for population health management of a frail elderly cohort as well as for managing preferred partnerships with therapy providers, given the wide array of therapy patterns delivered.

Preoperative Activities of Daily Living Dependency is Associated With Higher 30-Day Readmission Risk for Older Adults After Total Joint Arthroplasty

BACKGROUND

With recent Medicare payment changes, older adults are increasingly likely to be discharged home instead of to extended care facilities after total joint arthroplasty (TJA), and may therefore be at increased risk for readmissions. Identifying risk factors for readmission could help re-align care pathways for vulnerable patients; recent research has suggested preoperative dependency in activities of daily living (ADL) may increase perioperative and postoperative surgical complications. However, the proportion of older surgical patients with ADL dependence before TJA, and the impact of ADL dependency on the frequency and timing of hospital readmissions is unknown.

QUESTIONS/PURPOSES

(1) What proportion of older adults discharged home after TJA have preoperative ADL dependency? (2) Is preoperative ADL dependency associated with increased risk of hospital readmissions at 30 days or 90 days for older adults discharged home after TJA?

METHODS

This was a retrospective cohort analysis of 6270 Medicare fee-for-service claims from 2012 from a 5% national Medicare sample for older adults (older than 65 years) receiving home health care after being discharged to the community after elective TJA. Medicare home health claims were used for two reasons: (1) the primary population of interest was older adults and (2) the accompanying patient-level assessment data included an assessment of prior dependency on four ADL tasks. Activities of daily living dependency was dichotomized as severe (requiring human assistance with all four assessed tasks) or partial/none (needing assistance with three or fewer ADLs); this cutoff has been used in prior research to evaluate readmission risk. Multivariable logistic regression models, clustered at the hospital level and adjusted for known readmission risk factors (such as comorbidity status or age), were used to model the odds of 30- and 90- day and readmission for patients with severe ADL dependence.

RESULTS

Overall, 411 patients were hospitalized during the study period. Of all readmissions, 64% (262 of 411) occurred within the first 30 days, with a median (interquartile range [IQR]) time to readmission of 17 days (5 to 46). Severe ADL dependency before surgery was common for older home health recipients recovering from TJA, affecting 17% (1066 of 6270) of our sample population. After adjusting for clinical covariates, severe ADL dependency was not associated with readmissions at 90 days (adjusted odds ratio = 1.20 [95% CI 0.93 to 1.55]; p = 0.15). However, severe preoperative ADL dependency was associated with higher odds of readmission at 30 days (adjusted OR = 1.45 [95% CI 1.11 to 1.99]; p = 0.008).

CONCLUSIONS

Severe preoperative ADL dependency is modestly associated with early but not late hospital readmission after TJA. This work demonstrates that it may important to apply a simple screening of ADL dependency preoperatively so that surgeons can guide changes in care planning for older adults undergoing TJA, which may include participation in preoperative rehabilitation (pre-habilitation) or more aggressive follow-up in the 30 days after surgery. Further research is needed to determine whether severe ADL dependence can be modified before surgery, and whether these changes in dependency can reduce readmission risk after TJA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system

Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.

Relationship Between Baseline Patient-reported Outcomes and Demographic, Psychosocial, and Clinical Characteristics: A Retrospective Study

Introduction

Alternative payment models in total lower extremity joint replacement (TJR) increasingly emphasize patient-reported outcomes (PROs) to link the latter to value-based payments. It is unclear to what extent demographic, psychosocial, and clinical characteristics are related to PROs measured preoperatively with the commonly used Hip/Knee Osteoarthritis Outcome Scores (HOOS/KOOS) and the Veterans RAND 12-Item Health Survey (VR-12) questionnaires. We aim to identify (1) the preoperative relationship between HOOS/KOOS and VR-12 scores and several demographic, psychosocial, and clinical patient characteristics and (2) the best modifiable factors for optimization, which may result in improved baseline PROs before TJR.

Methods

All TJR cases performed in 2017 at the two highest-volume hospitals within an urban academic health system were queried. Preoperative HOOS/KOOS and VR-12 surveys were administered through an e-collection platform. VR-12 physical and mental component scores (PCS, MCS) were generated. Patient information was extracted from the electronic health record. Bivariate and multivariate regression analyses were performed. Odds ratios (ORs) and 95% confidence intervals were reported.

Results

In univariate analysis, patients with HOOS/KOOS, VR-12 PCS, and MCS in the ≤25th percentile group were more likely to have an ASA score of ≥3 compared with those with higher scores. In multivariate analysis, increased and decreased odds of low HOOS/KOOS were associated with a one-unit increase in Charlson Comorbidity Index (OR, 1.16) and VR-12 MCS (OR, 0.97), respectively. Increased odds of low baseline VR-12 PCS and MCS were associated with ASA class ≥3 (OR, 1.65 and 1.40). Decreased odds of a low MCS were associated with an increase in HOOS/KOOS (OR, 0.98) (P ≤ 0.05 for all).

Conclusion

Of the factors that are associated with low baseline PRO scores, preoperatively addressing mismanaged comorbidities, mental health, and physical function were identified as the best modifiable factors for optimization, which may result in improved baseline PROs before TJR.

Perioperative Orthopedic Surgical Home: Optimizing Total Joint Arthroplasty Candidates and Preventing Readmission

BACKGROUND

It is well recognized that unplanned readmissions following total joint arthroplasty (TJA) are more prevalent in patients with comorbidities. However, few investigators have delayed surgery and medically optimized patients prior to surgery. In its current form, the Perioperative Orthopedic Surgical Home (POSH) is a surgeon-led screening and optimization initiative targeting 8 common modifiable comorbidities.

METHODS

A total of 4188 patients who underwent TJA between January 2014 and December 2016 were retrospectively screened by the Readmission Risk Assessment tool (RRAT) score. one thousand one hundred and ninety four subjects had a preoperative RRAT score ≥3 and were eligible for inclusion. Patients were then separated into 2 cohorts based on whether they were enrolled into the POSH initiative (POSH; n = 216) or continued with surgery (non-POSH; n = 978) despite their risk.

RESULTS

Since the implementation of the POSH initiative, patients with RRAT scores ranging from 3 to 5 have experienced lower 30-day (1.6% vs 5.3%, P = .03) and 90-day (3.2% vs 7.4%, P < .05) readmission rates when compared to the non-POSH cohort. Only 15.3% of medically optimized patients enrolled in the POSH initiative were discharged to a post-acute care facility, whereas 23.4% of non-POSH patients were discharged to a post-acute care facility (P = .01). There were no differences in length of stay and infection rates between the 2 cohorts. Moreover, 90-day episode-of-care costs were 14.9% greater among non-POSH Medicare TJA recipients and 32.6% higher if a readmission occurred.

CONCLUSION

The identification and medical optimization of comorbidities prior to surgical intervention may enhance the value of care TJA candidates receive. A standardized multidisciplinary approach to the medical optimization of high-risk TJA candidates may improve patient engagement and perioperative outcomes, while reducing cost associated with TJA.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Enhanced recovery after surgery (ERAS) in hip and knee replacement surgery: description of a multidisciplinary program to improve management of the patients undergoing major orthopedic surgery

PURPOSE

Enhanced recovery after surgery (ERAS) protocols aim to develop peri-operative multidisciplinary programs to shorten length of hospital stay (LOS) and reduce complications, readmissions and costs for patients undergoing major surgery. The aim of this study is to evaluate the effects of an ERAS pathway for total hip (THR) and knee (TKR) replacement surgery in terms of length of stay, incidence of complications and patient satisfaction.

METHODS

Patients scheduled for hip and knee replacement were included in the study. The main aspects of this program were preoperative education/physical therapy, rational choice of the anesthetic technique, optimization of multimodal analgesia, reduction of incidence of urinary retention and catheterization, active management of risk for blood loss and deep vein thrombosis, and early mobilization of the patients. All patients had 6 months predicted and planned follow-up appointments. Primary outcomes of the study were the mean LOS, readmission and complication rates. Secondary Outcomes were percentage of Knee Injury & Osteoarthritis Outcome Score (KOOS) and Hip disability and Osteoarthritis Outcome Score (HOOS) increase and patient's satisfaction.

RESULTS

We consecutively enrolled 207 patients who underwent total joint arthroplasty, 78 hip and 129 knee joint replacements. The mean length of stay (LOS) for patients of the two groups was 4.3 days for ASA 3-4 patients subjected to TKR and THR, in ASA 1-2 patients 3.6 days for TKR and 3.9 days for THR respectively. Postoperative satisfaction level was higher than 7 (very satisfied) in 94.4% of the cases. All patients were discharged home: 61.8% continued physical therapy in complete autonomy, 23.7% supported by a home-physiotherapist and only 14.5% needed the attendance to a physiotherapy center on a daily basis. The overall incidence of major complications was 3.4%.

CONCLUSIONS

The implementation of an ERAS program for hip and knee replacement surgery allows early patient's discharge and a quick return to independency in the daily activities.

LEVEL OF EVIDENCE

IV.

Preoperative Patient-Reported Outcomes and Clinical Characteristics as Predictors of 90-Day Cost/Utilization and Complications

BACKGROUND

With the advent of mandatory bundle payments for total joint arthroplasty (TJA), assessing patients' risk for increased 90-day complications and resource utilization is crucial. This study assesses the degree to which preoperative patient-reported outcomes predict 90-day complications, episode costs, and utilization in TJA patients.

METHODS

All TJA cases in 2017 at 2 high-volume hospitals were queried. Preoperative HOOS/KOOS JR (Hip Injury and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score) and Veterans RAND 12-item health survey (VR-12) were administered to patients preoperatively via e-collection platform. For patients enrolled in the Medicare bundle, cost data were extracted from claims. Bivariate and multivariate regression analyses were performed.

RESULTS

In total, 2108 patients underwent TJA in 2017; 1182 (56%) were missing patient-reported outcome data and were excluded. The final study population included 926 patients, 199 (21%) of which had available cost data. Patients with high bundle costs tended to be older, suffer from vascular disease and anemia, and have higher Charlson scores (P < .05 for all). These patients also had lower baseline VR-12 Physical Component Summary Score (PCS; 24 vs 30, P ≤ .001) and higher rates of extended length of stay, skilled nursing facility discharge, 90-day complications, and 90-day readmission (P ≤ .04 for all). In multivariate analysis, higher baseline VR-12 PCS was protective against extended length of stay, skilled nursing facility discharge, >75th percentile bundle cost, and 90-day bundle cost exceeding target bundle price (P < .01 for all). Baseline VR-12 Mental Component Summary Score and HOOS/KOOS JR were not predictive of complications or bundle cost.

CONCLUSION

Low baseline VR-12 PCS is predictive of high 90-day bundle costs. Baseline HOOS/KOOS JR scores were not predictive of utilization or cost. Neither VR-12 nor HOOS/KOOS JR was predictive of 90-day readmission or complications.

The role of prehabilitation with a telerehabilitation system prior to total knee arthroplasty

Background

The purpose of the current study was to evaluate the usage of prehabilitation on a telehealth platform prior to total knee arthroplasty (TKA) and its impact on short-term outcomes. Specifically, the study examined whether patients participating in a prehabilitation program impacted length of stay (LOS) and discharge disposition.

Methods

A total of 476 consecutive patients who underwent TKA at three institutions were included. The average age of the 476 patients was 65.1 years (range, 35 and 93 years). There was a total of 114 patients who utilized the novel prehabilitation program that provided exercises, nutritional advice, education regarding home safety and reducing medical risks, and pain management skills prior to surgery. A group of 362 patients who did not utilize the program formed the control cohort. The outcomes evaluated were LOS and discharge disposition to home, home with health aide (HHA), or skilled nursing facility (SNF).

Results

The average LOS in the prehabilitation group was significantly shorter than in the control group (2.0 vs. 2.7 days, P<0.001). Additionally, prehabilitation patients had more favorable discharge disposition status in comparison to the control group. In the prehabilitation patients, 77.2% went home without assistance, compared to 42.8% in the control group (P<0.001). Also, significantly fewer patients in the prehabilitation group were discharged to a SNF when compared to the control group (1.8% vs. 21.8%, P<0.0001).

Conclusions

Prehabilitation preceding TKA in the current study showed early benefits in LOS and discharge disposition. This study will help expand the current literature and educate orthopaedic surgeons on a novel technology. To truly appreciate the role of telerehabilitation in the setting of TKA, further investigation is needed to investigate long-term outcomes, cost analysis, and patient and clinician satisfaction.

Obesity-Related Foot Pain: Diagnosis and Surgical Planning

Obese patients are at higher risk for surgical complications and consist of a large portion of podiatric patients. Obese patients are additionally at increased risk of developing specific podiatric conditions, and it is important to be able to identify and appropriately treat these conditions accordingly. Initially, conservative treatment is adequate for a variety of pathologic conditions related to obesity. Occasionally surgical intervention is warranted depending on the severity and lack of response to conservative measures. Arthrodesis-type procedures are often preferable and may be necessary, as opposed to periarticular osteotomy, in obese patients even if the deformity is flexible.

Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients

BACKGROUND

Preoperative optimization of risk factors has been suggested as a strategy to improve the value of total joint arthroplasty (TJA) care. We assessed the implementation of a TJA preoperative optimization protocol and its impact on length of hospital stay, discharge destination, 90-day readmissions, and hospital direct variable costs.

METHODS

This retrospective cohort study included adults undergoing primary elective TJA from 07/2015-09/2016 at an urban tertiary care hospital. Post-implementation patients were preoperatively screened for 19 risk factors; results and recommended interventions were reported to surgeons, who had the option to postpone or continue surgery as scheduled. Metrics from hospital administrative databases were compared between post-implementation (02/2016-09/2016) and pre-implementation cohorts (07/2015-11/2015).

RESULTS

The 314 post-implementation patients were slightly younger compared to the 351 pre-implementation patients (64.2 years vs 65.8 years, P = .02) and a higher percentage of patients had diabetes (18% vs 5.1%, P < .001). Of the 98% of post-implementation patients screened, 74% had at least 1 risk factor identified. Obstructive sleep apnea was the most common risk factor (52%), followed by depression (22%) and obesity (body mass index > 40 kg/m² or 35-40 kg/m² with comorbidities) (13%). Forty-six patients (20%) did not follow through with the recommended optimization before undergoing elective surgery. The post-implementation cohort had shorter average length of hospital stay (1.9 days vs 2.2 days, P < .001) and lower average total direct variable costs excluding implants ($5409 vs $5852, P < .001). There was no difference in patients discharged home (90% vs 89%, P = .53) or 90-day readmissions (4.1% vs 4.3%, P = .93).

CONCLUSION

In our experience, the majority of elective TJA patients have modifiable risk factors, indicating opportunity for preoperative intervention. Our evidence-based preoperative optimization program resulted in higher value care, demonstrated by similar outcomes with lower resource utilization.

Patient Perceptions of Home Health Care Services After Total Joint Replacement

Value-based payment programs have incentivized the reduction of many post-acute care services, including home health care. Patient perceptions of home health care services are currently unknown. The objectives of this study were to determine the value that patients place on home health care after joint replacement surgery and to assess their impression of Medicare reimbursement for these services. Patients with traditional Medicare insurance who underwent primary total hip or knee arthroplasty between January 2016 and July 2017 were given a questionnaire in which they were asked to quantify their satisfaction with home health care, estimate Medicare reimbursement for these services, and give their impression of actual reimbursement. One hundred sixtythree patients completed the questionnaire. Patients were generally satisfied with the services received, giving an overall mean ranking of 9.3 (range, 1-10). Respondent estimates of the cost of home health care services ranged from $0 to $300,000 (average, $8067). Ninety-three percent of patients would choose home health care again if they were to undergo another joint replacement. Patients in this study placed significant value on home health care services after total hip and knee replacement surgery. Further consideration of patient satisfaction may be warranted prior to eliminating home health care services following total joint arthroplasty. [Orthopedics. 2018; 41(5):e713-e717.].

Obesity in Elective Foot and Ankle Surgery

Obesity is a global health problem with significant economic and health consequences. There is very little literature in regards to obesity and its effect on foot and ankle surgery, and to the author's knowledge, there has been no consolidated review on this subject to date. The purpose of this article is to provide a comprehensive review as it pertains to foot and ankle surgery, with hopes of improving surgeon decision making, mitigating risk, and providing better outcomes for patients. A better understanding of the effects of obesity also allows for improved prognostic performance.

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.

Frailty as a predictor of hospital length of stay after elective total joint replacements in elderly patients

Background

Total joint replacement procedures are increasing in number because of population aging and osteoarthritis development. Defined as a lack of physiological reserves and the inability to adequately respond to external stressors, frailty may be more common than expected in older patients with degenerative arthritis awaiting total joint replacements.

The aim of the present study was to assess associations between frailty and adverse outcomes, frailty prevalence among elderly patients awaiting elective TJR, and agreement between 2 frailty screening instruments.

Methods

We undertook a prospective, observational, pilot study in our institution. We enrolled patients 65 years or older who were awaiting elective knee or hip replacement surgery and evaluated them in our preoperative clinic with planned postoperative hospital length of stay greater than 24 h. Patients were asked to grade their perceived well-being on the Clinical Frailty Scale and to answer questions on the FRAIL Scale.

Results

The Clinical Frailty Scale classified 40 patients (45.9%) as robust, 43 patients (49.4%) as prefrail and 4 patients (4.5%) as frail, while the FRAIL Scale categorized 12 patients (13.7%) as robust, 54 patients (62.0%) as prefrail, and 20 patients (22.9%) as frail. Robustness, ascertained on the Clinical Frailty Scale was, while the FRAIL Scale was not, significantly associated with shorter hospital length of stay and fewer discharges to the rehabilitation center. Both scales showed moderate mutual agreement.

Conclusion

Screening for frailty identified between 5% and 10% of patients at risk of adverse outcomes. The Clinical Frailty Scale was, while the FRAIL scale was not, significantly associated with hospital length of stay and discharge to rehabilitation center in our cohort of total joint replacement patients.

Geriatric comanagement reduces perioperative complications and shortens duration of hospital stay after lumbar spine surgery: a prospective single-institution experience

OBJECTIVE Geriatric patients undergoing lumbar spine surgery have unique needs due to the physiological changes of aging. They are at risk for adverse outcomes such as delirium, infection, and iatrogenic complications, and these complications, in turn, contribute to the risk of functional decline, nursing home admission, and death. Whether preoperative and perioperative comanagement by a geriatrician reduces the incidence of in-hospital complications and length of in-hospital stay after elective lumbar spine surgery remains unknown. METHODS A unique model of comanagement for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Perioperative Optimization of Senior Health (POSH) program was launched with the aim of improving outcomes in elderly patients (> 65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, in addition to performing routine preoperative anesthesia surgical screening, and comanages them daily throughout the course of their hospital stay to manage medical comorbid conditions and coordinate multidisciplinary rehabilitation along with the neurosurgical team. The first 100 cases were retrospectively reviewed after initiation of the POSH protocol and compared with the immediately preceding 25 cases to assess the incidence of perioperative complications and clinical outcomes. RESULTS One hundred twenty-five patients undergoing lumbar decompression and fusion were enrolled in this pilot program. Baseline characteristics were similar between both cohorts. The mean length of in-hospital stay was 30% shorter in the POSH cohort (6.13 vs 8.72 days; p = 0.06). The mean duration of time between surgery and patient mobilization was significantly shorter in the POSH cohort compared with the non-POSH cohort (1.57 days vs 2.77 days; p = 0.02), and the number of steps ambulated on day of discharge was 2-fold higher in the POSH cohort (p = 0.04). Compared with the non-POSH cohort, the majority of patients in the POSH cohort were discharged to home (24% vs 54%; p = 0.01). CONCLUSIONS Geriatric comanagement reduces the incidence of postoperative complications, shortens the duration of in-hospital stay, and contributes to improved perioperative functional status in elderly patients undergoing elective spinal surgery for the correction of adult degenerative scoliosis.

Improving Quality and Decreasing Cost by Reducing Re-admissions in Patients Undergoing Total Joint Arthroplasty

PURPOSE OF REVIEW

Total joint arthroplasty (TJA) has had an increased demand over the recent years. It is a successful procedure, and there are relatively few complications, but there is a high overall cost. There is a push to increase the quality of care, lessen complications, and decrease cost by reducing readmissions. This article will discuss the risk factors that can contribute to the complication and readmission rates following TJA.

RECENT FINDINGS

Several risk factors have been found to contribute to the complication and readmission rates following a TJA. It is important to understand these risk factors and mitigate them as much as possible in order to optimize the patient experience. There are risk factors that cannot be modified, and the treatment team as well as the patient should be made aware of these and account for them when making the decision whether to undergo elective primary TJA or not. In general, an increased number of risk factors is associated with increased complications and increased readmission rates. At our institution, we have used this knowledge to improve our outcomes and decrease costs. It is important to be mindful of risk factors for poor outcomes prior to performing TJA. This allows for the optimization of patients prior to undergoing surgery. This can lead to improved outcomes at a lower cost.

Benign heart murmurs as a predictor for complications following total joint arthroplasty

BACKGROUND

There is scant literature examining the predictive role of heart murmurs in the absence of suspected structural heart disease on complications of non-cardiac surgery. We hypothesize the detection of heart murmurs in the absence of structural heart disease will help identify patients at risk for complications following total joint arthroplasty (TJA) surgery.

METHOD

This was a prospective cohort of patients undergoing TJA over a twenty-month period. The study was performed at a single academic institution with four subspecialty surgeons. Patients undergoing primary TJA who were over eighteen years old, gave informed consent, and had adequate documentation were included in the study. Patients with a preoperative murmur or a newly discovered postoperative murmur were compared against patients with no murmur. Surgery-related complications, performance with physical therapy, and discharge to a non-home facility were measured in each group.

FINDINGS

345 (63%) eligible patients were included. 20 (5.8%) patients had a documented preoperative murmur and 36 (10.4%) patients had a new postoperative murmur. No patient had concern for major structural heart disease. Preoperative murmurs independently predicted development of acute kidney injury (OR 7.729, p < 0.001; RR 1.36). Preoperative murmurs also predicted likelihood to be discharged to a non-home facility (OR 2.97, p = 0.03; RR 1.87). New postoperative murmurs independently correlated with decreased performance with physical therapy (OR 0.466, p = 0.045; RR 0.664).

INTERPRETATION

Detection of heart murmurs both preoperatively and postoperatively is a low cost strategy to identify post-TJA surgical patients at risk for postoperative acute kidney injury, decreased physical performance, and discharge to non-home facilities. These patients may benefit from early fluid resuscitation and renally-dosed post-operative medications.

Evaluation of the impact of preoperative assessment on length of stay after a total hip arthroplasty

Introduction

To investigate if preoperative assessment delivered by occupational therapists, physiotherapists and social workers for people awaiting a total hip arthroplasty decreased the length of stay in hospital postoperatively.

Method

A retrospective data review was conducted on all patients who had a primary total hip arthroplasty across a 6-month period. A total of 101 patients (mean age 67.16 years) was included in this evaluation. Clinical notes were used to determine which patients attended or did not attend preoperative assessment. Statistical modeling was used to analyse the association of a series of variables and time spent in hospital after a total hip arthroplasty.

Results

There was no significant difference in the length of stay for patients who attended preoperative assessment ( P < 0.05) while patients who were medically unfit, lived alone and/or required a care package experienced a significantly higher length of stay ( P < 0.05).

Conclusion

These results do not support the British Orthopaedic Association’s recommendation that preoperative assessment delivered by allied health professionals helps reduce length of stay. However, it identifies variables which could be managed potentially to reduce length of stay. A large multisite clinical trial is required to determine if preoperative assessment reduces length of stay for people undergoing this surgical procedure.

Information Sharing: Best Practices That Support Transitions in Care

Care coordination that improves patient care and patient outcomes is becoming increasingly necessary as bundled payment programs are developed. Rather than looking at each aspect of the patient's care, the entire care continuum from preoperative preparation through completion of the episode will become the norm. The length of the episode of care may be 30 days or as long as 90 days. The transition to different care providers during that episode requires information sharing. This is best accomplished by a technology platform that allows for real-time information sharing. This article describes one organizations experience with managing the full continuum of care.

Patient Perception of Value in Bundled Payments for Total Joint Arthroplasty

BACKGROUND

A central concern for providers in a bundled payment model is determining how the bundle is distributed. Prior studies have shown that current reimbursement rates are often not aligned with patients' values. While willingness-to-pay (WTP) surveys are perhaps useful in a fee-for-service arrangement to determine overall reimbursement, the percentage of payment distribution might be as or more important in a bundled payment model.

METHODS

All patients undergoing primary total joint arthroplasty by a single surgeon were offered participation in a preoperative WTP survey. At a minimum 3 months postoperatively, patients were mailed instructions for an online follow-up survey asking how they would allocate a hypothetical bonus payment.

RESULTS

From January through December 2014, 45 patients agreed to participate in the preoperative WTP survey. Twenty patients who were minimum 3 months postoperative also completed the follow-up survey. Patients valued total knee and hip arthroplasty at $28,438 (95% confidence interval [CI]: $20,551-36,324) and $39,479 (95% CI: $27,848-$51,112), respectively. At 3 months postoperatively, patients distributed a hypothetical bonus payment 55.5% to the surgeon (95% CI: 47.8%-63.1%), 38% to the hospital (95% CI: 30.3%-45.7%), and 6.5% (95% CI: -1.2% to 14.2%) to the implant manufacturer (P < .001).

CONCLUSION

The data suggest that total joint arthroplasty patients have vastly different perceptions of payment distributions than what actually exists. In contrast to the findings of this study, the true distribution of payments for an episode of care averages 65% to the hospital, 27% to the implant manufacturer, and 8% to the surgeon. While many drivers of payment distribution exist, this study suggests that patients would allocate a larger proportion of a bundled payment to surgeons than is currently disbursed. This finding may also provide a plausible explanation for patients' consistent overestimation of surgeon reimbursements.

Day of Surgery and Surgical Start Time Affect Hospital Length of Stay After Total Hip Arthroplasty

BACKGROUND

The United States spends $12 billion each year on ∼332,000 total hip arthroplasty (THA) procedures with the postoperative period accounting for ∼40% of costs. The purpose of this study was to evaluate the effect of surgical scheduling (day of week and start time) on clinical outcomes, hospital length of stay (LOS), and rate of nonhome discharge in THA patients.

METHODS

Analysis of perioperative variables was performed for patients who underwent THA at an urban tertiary care teaching hospital from 2009 to 2014.

RESULTS

A total of 580 THA patients were included for analysis. LOS was higher for the Thursday/Friday cohort compared to Monday/Tuesday (3.7 vs 3.4 days; P = .03). Patients who had a surgical start time after 2 PM had longer LOS compared to patients operated on before 2 PM (3.9 vs 3.5 days; P = .03). After controlling for patient comorbidities and THA surgical approach (direct anterior vs posterior), Thursday/Friday THAs were associated with a 3.27 times risk of extended LOS (>75th percentile LOS) compared to Monday/Tuesday THAs (P < .001). Additionally, case start before 2 PM was protective and associated with a 0.46 times odds of extended LOS (P = .01). LOS reduction opportunity for changing surgical start time to before 2 PM was 0.9 days for high-risk patients (American Society of Anesthesiology class 3/4 and/or liver disease) and 0.2 days for low-risk patients (American Society of Anesthesiology class 1/2).

CONCLUSION

Patients who underwent THA Thursday/Friday or had start times after 2 PM had significantly extended hospital LOS. Preoperative risk modification along with adjustments to surgical scheduling and/or perioperative staffing may reduce LOS and thus hospital expenditures for THA procedures.

Discharge Destination After Revision Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes and Placement Risk Factors

BACKGROUND

Given the rising incidence of revision total joint arthroplasty (RJR), bundled payments will likely be applied to RJR in the near future. This study aimed to compare postdischarge adverse events by discharge destination, identify risk factors for discharge placement, and stratify RJR patients based on these risk factors to identify the most appropriate discharge destination.

METHODS

Patients that underwent revision total hip or knee arthroplasty from 2011 to 2013 were identified in the American College of Surgeon's National Surgical Quality Improvement Program database. Analysis of risk factors was assessed using preoperative and intraoperative variables.

RESULTS

A total of 9973 RJR patients from 2011 to 2013 were included for analysis. The most common discharge destination included home (66%), skilled nursing facility (SNF; 23%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed higher rate of postdischarge 30-day severe adverse events (6.1% vs 4.1%, P < .001) and unplanned readmissions (9.3% vs 6.1%, P < .001) in nonhome vs home patients. In multivariate analysis, SNF and IRF patients were 1.30 and 1.51 times more likely to suffer an unplanned 30-day readmission relative to home patients (P ≤ .01), respectively. After stratifying patients by number of significant risk factors and discharge destination, IRF patients consistently had significantly higher rates of unplanned 30-day readmission than home patients (P ≤ .05).

CONCLUSION

RJR patients who are discharged to SNF or IRF have significantly increased risk for unplanned readmissions as compared with patients discharged home. Across risk levels, home discharge destination (when feasible) is the optimal strategy compared with IRF, although the distinction between SNF and home is less clear.

Can We Reduce the Utilization of Home-Visiting Nurse Services After Primary Total Joint Arthroplasty?

BACKGROUND

Home-visiting nurse services (HVNSs) after total joint arthroplasty (TJA) are touted as advantageous compared with inpatient rehabilitation. No study has established the utility of HVNSs compared with discharge home without services.

METHODS

A retrospective single-surgeon consecutive series of 509 primary TJA patients compared discharge disposition, length of stay, complications, and patient satisfaction between 2 cohorts. The cohorts were defined by the elimination of routine HVNSs.

RESULTS

Surprisingly, without routine HVNSs, more patients were discharged home (95% vs 88.3% with routine HVNSs) and mean length of stay significantly decreased. Complication rate was similar (2.9% vs 3.9% with routine HVNSs). Patient satisfaction remained favorable. We estimated that eliminating HVNSs avoids excess costs of $1177 per hip and $1647 per knee arthroplasty.

CONCLUSIONS

With dramatically diminished HVNS utilization after primary TJA, there was an associated decrease in length of stay and no increase in complication rate suggesting no compromise of patient care with significant cost savings.

Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends

BACKGROUND

This study aimed to compare risk of postdischarge adverse events in elective total joint arthroplasty (TJA) patients by discharge destination, identify risk factors for inpatient discharge placement and postdischarge adverse events, and stratify TJA patients based on these risk factors to identify the most appropriate discharge destination.

METHODS

Patients who underwent elective primary total hip or knee arthroplasty from 2011 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were assessed using perioperative variables.

RESULTS

A total of 106,360 TJA patients were analyzed. The most common discharge destinations included home (70%), skilled nursing facility (SNF) (19%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed that rates of postdischarge adverse events were higher in SNF and IRF patients (all P ≤ .001). In multivariate analysis controlling for patient characteristics, comorbidities, and incidence of complication predischarge, SNF and IRF patients were more likely to have postdischarge severe adverse events (SNF: odds ratio [OR]: 1.46, P ≤ .001; IRF: OR: 1.59, P ≤ .001) and unplanned readmission (SNF: OR: 1.42, P ≤ .001; IRF: OR: 1.38, P ≤ .001). After stratifying patients by strongest independent risk factors (OR: ≥1.15, P ≤ .05) for adverse outcomes after discharge, we found that home discharge is the optimal strategy for minimizing rate of severe 30-day adverse events after discharge (P ≤ .05 for 5 out of 6 risk levels) and unplanned 30-day readmissions (P ≤ .05 for 6 out of 7 risk levels). Multivariate analysis revealed incidence of severe adverse events predischarge, female gender, functional status, body mass index >40, smoking, diabetes, pulmonary disease, hypertension, and American Society of Anesthesiologists class 3/4 as independent predictors of nonhome discharge (all P ≤ .001).

CONCLUSION

SNF or IRF discharge increases the risk of postdischarge adverse events compared to home. Modifiable risk factors for nonhome discharge and postdischarge adverse events should be addressed preoperatively to improve patient outcomes across discharge settings.

Episode of Care Payments in Total Joint Arthroplasty and Cost Minimization Strategies

Total joint arthroplasty (TJA) is receiving significant attention in the US health care system for cost containment strategies. Specifically, payer organizations have embraced and are implementing bundled payment schemes in TJA. Consequently, hospitals and providers involved in the TJA care cycle have sought to adapt to the new financial pressures imposed by episode of care payment models by analyzing what components of the total "event" of a TJA are most essential to achieve a good outcome after TJA. As part of this review, we analyze and discuss a health economic study by Snow et al. As part of their study, the authors aimed to understand the association between preoperative physical therapy (PT) and post-acute care resource utilization, and its effect on the total cost of care during total joint arthroplasty. The purpose of this current review therefore is to (1) describe and analyze the findings presented by Snow et al. and (2) provide a framework for analyzing and critiquing economic analyses in orthopedic surgery. The study under review, while having important strengths, has several notable limitations that are important to keep in mind when making policy and coverage decisions. We support cautious interpretation and application of study results, and we encourage maintained attention to economic analysis in orthopedics as well as continued care path redesign to maximize value for patients and health care providers.

Preventing Hospital Readmissions and Limiting the Complications Associated With Total Joint Arthroplasty

Total joint arthroplasty is a highly successful surgical procedure for patients with painful arthritic joints. The increasing prevalence of the procedure is generating significant expenditures in the American healthcare system. Healthcare payers, specifically the Center for Medicare and Medicaid Services, currently target total joint arthroplasty as an area for healthcare cost-savings initiatives, resulting in increased scrutiny surrounding orthopaedic care, health resource utilization, and hospital readmissions. Identifying the complications associated with total hip and total knee arthroplasty that result in readmissions will be critically important for predictive modeling and for decreasing the number of readmissions following total joint arthroplasty. Additionally, improving perioperative optimization, providing seamless episodic care, and intensifying posthospital coordination of care may result in a decreasing number of unnecessary hospital readmissions. Identified modifiable risk factors that significantly contribute to poor clinical outcome following total joint arthroplasty include morbid obesity; poorly controlled diabetes and nutritional deficiencies; Staphylococcus aureus colonization; tobacco use; venous thromboembolic disease; cardiovascular disease; neurocognitive, psychological, and behavioral problems; and physical deconditioning and fall risk. Both clinical practice and research will be enhanced if there is standardization of defined total joint arthroplasty complications and utilization of stratification schemes to identify high-risk patients. Subsequently, clinical intervention would be warranted to address modifiable risk factors before proceeding with total joint arthroplasty.